Synopsis of Oral and

Maxillofacial Surgery
 Synopsis of Oral and
Maxillofacial Surgery
(An Update Overview)

Pradip K Ghosh
BDS (CAL), MDS (MAS)
Post PG Trained in Eastman and
University College Hospitals, London
Presently, Principal and Professor, HOD Oral and Maxillofacial Surgery
Sarjug Dental College, Lahariasarai, Darbhanga
Ex-Associate Professor and Head, Dept of Dentistry
NRS Medical College, Kolkata
PG Guide and Examiner
Paper Setter and Member, Board of Studies of Calcutta University

JAYPEE BROTHERS
MEDICAL PUBLISHERS (P) LTD
New Delhi
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi 110 002, India
Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021, +91-11-23245672
Fax: +91-11-23276490, +91-11-23245683
e-mail: jaypee@jaypeebrothers.com Visit our website: www.jaypeebrothers.com

Branches
• 2/B, Akruti Society, Jodhpur Gam Road Satellite
Ahmedabad 380 015 Phones: +91-079-30988717, +91-079-26926233
e-mail: jpamdvd@rediffmail.com
• 202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East
Bangalore 560 001, Phones: +91-80-22285971, +91-80-22382956, +91-80-30614073
Tele Fax: +91-80-22281761 e-mail: jaypeemedpubbgl@eth.net
• 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon Road
Chennai 600 008, Phones: +91-44-28193265, +91-44-28194897, +91-44-28193231
Fax: +91-44-28262331 e-mail: jpchen@eth.net
• 4-2-1067/1-3, Ist Floor, Balaji Building, Ramkote Cross Road
Hyderabad 500 095, Phones: +91-40-55610020, +91-40-24758498, +91-40-30940929
Fax: +91-40-24758499 e-mail: jpmedpub@rediffmail.com
• 1A Indian Mirror Street, Wellington Square, Kolkata 700 013
Phones: +91-33-22456075, +91-33-22451926, +91-33-30901926 Fax: +91-33-22456075
e-mail: jpbcal@cal.vsnl.net.in
• 106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital Parel
Mumbai 400 012 Phones: +91-22-24124863, +91-22-24104532, +91-22-30926896
Fax: +91-22-24160828 e-mail: jpmedpub@bom7.vsnl.net.in
• “KAMALPUSHPA” 38, Reshimbag, Opp. Mohota Science College
Umred Road, Nagpur 440 009 (MS) Phones: +91-712-3945220, +91-712-2704275
Fax: +91-712-2704275 e-mail: jpmednagpur @rediffmail.com

Synopsis of Oral and Maxillofacial Surgery (An Update Overview)

© 2006, Pradip K Ghosh
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form
or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the
author and the publisher.

This book has been published in good faith that the material provided by author is original. Every effort is made to ensure
accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of
any dispute, all legal matters to be settled under Delhi jurisdiction only.

First Edition: 2006

ISBN 81-8061-637-1
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd., A-14, Sector 60, Noida
 Dedicated to
My beloved teachers
Prof Malcolm Harris,
Late Prof Arbinda Dutta
and Prof PV Janardhanan
 Foreword
This to me is, indeed, a labor of love. The three chapters, which I am privileged to edit, have been meticulously
researched and compiled specifically on impactions, odontogenic and non-odontogenic cysts of the jaws, and
diseases of the maxillary antrum.
This is no surprise that the author, who has a penchant for detail, writes this book with all good intention
covering maximum of information on the subject.
The Synopsis of Oral and Maxillofacial Surgery (An Update Overview) will be eventually-ideal not only
for the students but also for the senior practitioners and teachers of this speciality too.
For the students, teachers, and practitioners who like to know the historical and the minutiae of this
speciality, this is the book of choice.
This is what our teachers and mentors taught Pradip and I, and, this handbook will surely pass on this
message to our future generation of oral and maxillofacial surgeons.

Prof. Kali HC Kapadia

 Preface
The Synopsis of Oral and Maxillofacial Surgery (An Update Overview), is not a textbook
in true sense but as “compendium” a brief summary of large work, and collective thoughts
of eminent authorities, for the students, professionals and teachers.
My special emphasis is given to project the ideas on the subject mainly for under-
graduate level, but it can be considered as bridge book in between undergraduate and
postgraduate students too. The present subject is changing dynamically day-to-day.
Therefore, my intention is limited to focus on the subject as much as possible.
Though I have started write this book very slowly with constant patience with
alteration, additions, necessary corrections, omission and improvisation and took lot of
time. But I am still not satisfied for ensuing publication of the book.
This book is my humble and honest presentation in lucid and understandable language for our present
and future students.
Though the title of the book is an update overview but certain old concepts are still alive and used in recent
time, mentioned in this book. Such as, ‘Alveolar Purchase’ a technique described by Gustav Kruger. ‘Stick Tie’
by La Quentein Royer recommended a method to control bleeding following injury to the greater palatine
artery. The Stobie technique one of the method of extraction and migratory abscess of buccal sulcus, is a
common important condition explained by Prof GL Howe.
The present author fortunate enough to attend the British Oral Surgeon’s Conference held in London in
the year 1990, during his Post PG Training Program in Eastman and University College Hospital, London.
The Scandenavian oral pathologist Professor Vorsmith delivered a lecture on primordial cyst; he discussed
the tremendous growth potential of the cyst, explaining the treatment modalities after enucleation and careful
curettage recommended the use of Cornoy’s solution, as chemocautarization for destruction of any remnants
of cystic lining if present. Majority of the participants asked Prof Vorsmith about composition and use of
Cornoy’s solution, but it was surprisingly to be mentioned our legend authorities like Prof Kurt H Thoma and
Prof Harry Archer discussed long before.
Another operation I have to have mentioned where the Norwegian Oral and Maxillofacial Surgeon
Mayerhaug described an eminectomy technique in the year 1952, till now, considered as ultramodern method
and it was also supported by eminent Prof William Irby and Prof Wanderkwast.
Late Prof Ivor RH Kramer’s dictum the management of ameloblastoma in the year 1965, is still alive and
also supported by MacIntosh and Marx et al 1991/93.
Recent concepts to TMJDS/MPDS/FAM. The growth and development of odontogenic cyst, osteoclast
activating factor (OAF) are quoted and recorded from Hunterian lecture of Prof Malcolm Harris in March
1974 mentioned in this book.
I am indebted a lot to my respected and beloved teachers, Late Prof Arabinda Dutta, Prof PV Janardhanan
and especially to legend Prof Malcolm Harris to write this book.
Thought’s knowledge, notes, lectures, total concepts, clinical discussion, operative session and perspective
of Prof Harris are instilled and saturated in every page of my book, such as ultrasound treatment in ORN.
Facial pain lecture, calcitonin therapy in central giant cell lesion, an appraisal of TM Jt ankylosis over 15 years
review of management and so many things.
I am grateful to Prof Teruo Ito of Nagasaki University of Japan and Prof Valerian Popescu Institute of
Medicine Bucharest, Rumania, for a new technique of repair of oroantral fistula and treatment method of
hemangioma. I am also grateful to Prof Heinz Kole of Graz University, Austria and Bruce N Epkar for personal
communication in early 80s regarding orthognathic surgery.
 Synopsis of Oral and Maxillofacial Surgery
x
In most of the chapters, I intend to put a heading named ‘Analytical Observation’, which contains comments
and concepts of various observer as well as important points for discussion and reappraisal and ready references
for the readers.
Lastly, I mention the Snawdon’s technique for treatment of large maxillary dental and dentigerous cyst
involving maxillary antrum, which was appraised by Margarate and Prof Gordon R Seward in their excellent
review article, which contains the observation of Prof Ficking. I convey my deepest respect to Prof Kali HC
Kapadia having, an extra-large sympathetic heart and loveable teacher who gave valuable time for correction,
addition, alteration, and suggestion for few chapters and forward of my book.
I know my maiden sincere efforts having many mistakes, omission etc need more correction, alteration
and addition. I personally feel elated and welcome the constructive criticism from all corners of the learned
readers.
Lastly, I convey my best wishes and love to Dr Kamala P Singh, Chairman and DG, Sarjug Dental College,
Darbhanga and specially to all my students and colleagues past, present and future.

(Pradip K Ghosh)
 Acknowledgements and
Remembrance
Firstly, my humble submission and pray to Almighty Suprimo (Adyama). Without her blessing, it is not
possible for my dream ultimately to come into shape.
I personally submit my humble deep gratitude and acknowledge the legendary authorities, which enriched
my thoughts, knowledge indirectly and directly during my movements in academic field. Some of them are
deceased; man is mortal but their extensive work is still alive and countable beyond the ages.
I like to mention the following legendary authorities, which include Prof Kurt H Thoma, Prof Harry Archer,
Prof Gustav Kruger, Prof William Irby, Prof Charles A Waldron, Prof Shafer, Sir William K Fry, Sir Terrence
G Ward, Prof JR Moore, Prof Toller, Prof Poswillo, Prof Lucas, Prof D Laskin, Prof Paul Bramley, Prof Heinz
Kole, Prof Ivor RH Kramer, Prof Homer C Killy, Prof Norman Rowe, Prof GL Howe, Prof John William, Bruce
N Epkar Peter Bank, Prof Jens J Pindborg, Prof Gordon and Margarrette Seward obviously Prof Malcolm
Harris and so many.
I convey my best wishes and regards to my ex-teachers mainly Prof Arup K Das, Late Prof Arabinda
Dutta, Prof PV Janardhanan, Late Dr Sankarananda Talukdar, Dr SN Sikdar.
I am indebted a lot and regard to my mentors late Pabitra Kumar Ghosh the then Private Secretary to CM
West Bengal and Prof Ramendranath Kundu; without their help, it is not possible for me to reach this level
presently. I also convey my sincere thanks and love to my well-wisher family friend Sri Sumantra Chowdhury,
MSc, IAS for constant encouragement in my life.
I still remember ever-smiling Dr K Kamal, Dr Uma Maheswari and Jovial Dr Mahalingam, Dr Manivannan
the then academic staff members of the Department and still remember the tough administrator but soft-
spoken to me Prof BP Rajan (The then principal, Madras Dental College). I still remember the Senior Prof B
Srinivasan of Annamalai University. I am grateful to Prof D Basak, MS Mch for writing the chapter of Cleft
Palate and Cleft Lip. I am also grateful to Prof S Srivastava, MD Pharmacology, Ex-principal, DMC for his
kind co-operation. I also convey my thanks to Sri Promod K Singh and Sri Lalan Singh, Directors, Sarjug
Dental College and my family friend and well-wisher Sri Biplob Chakraborty for his moral support.
I convey my best wishes and love to my family for their constant encouragement for writing this book. I
also convey my sincere thanks to my batchmate Prof TK Saha, Ex. Principal R Ahmed Dental College and past
PG students specially Dr Debdutta Das MDS, Dr Nupur Chakraborty MDS, Dr Amit Roy Jr MDS, Dr Monimoy
Banerjee, MDS and Dr BK Biswas, MDS, Dr Sunil Thapar for their intense involvement in writing this book.
I also convey thanks to Sri Jayanta Chatterjee, my DTP typist for his efforts to publish my book.
I also thank Shri JP Vij, Chairman and Managing Director, Mr Tarun Duneja, GM (Publishing), Mr PS
Ghuman, Senior Production Manager, Ms Mubeen Bano, Mr Bharat Bhushan and Mr Sanjoy Chakraborty,
RSM (Kolkata) of Jaypee Brothers Medical Publishers for their entire support.
 Contents
1. Sterilization and Disinfection 1
2. Healing of Extracted Socket and Healing of Bone Following Fracture/Surgery 4
3. Exodontics or Exodontia 6
4. Impaction 14
5. Common Precancerous Lesions and Oral Cancer 28
6. Biopsy 38
7. TM Joint and Its Diseases 40
8. Odontogenic and Non-odontogenic Cysts of Jaws 52
9. Role of Oral Surgeon in the Adjuvant Management for the Orthodontic Treatment 66
10. Pain, PTN and Facial Palsy 70
11. Diseases of Maxillary Antrum 83
12. Surgical Endodontics 92
13. Odontogenic and Non-odontogenic Tumors 96
14. Some Soft Tissue Tumors and Central Oral Lesions or Tumors-like Growth 106
15. Inflammation of Bone 112
16. Various Common Sutures and Suture Techniques 117
17. Clinical History and Examination in Oral Surgery and Some Surgical Dictum and Discipline 120
18. Orofacial Infection and Its Spread 126
19. Excerpts of Orthognathic Surgery 132
20. Tidbits of Cryo and Laser Surgery Used in Oral Maxillofacial Surgery 139
21. Hemorrhage and Shock 146
22. Cleft Lip and Palate 152
23. Dental Emergencies 159
24. AIDS and Oral Surgery 162
25. Maxillofacial Trauma and Management 164
26. Diseases of Salivary Gland 182
27. Preprosthetic Surgery 187
28. Tidbits of Implants and the Role of Oral Surgeon 193
29. Excerpts of Osteodistraction Technique 195
30. Tissue Transplantation, Flap and Current Concept of Bone Grafting 197
31. Tidbits of Commonly Used Therapeutics in Oral Surgery 201
Index 203
 ONE
Sterilization and Disinfection

• Sterilization and Disinfection — Role • Sterilization or Disinfection of Dental

Equipment

Sterilization and Disinfection Play Very Autoclaves are mechanized versions of home
Important Role of Any Surgical Modality pressure cookers. Water is boiled and the air inside
the vessel is expelled by the steam. The vessel is
Sterilization means complete killing or removal of all then sealed; and, the pressure is allowed to build
living forms including endospores from an object or a up. The rise of pressure causes the temperature of
location. It is an absolute term, i.e. an object is either steam to exceed that of boiling water. Safety release
sterile or not sterile. valves prevent excess pressure from building up.
Disinfection means destruction of pathogenic Autoclaves are usually operated at 15 psi at 121oC
microorganisms only and does not necessarily include for 15 minutes or at 20 psi at 134oC for 3 minutes.
endospores or viruses. Boiling is not a method of sterilization because a
Antiseptics means chemical disinfection of the skin, temperature of 100oC is not high enough to kill all
mucous membranes, or other living tissues. The agents organisms. Autoclaves are available in many sizes,
with which this state is achieved are called anti- with various automatic features. Autoclaves are the
microbial agents. best and most dependable method of sterilization
Asepsis is the avoidance of pathogenic micro- and used for surgical packs, rubber materials,
organisms. In practice, ‘aseptic technique’ is one, metallic instruments, glasswares, culture media,
which aims to exclude all microorganisms. Surgical and any heat-resistant contaminated material.
technique is aseptic in the use of sterile instruments, Moist heat cannot be used for sterilization of
clothing and the ‘no touch’ technique. substances in sealed containers or hydrophobic
Antisepsis is the procedure or application of an substances like oils and waxes. The major draw-
antiseptic solution, or an agent, which inhibits the back of moist heat is rusting of non-stainless steel
growth of microorganisms. Examples are, scrubbing instruments. Hot air ovens are usually operated at
and preparation of operative site. 160 to 170oC for 1 to 2 hours. Dry heat requires
1. Pattern of microbial death: A population of micro- higher temperatures and longer times than to do
organism treated with antimicrobial agent does not usual steam sterilization, because proteins are
die all at once; instead, they die at a constant rate. denatured less-readily when dehydrated. Hot air
The total time required is dependent upon the ovens are used to sterilize glassware, metallic
initial microbial concentration (as well as the instruments, and hydrophobic substances. Micro-
temperature and/or concentration of the chemical wave is not a reliable method of sterilization.
agent). Endospores are the most resistant forms of 4. Radiation: Ionizing radiation such as X-rays and
life. gamma-rays inactivate microorganisms by
2. Sterilization frees an object of all forms of life. It reacting with their DNA. Radiation is used to
can be achieved by using heat, radiation, filtration sterilize pharmaceutical and disposable medical
and chemicals. supplies.
3. The heat used in sterilization is either moist heat 5. Filtration is used to sterilize heat-sensitive material
such as in an autoclave or dry heat in a hot air oven. in solution and gases. Membrane filters with

Theme author of this chapter—Late Prof Biprodas Sanyal. Edited and modified by Dr Pradip K Ghosh.
 Synopsis of Oral and Maxillofacial Surgery
2
varying pore sizes have replaced the earlier filters important to know about them. In general their
such as Seitz (asbestos) and Chamberland activity is affected by the following factors:
(ceramic). 1. Concentration of the chemical.
6. Ethylene oxide is an example of a chemical 2. Length of exposure time.
sterilizing agent; it is used to sterilize heat-sensitive 3. Temperature and pH.
materials such as plastic catheters, prosthetic 4. Number, nature and types of microorganisms.
devices and disposable medical supplies. 5. Amount of organic material present.
7. The effectiveness of a sterilizing technique is 12. Alcohols: Ethyl alcohol, isopropyl alcohol and
assessed by its ability to kill the most resistant life- methylated spirits are bactericidal but not
forms such as bacterial spores (e.g., Bacillus sporicidal. They act by denaturing protein. Because
stearrothermophilus spores). Records of tempe- proteins are not hot denatured in the absence of
rature, pressure and time are regularly made. water, a 70 percent solution of alcohol in water
Autoclave tape such as Bowie-Dick is routinely better than absolute alcohol. Alcohols are often
used to ensure that the autoclave is functioning used with other disinfectants such as chlorhexidine
properly. and povidone iodine.
8. Disinfection is defined as removal or killing of 13. Aldehydes: Formaldehyde and glutaraldehyde act
infectious microorganisms. Disinfectants are anti- by denaturing protein and nucleic acids.
microbial agent applied to inanimate objects for Formaldehyde is used as a 37 percent solution in
disinfection. Antiseptics are chemical disinfectants water (called formalin). Glutaraldehyde is effective
used on living tissues. Disinfection is achieved by against bacteria, viruses and fungi. It is used to
physical or chemical agents. sterilize instruments such as endoscopes that
9. Moist heat is the best method of disinfection. cannot be autoclaved. Both are skin and eye irritant.
Boiling for 5 to 10 minutes kills most pathogens. 14. Chlorhexidine is a bisguanide that affects bacterial
Pasteurization involves heating to 60 to 80oC for cell membrane permeability, leading to leakage of
30 minutes to 30 seconds; it kills most vegetative intracellular materials. It is less effective against
forms of bacteria but not spores. gram-negatives. It is used in combination with
10. Ultraviolet light is a form of non-ionizing radiation alcohol or detergent for antiseptic use, and is a good
that is lethal to microorganism. However, it has antiplaqe agent when used as mouthwash. It has
very little penetrability, and therefore used on flat low toxicity. Long-term oral use causes tooth
surfaces and air. staining.
11. There are many chemical disinfectants and 15. Halogens used as disinfectants and antiseptics
antiseptics. Before we can use them properly, it is include chlorine and iodine.

Sterilization or disinfection of dental equipment

Equipment Suggested treatment
Dental hand piece Autoclave, ethylene oxide
Hand instruments Hot air oven, autoclave
Mirrors Hot air oven, autoclave
Forceps, elevators, scalpel handles, retractors and other surgical items Autoclave
Endodontic instruments Hot air oven, autoclave
Gauzes, cotton wool and paper points Autoclave after wrapping
Linen Autoclave after wrapping
Surgery floors Wash daily with detergent and dry
General working surfaces Wash daily with detergent and dry
Bracket table Wipe with chlorhexidine in alcohol or 70 percent
isopropyl alcohol between patients
Bullk disposable syringe, gloves, mask and dressing Gamma radiation
Purification of air in the operating room Ultraviolet rays
 Sterilization and Disinfection
3
16. Hypochlorites act by releasing chlorine that is an 19. Detergents or surface-active agents act by
oxidizing agent killing most bacteria and viruses damaging microbial cell membrances. They are
including hepatitis B virus. It is a very effective generally used as cleaning agents. Benzalkonium
disinfectant in hospitals and home. The main chloride (a quaternary ammonium compound) is
disadvantages are corrosion of metals and inacti- used as a skin antiseptic.
vation in the presence of organic matter. 20. Hydrogen peroxide is a strong oxidizing agent and
17. Iodine, like chlorine, it is a strong oxidizing agent used as an antiseptic to clean wounds.
and an effective antiseptic. Its drawbacks are
21. Tests for effectiveness of disinfectants and
staining, hypersensitivity and corrosion. Iodine is
antiseptics. The in-use test is one of many widely-
used either as tincture of iodine (i.e., iodine in
used tests. In this test, sample of the diluted
alcohol) or as povidone iodine (i.e., iodine complex
with polyvinyl-pyrrolidone). disinfectant in use is examined for viable
18. Phenols are very toxic and so only the less toxic bacteria.
derivatives are used. They act by damaging the cell 22. The choice of antimicrobial agent to be used
membrane and denaturing proteins. Some well- depends on many factors:
known phenol derivatives are: Dettol (chloroxy- 1. Nature of the item and its intended use.
phenols), hexachlorophene (bis-phenol), and cresol 2. The kind of microbe to be treated.
(methyl phenol). 3. The risk of cross-infection.
TWO
Healing of Extracted Socket and Healing of
Bone Following Fracture/Surgery

• Various Modalities of Healing • Healing of Bone • Factors Influencing Healing

The healing of soft tissue and bone are natural physio- Remodeling phase: Three weeks after injury. Collagen
logical phenomenon, provided conditions are is usually laid down in abundant fashion and after
favourable for revival of tissue damage (healing). that the arranged orientation of this collagen is more
This automatic process having different phases. or less form normal pattern without replacing elastin.
The surgical induce trauma, e.g. extracation, oral
Primary intention of healing means close approxi-
surgery or even fracture needs healing. The knowledge
mation of wound edges, which produce small
about healing is necessary before entering into the
hematoma, subsequently the granulation tissue;
other topics.
reorganization is therefore minimal and healing
Theme of healing is summarized below:
results.
Surgery induce tissue trauma → Hematoma →
Organization of hematoma → Fibrin (clot) → Secondary intention of healing means separation of
Organization of clot and formation of healthy wound edges, which produces large hematoma and
granulation tissue → Fibrous tissue → Callus needs volume of organization more with increased
formation → Organization of callus in different stages activity of fibroblast, capillary network in the greater
→ Calcification of bone (osteoid tissue) → Remodeling surface areas over which new epithelium must spread.
of bone.
First Week
Various Modalities of Healing
Extraction socket healing an example of secondary
Healing of Primary and Secondary Intention intention: The features of inflammatory reaction
consists of rubor (redness), tumor, (swelling), color
Phases of wound healing consist of phases like:
(heat), dolar (pain), and loss of function. Hematoma
Inflammation: Starts from 0–4 days after injury. This
within socket formation of clot followed by prolife-
phase produces the vascular and cellular changes.
rative phase that is activation and formation of in
Vascular consequences are, initial vasoconstriction
growth fibroblasts and capillaries. Epithelium
and subsequent vasodilatation, and fibrin and plasma
migration to cover the underlying granulation tissue
leakage within the tissue. Cellular consequences are
followed by resorption of bone from socket margins.
polymorph releases the lysosomal enzymes. Activity
of macrophages increased and later, the process of
phagocytosis propagated on addition to lymphocytic Second Week
infiltration. Activation of osteoid tissue and formation callous.
Proliferative phase: Days 3–3 weeks after injury. Epithelialization process about to complete.
Activity of fibroblast is increased and produces
Third to Six Week
ground substance and collagen precursors along with
new capillary buds, fibroblasts form the granulation Callous is replaced by bone, remodeling of the bone.
tissue. Resorption of lamina dura completed.
 Healing of Extracted Socket and Healing of Bone Following Fracture/Surgery
5
Healing of Bone divided into different categories, depending on
Healing by primary intention, less than one mm gap/ location and function.
preposition between bone ends and rigid fixation. This a. Anchoring callus—Develops on outer surface
produces minimum callus. of the bone near the periosteum.
Healing by secondary intention where the greater b. Sealing callus—Develops on inner surface of the
gap of bone ends, osteoblasts (from periosteum and bone and sheals the marrow space and form
endosteum and blood) produces larger organising endosteal proliferation.
callus and extending between and beyond the end of c. Bridging callus—It forms on the outside surface
the fracture. This is emphasized even more if fixation between the anchoring callus on end of fracture
is not rigid. lines. This callus is primarily cartilaginous.
According to Kruger healing of bone is divided into d. Uniting callus—Forms between the ends of
three overlapping phases: bones.
1. Hemorrhage followed by organisation clot and 5. Formation of secondary bone callus: This is actually
proliferation of blood vessels, this is considered as matured bone, which replaces the immature bone
a non-specific phase occur during 0 – 10 days. of the primary callus (20 – 60 days).
2. Callus formation—A rough woven bone or 6. Functional reconstruction of fractured bone: It
primary callus looks overlap is formed in the next requires over months or year to fulfill the process
10 – 20 days. A secondary callus, which form with alternate activity of osteoclast as well as
Haversian systems during period of 3 week to 2 osteoblast cells.
months.
3. Functional reconstruction—It takes 2 to 3 years. Factors Influencing Healing
Weinmann and Sicher divided the healing of Tissue factors—blood supply reduced in smoking and
fracture into six stages: diabetes. Drainage (venules and lymphatic are poor
1. Hematoma (Clotting of blood)—Surrounds the post-radiation therapy). Nutrition (low protein level
fracture end and extends to bone marrow to the in debilitated patient)
soft tissues. It coagulates 6 to 8 hours after the
injury.
Pre-existing Infection
2. Organization of hematoma: A meshwork of fibrin
fragments of periosteum, mussel fascia, bone and General immune response reduce (elderly concurrent
bone marrow. Most of the fragments are digested disease, steroids immunosuppression). Local immune
and removed by the inflammatory cells. Which are response reduced (radiotherapy, topical steroids).
requisite criteria of hemorrhagic phase of bone
healing. Capillaries and fibroblast invade the clot Physical Factors
in the same time, i.e. 24 to 48 hours. The
proliferation of blood vessels is a characteristic Barriers cuts, tissue planes open, reduced salivary
feature of early organising hematoma. flow. Microbes from patient to other patient via
Resorption of bone is a characteristic in late instruments/working surfaces, microbes from
hematoma. The movements of blood running via operator.
the area of active hyperemia and not disuse
atrophy responsible for resorption of bone. BIBLIOGRAPHY
3. Formation of fibrous callus: The organized 1. Bone and Bones by Harry Sicher.
hematoma is replaced by granulation tissue. 2. Illustrated Pathology by Govan.
4. Formation of primary bony callus: 10 to 30 days 3. Textbook of Oral and Maxillofacial Surgery by Gusta
after injury or fracture. This primary callus is again Kruger.
THREE
Exodontics or Exodontia

• Indication of Extraction of Teeth • Contraindication of Extraction of Teeth

• Extraction Technique • Method of Extraction • Principles of Extraction • Closed
Method • Indication for Open Method • Principal Modalities of Transalveolar
Extraction • Principles of Elevator in Exodontia • Order of Extraction • Principles
of Primary Tooth Extraction • Complications of Tooth Extraction

Oral and maxillofacial surgery is a branch of dentistry, stomatitis, acute maxillary sinusitis in relation to
which deals with clinical and radiological diagnosis, upper molar and premolars.
medical and surgical management of disease, injuries, 2. Extraction in case of irradiated jaw may leads to
correction of defects of jaws and orofacial structures osteoradionecrosis.
including soft and hard tissues. 3. Tooth within the malignant growth.
4. Central hemangioma, arteriovenous shunt,
Exodontia or exodontics, the technique of methodical
aneurysmal bone cyst.
modalities of tooth extraction is known as Exodontia.
Exodontia or extraction of tooth is defined as, painless
Systemic Factors
removal of tooth or root with minimal injury to the
surrounding soft tissue and bone. Extraction of teeth 1. Bleeding disorders like hemophilias, leukemias
is one of the minor oral surgical procedures. and purpuras in case of extraction. Haematologist’s
consultation is mandatory to avoid complications.
Indication of Extraction of Teeth 2. Cardiac problems: Hypertension, congestive
1. Periodontal disease, when periodontal treatment cardiac failure, ischemic heart disease, septal and
fails to recover the disease. valvular defects. Consultation of physician is
2. Dental caries and its consequences, when the necessary before the surgery. The oral flora contain
conservative treatment fails after or even RCT/ Streptococcus viridans which is active during
Apicoectomy. minor oral surgical procedure that may cause
3. Erosion, abrasion and attrition. subacute bacterial endocarditis in the rheumatic
4. Trauma and injuries of teeth and dislocation of valvular defects. This can be controlled by suitable
tooth from its socket. antibiotic coverage before surgery.
5. Impaction. 3. Uncontrolled diabetes mellitus: Leads to risk of
6. Therapeutic extraction, which includes extraction infection and delayed healing. In case of controlled
of upper and lower 1st and 2nd premolars. blood sugar or patient under the antidiabetic treat-
7. Extraction due to orthodontic reasons, extraction ment, extraction or minor surgery can be done
of supernumerary, serial extraction and under the prophylactic antibiotic coverage.
Wilkinson’s theory. 4. Pregnancy: The first and last trimester is contra-
indicated for extraction, risk of premature delivery
Contraindication of Extraction of Teeth and the chance of supine hypotensive syndrome.
Only the middle trimester is safe for extraction.
Local Factors 5. The patient under anticoagulant therapy:
1. Acute pericoronitis in relation to 3rd molar Extraction can be done under precaution with
infection with facial cellulitis, acute gingivitis and consultation of physician.
 Exodontics or Exodontia
7
Table 3.1: Extraction technique
Mandibular Teeth
Incisors: Slim ovoid root Slow labial and lingual expansion, little rotation at the end.
Canines: Long ovoid root
1st and 2nd premolars: Single ovoid root Rotation in horizontal direction, slight movements to start with
1st and 2nd molars: Two roots, mesial and distal, Lingual and buccal expansion – ‘figure of 8’ movement when
may be divergent. tooth moving may take time
3rd molars: Two roots, variable

Maxillary Teeth
Incisors: Single cone-shaped Mostly rotation
Canine: Very long root Requires very slow buccal expansion to avoid fracture
in buccal plate some rotation
Premolars
1st premolars – Two fine roots easily fractured Again more buccal than palatal expansion with less force; great
2nd premolars – Single oval root care with I premolar
1st and 2nd molars: Three roots- masiobuccal, Forceps beak placed both buccal roots and the palatal,
distobuccal and palatal the main movement is buccal.
Divergent in the 1st molar Once the main buccal expansion has been achieved other
movement can be employed gently
3rd molars: Three roots, frequently confluent Consider elevator if access poor.
and fused together

6. Patient with liver disorders like hepatitis or b. In case of upper teeth the mandible should be
cirrhosis with jaundice having the bleeding 45-degree angle to the floor.
problems: Proper clearance from the physician is 2. Position of the chair: In case of upper tooth position
necessary prior to extraction, examination of blood of the chair should be 3 inches below the shoulder
biochemistry and liver function test. level of the operator, in case of lower teeth the chair
height should be adjusted 6 inches below of the
Extraction Technique operator’s elbow. If the operator standing behind
the patient the chair should be sufficiently lower
All the suggested modalities apical thrust with the
to enable the operator to have maximum
forceps or push directed towards apically is
mechanical and visual access.
mandatory (Table 3.1).
3. Position of the operator: All teeth except lower
teeth, cheek teeth, front and right side of the
Method of Extraction
patient, in case of right-handed operator, in case
1. Closed or intra-alveolar. of left-handed operator the above position in
2. Open or transalveolar extraction: Some prefers to reserve. In case of right mandibular cheek teeth,
consider the open method or TAE consider as behind the patient. In case of all upper teeth, the
surgical method but all extraction methods front and right side of patient in case of right-
consider oral minor surgical procedure. handed operator. In case of left-handed operator,
3. Stobie technique: It is one of the method of the case is reverse.
extraction for multiple lower incisors engaging a 4. Position of the left arm in case of right-handed
straight elevator inserted in between tooth and operator. Left thumb should support the mandible
rotated for luxating teeth within the socket and and index finger retract the cheek tissues and
gradually remove by forceps easily. middle finger control the hyperactive tongue for
maximum visual and mechanical access of the
Principles of Extraction operator. In case of lower teeth left side. In case of
1. Position of the patient right lower teeth the index finger retract the cheek
a. In case of lower teeth, mandible should be tissues and thumb will act to control the tongue
parallel to the floor. and remaining fingers support the mandible to
 Synopsis of Oral and Maxillofacial Surgery
8
avoid the injury to T.M. Jt. In case of left upper a. In case of mandibular first and second premolar
teeth thumb will support the palatal alveolar bone careful about the position of mental nerve.
and index finger retract the buccal cheek tissues. b. In case of mandibular second and third molar
In case of right upper teeth the thumb will retract careful about facial artery (both 1 and 2 placed
the buccal cheek and index finger support the bucally).
palatal alveolar bone. In case of left-handed c. In case of mandibular 3 molar lingual nerve
operator, the function of right hand will be reverse place lingually.
as mention above. d. In case of maxillary 2 and 3 molar pterygoid
venous plexus placed buccaly.
Closed Method: Principles of Extraction e. The base of the incision should be broader than
its tip to provide an adequate blood supply.
1. Forcep blade should be placed below the C. E. f. Reliving incision should not be made at acute
junction on the sound root mass, apical thrust angle.
should be first. g. The design of incision should be sufficient to
2. Use of mechanical principals which includes: achieve to maximum visual and mechanical
a. Expansion of the bony socket to achieve the access for the surgery.
dislodge and removal of concerned tooth or h. The flap margin should rest on sound bone,
root. post-operatively.
b. The use of lever and fulcrum–using force to 2. Raising the mucoperiosteal flap.
elevate the tooth or root. 3. Removal of bone in around retained root or tooth
c. The use of wedge or wedges within the root by bur or chisel.
and its bony socket. 4. Establishment of point of application for elevator.
3. Traction towards least resistance. 5. Removal of tooth or root from socket.
4. Alveolar purchase: Kruger recommended a unique 6. Trimming of the bone by bur or bonefile.
closed method technique. 7. Toileting of the wound.
For removal of mostly anterior teeth or root. A 8. Control of bleeding.
fractured tooth often can be grasped by root forceps 9. Reposition of the mucoperiosteal flap and wound
or anterior forceps. Alveolar purchase may obtained repaired by suture.
by detaching the labial gingival cuff with a small, 10. Pack.
sharp curet. Then labial beak of forceps is then placed 11. Prescription, which includes advises, instructions
under the tissue on the labial plate of alveolar bone. and medicine.
Pressure on a sharp forceps will grasped the root along
with labial alveolar bone. The root with the cut
alveolar bone delivered easily. This method is very
much successful.

Indication for Open Method or

Transalveolar Extraction
1. Failure to remove a tooth or root by open method
2. Unfavourable root pattern
3. An abnormal number and shape of roots
4. Fracture or caries extending into the root mask
5. Hypercementosis and ankylosis of tooth or root
6. Bony sclerosis and pathological lesions
7. Impacted teeth.
Fig. 3.1: Steps of surgical removal of the
Principal Modalities of Transalveolar Extraction right first mandibular molar
Steps and Caution with Criteria (Fig. 3.1) 1. Raising the buccal mucoperiosteal flap, 2. Retained root
mandibular first molar, 3. Lateral plate of mandibular alveolus,
1. Incision—considering the anatomical underlining 4. Initial area of bone removal in a “trench” around retained
structures carefully making an incision for TAE. root, 5. Establishment of a ‘point of application’ for elevator.
 Exodontics or Exodontia
9
The Principles of Elevator in Exodontia • Adjacent or opposing tooth
• Mandible
1. Class I and II levers
Dislocation of:
2. Wedge
• Adjacent tooth
3. Pulley
• Temporomandibular joint
4. Wheel and axle.
Displacement of a root:
The elevator should always be placed between the
• Into the soft tissues
tooth and alveolar bone and alveolar bone should be
• Into the maxillary antrum
used as fulcrum. Adjacent teeth and lingual cortical
• Under general anesthesia in the dental chair
plate should never be used as fulcrum.
Excessive hemorrhage:
To obtain maximum mechanical advantage the
• During tooth removal
fulcrum should be near the point of resistance and
• On completion of the extraction
effort arm should be longer than resistance arm
• Postoperatively
(principal of class I levers).
Injury to:
• Gums
Order of Extraction (Prof J Moore) • Lips
To prevent bleeding from the socket of a extracted • Inferior dental nerve or its branches
teeth obscuring the field of operation it is better to • Lingual nerve
remove the lower teeth before uppers, and posteriors • Tongue and floor of mouth
before anteriors. It is wise to begin with the most • Greater palatine artery
painful and problem tooth. Postoperative pain due to:
According to Prof Harry Archer, Maxillary teeth • Damage to hard and soft tissues
should be extracted first because: • ‘Dry socket’
1. Early action of LA in maxilla is there. • Acute osteomyelitis of the mandible
2. The debris etc. does not fall once maxillary molars • Traumatic arthritis of the temporomandibular joint
have been placed thus allowing clean field for Postoperative swelling due to:
mandible. • Edema
• Hematoma formation
The Principles of Primary • Infection
Tooth Extraction • Trismus
• The creation of an oro-antral communication
Almost same as permanent. • Syncope
Gentle care should be taken during extraction: • Respiratory arrest
1. Judicious use of elevator. • Cardiac arrest
2. During extraction of primary teeth the beak of the • Anesthetic emergencies
forceps must be carefully placed. So that it should Complication of tooth extraction which
not injured the hidden permanent tooth bud. summarized above of which the following important
3. Identification of primary is very important. and common complication will be discuss below:
1. Syncope
Complications of Tooth Extraction 2. Pain, which includes dry socket (ASD)
(Summarized From Prof Geoffray L Howe) 3. Postoperative swelling
Failure to: 4. Bleeding (paroperative and postoperative)
• Achieve anesthesia 5. Trismus
• Remove the tooth with either forceps or elevators Remaining complication will be discussed in subse-
Broken or fracture of: quent chapter.
• Crown of tooth being extracted
• Roots of tooth being extracted Syncope
• Alveolar bone Transient loss of consciousness due to cerebral
• Maxillary tuberosity ischemia.
 Synopsis of Oral and Maxillofacial Surgery
10
Probable Causes Supine Hypotensive Syndrome
a. Apprehension and fear during sitting in the dental The indication of extraction in pregnancy only the
chair for injection of LA solution and for extraction third trimester, the position of the patient during the
procedure. treatment is very important. If the patient is in semi-
b. Failure to achieve confidence of the patient. reclined or full supine position, fetus will compress
c. Rapid pushing of injection of LA solution or acci- the inferior vena cava, thereby interfering the venous
dental injection of solution to the vessels. return. This may be result in supine hypotensive
syndrome.
Prevention By turning the patient to the left side either in the
a. Reassurance. sitting or in the relying posture, pressure on the vessels
b. To achieve confidence of the patient with soft can be avoided.
conversation.
c. Anxiolytic medicine prior to surgery. Diazepam Pain, Which Includes Dry Socket (ASD)
(5 mg) day before surgery night and one dose half
Post-extraction pain is mainly due to surgical induced
an hour before surgery.
trauma. Any suitable anti-inflammatory analgesic is
d. Patient should not come with empty stomach.
suitable for eradication of above problem.
Clinical Features
Dry Socket (Alveolitis-Sicca-Dolorasa)
a. Pallor (skin and mucous membrane).
b. Abnormal sweating and respiration. Dry socket the term coined by Crawford (1896),
c. Cold calmy skin, fall of blood pressure, reduce characterized by local complication of tooth extraction.
pulse rate. Many other descriptive terms used in time to time,
d. Feeling of nausea, tongue and lip become pale starting from:
(very important sign). • Necrotic alveolar socket by Alling (1959).
• Alveoalgia by Bjercke (1960).
Treatment • Alveolar osteitis by Shafer (1974).
a. Change the patient position. Sitting to supine. Head • Localized osteomyelitis by Israel (1976).
should be lower than feet (15o Trendelenburg
position). The Probable Causes
b. Flashing the face with cold water. a. Undue trauma during extraction.
c. Therapeutic oxygen inhalation. b. Pre-existing infection.
d. Sp. Ammon Aromaticus (stimulant haustus). c. Disturbances of the clot may be due to vigorous
e. Glucose drinks. mouth wash or violent curettage.
f. Injection dexamethasone if necessary. d. Increase fibronolytic activity.
g. Injection mephetemine sulphate is given in case of e. Localized impaired vascular supply.
fall of BP. f. Smoking and use of oral contraceptive increases
h. If the pulse is extremely weak, injection atropine the incidence.
sulphate is given slow IV 0.6 mg diluted in 5 ml
distilled water till the pulse become palpable.
Clinical Features
If extraction was completed, carefully, observe
the patient at least two hours, before leaving the a. Continuous throbbing and excruciating pain may
patient. Check the pulse and BP. If extraction is not refer to other areas.
completed patient may be release after recovery. And b. History of extraction 48 to 72 hours before.
inform the patient to come the next convenient dates. c. The alveolar socket covered with grayish necrotic
Sympathetic behaviour is essential for treating the tissues.
above problems. d. Denuded alveolar bone with halitosis.
 Exodontics or Exodontia
11
Treatment e. Chymoral (Chymotrypsin enzymes) may be
prescribed to reduce the swelling.
a. Obtained LA.
b. Irrigation with warm saline or antiseptic sol. like Emphysema
chlorhexidin for removal of dead bone if any or
infected tissues. a. This is due to the air entrapment in the tissue
c. Curettage is contraindicated. planes, use of air instruments during cutting the
d. Obtundant soothing dressing, i.e. ZOE mixed with bone. This can be avoided non-inclusion of air
cotton to cover denuded bone or whitehead instruments.
varnish packs are also used. b. The features may be detected by tender palpation
e. A suitable paste composed of water-soluble waxes: of crackling sound.
Polyethylene glycol incorporating with lignocaine
hydrochloride and domiphan bromide and Bleeding (Paroperative, Reactive
distilled water. The material slightly softens with and Postoperative)
warm and inserted painlessly into the socket.
• During extraction
f. Whitehead varnish (composition of WHV Benzoin
• Reactive bleeding after 24 hrs
10 parts prepared Storax 7.5 parts, Balsum of Tolu
• Post-extraction after 48 to 72 hrs
5 parts, Iodoform 10 parts, solvent Ether 100 ml)
soaked with cotton gauge. After drying the gauge During Extraction or Paroperative Bleeding
this can be used as pack or dressing.
g. A course of suitable antibiotics, analgesic, and Careful about tender handling of the soft tissue and
reassurance to the patient. alveolar bone. It will definitely help to control parope-
h. Follow up with frequent visit. rative extraction bleeding. Undue trauma causes
damaging the nutrient vessels of the bone.
The reactive bleeding: It is mostly due to the rise
Postoperative Swelling
of blood pressure in some patient because of
This may due to haematoma, that means the collection apprehension and fear of post-extraction bleeding. The
of blood during surgical maneuver in the tissue planes semi-supine position preferably sitting posture helps
which was not controlled prior to closing the surgical to reduce the bleeding and maximum visual and
wound. mechanical access can be achieves to control the above
problem.
Management Treatment includes reassurance. Diazepam 5 mg
at bed time/if necessary antihypertensive treatment
a. Control bleeding prior to closure the wound.
with consultation of physician or cardiologist.
b. Application of ice extraorally, consumption of
chilled water. Postextraction Bleeding after 48 to 72 hours
c. To avoid infection a suitable antibiotics.
d. Chymoral (Chymotrypsin enzymes) may be The postextraction bleeding is mostly due to infection.
prescribed to reduce the swelling and non-steroidal The toxin liberated by the local bacteria digested the
clot.
antiflammatory like ibuprofen with paracetamol
or injection diclofenac Na IM daily for 3 days. Management of Bleeding may be Summarized as:

Postoperative Edema 3P and 3S

3P
a. This is due to surgical handling of the tissue and • Pressure
liberation of certain enzyme like substance • Pack
histamine and heparin. • Posture
b. Management includes careful handling of the 3S
tissue. • Saline
c. Frequent saline mouth wash after 24 hours. • Styptic
d. To avoid infection a suitable antibiotic. • Suture
 Synopsis of Oral and Maxillofacial Surgery
12
a. Treatment modalities may be a combination of peroxide. Control of bleeding by pressure pack and
both or according to the case sutures.
b. Bleeding from the capillary bed presented by e. Then suitable antibiotics are the main treatment
oozing of blood modalities as because the cause is due to infection.
c. Controlled-method application of local haemo- f. Analgesics to relieve pain and above selected
static (styptic) like adenochorome monosemi- measures may be used.
carbazone (locally and systematic methods)
d. EACA (Epsilon aminocaproic acid) (local and Some Analytical Observation
systematic)
Certain bleeding disorders should consider with
e. Ethampsylate (local and systematic)
careful judgment and consultation with hematologist,
f. Oxidized cellulose (Oxycel, local)
prior to extraction if removal of tooth is absolutely
g. Human thrombin powder (local)
necessary. The main bleeding disorders are:
1. Hemophilia
Surgical (Oxidized Cellulose)
2. Purpura
a. It is glucose polimer based, sterile knitted fabric 3. Leukemia
by the control oxidation of regenerated cellulose
(local hemostatic). Hemophilia
b. Fibrin glue (local hemostatic). It is a biological
adhesive, composed of thrombin, fibrinogen and a. If AHG is 25 to 50 percent of normal – patient do
factor XIII and aprotinin. not suffer from bleeding unless major trauma and
c. Thrombin converts fibrinogen to unstable fibrin 10 to 25 percent with minor trauma.
clot, factor XIII stabilize the clot and aprotinin b. CT shows within normal time limits with factor
prevents its degradation. VIII above 1 to 2 percent, severe hemophilic have
d. Hemolock (Feracrylum HCl) 0 percent AHG.
e. Pressure and pack with soaked and dried with c. Replacement of factor VIII from:
white-head varnish gauge. • Fresh whole blood.
f. Suture if necessary. • Fresh and frozen plasma.
g. Bleeding from the arterial wall mostly due to • Cryoprecipitate AHG preserve from human
trauma or injury. The spurting of blood, frank red plasma.
in colour. d. Extraction method in case of hemophilia:
Anesthesia particularly block is absolutely
Management contraindicated. Injection of LA can be given to the
periodontal membrane that is Malamed intraliga-
a. Catch hold the artery and ligation. mentary anesthesia.
b. Surgical diathermy. e. GA: Nasal inhalation after full pre-medication is
Or satisfactory. Orotracheal tube is passed in direct
c. Electrocoagulation/Argon beam coagulator vision. Diazepam 5 mg IV and pentozocin lactate
(a superior form of electrocoagulation method 40 mg IV.
using Argon gas). f. Preparation of hemorrhagic splint. Use of oxidized
cellulose.
Bleeding from the Bony Bed g. Extraction should be done with caution and should
a. Crush the nutrient vessels supply the bone by blunt be atraumatic.
instruments or artery forceps. h. Squishing the socket and packing with white head
b. Application of Horsley’s bone wax (Bees wax 7 varnish.
parts, olive oil 2 parts, phenol 1 part). 1. Postoperative: Patient is sitting position, absolute
c. After control suture with pressure pack. bed rest with no suture. No talking, no hot drinks,
d. Postextraction bleeding usually the disturbances no aspirin, no alcohol. Apply barrel bandage liquid
of clot and due to intervention of infection. After diet. Paracetamol for pain may be phenobarbiton
obtain L A removal of infected clot. Irrigation with Na 30 mg at night. During extraction injection of
normal saline or povidone iodine or hydrogen EACA in a dose of 0.1 gm per kg body weight.
 Exodontics or Exodontia
13
Following extraction oral EACA 1gm per kg body b. Grazing of the needle, i.e. needle trauma causes
weight for every 6 hours for seven to ten days. injury to the soft tissues during block anesthesia.
Morning of operation, transfusion of cryopre- c. Postextraction trismus may be due to persisting
cipitate AHG to design to raise factor VIII level to infection of the extracting tooth.
50 percent of normal. No further cryoprecipitate is d. Management
given unless the patient bleeds (Rizza Regimen • Suitable antibiotic.
’74). • Anti-inflammatory analgesic.
2. Purpura: Purpura is a bleeding disorder. The • Muscle relaxant (diazepam 5 mg at bed time
patient complains of bleeding following surgery. for 7 to 10 days).
Consultation and clearance are mandatory from • Frequent warm saline mouthwash.
hematologist prior to surgery.
3. Leukemia: Avoid surgical procedure. Consultation BIBLIOGRAPHY
and clearance are mandatory from hematologist 1. Evans BE. Local haemostatic agents. NY J Dent 1977;47:109-
prior to surgery if at all necessary. 14.
2. Olson, et al. A comparative study of polylactic acid, gelfoam
Trismus and surgicel in healing extraction sites. Triple O 1982;53:
441-49.
a. Postextraction trismus is mainly due to infection 3. The Extraction of Teeth. GL Howe.
via the needle transmitted into the muscle plane. 4. Textbook of Oral Maxillofacial Surgery. Gusta Kruger.
FOUR
Impaction
• Definition • Classification of Various Impactions Including Lower Third Molar,
Upper Third Molar and Upper and Lower Canine • Importance of “WAR” Lines
• Diagnosis • Clinical Features • Investigation • Various Treatment Modalities
• Complications

Definition of Impaction c. Congenital syphilis

d. Tuberculosis
An impacted tooth is one, which fails to either erupt
e. Endocrine dysfunctions
partially or totally in its normal place in the mouth
f. Malnutrition.
due to inadequate of space, and obstruction of an
3. Rare condition:
adjacent tooth or teeth or soft tissue and bone, beyond
a. Cleidocranial dysostosis
its chronological age of eruption.
b. Progeria
An unerupted tooth is the one, which has not c. Achondroplasia
perforated the oral mucosa, and a malposed tooth is d. Cleft palate.
one, which is in an abnormal position and may be
erupted or un-erupted. The Consensus and the Criteria for Surgical
Berger suggested the following local and systemic Intervention for Removal of a Third Molar
causes of impaction. 1. Recurrent pericoronitis.
2. Caries not ameanable to restorative measure.
Local Causes 3. Dentigerous cyst.
1. Irregularity in the position and pressure of an 4. Internal and external resorption.
adjacent tooth. 5. Periodontal disease to which the third molar was
2. The density of the overlying and surrounding bone. contributing.
3. Long continued chronic inflammation with
resultant increase in density of the overlying Sequence of Impaction of Teeth
mucous membrane. According to Harry Archer (1975)
4. Lack of space due to underdeveloped jaw. 1. Upper third molar
5. Unduly long retention of the primary teeth. 2. Lower third molar
6. Premature loss of the primary teeth. 3. Upper canine
7. Acquired diseases such as necrosis due to infection 4. Lower canine
or abscesses and inflammatory changes in the bone 5. Lower premolar
due to exanthematous diseases in children. 6. Upper premolar
7. Upper central incisor
Systemic Causes 8. Lower lateral incisor
1. Prenatal causes
Classifications of Lower Third Molar
a. Heredity
2. Postnatal causes: All those conditions that may According to GB Winter in the year 1925 who first
interfere with the development of the child. devised a satisfactory classification of third molar on
a. Rickets the basis of the long axis of the impacted third molar
b. Anaemia in relation to long axis of the second molar.
 Impaction
15
The position of the impacted tooth to the long axis Position B : The highest portion of the tooth below the
of the second molar: occlusal line, but above the cervical line
1. Vertical of the second molar.
2. Horizontal Position C : The highest portion of the tooth on a level
3. Inverted with or below the cervical line of the
4. Mesioangular second molar.
5. Distoangular
6. Buccoverted Some Considerations and Observations Regarding
7. Lingeoverted the Complications During Surgical Intervention
8. Unusual position
(Fig. 4.1) 1. Abnormal root curvature
Pell and Gregory classified lower third molar on 2. Hypercementosis
the basis of relation of impacted tooth to ramus of the 3. Proximity to the madibular canal
mandible and the second molar. 4. Bone density
Class–I : Sufficient amount of space between the 5. Adipose tissue
ramus of the distal of the second molar for 6. Lack of accessibility
the accommodation of the mesiodistal 7. Inflexibility of the muscles of the mouth.
diameter of the crown of the third molar.
Class–II : The space between the ramus and the distal Diagnosis
of the second molar less than the
mesiodistal diameter of the crown of the A variety of symptoms ranging from atypical facial
third molar. pain, extraoral discharging sinus, osteomyelitis, cyst,
Class–III : All or most of the third molar within the neoplasm to several types of infections involving
ramus. various important anatomical spaces. The remarkable
improvement in the field of radiology has enabled
Relative Depth of the Third Molar in Bone the dental surgeon to diagnose the situation with
Position A : The highest portion of the tooth on a level the help of varieties of X-rays ranging from periapical
with or above the occlusal line. X-ray to orthopantomograph (OPG). Diagnosis should
be based on thorough clinical examination
supplemented by radiological examination (Killey
Kay, 1975).

Clinical Examination
The offending lower third molar is usually associated
with the following signs and symptoms.
1. Pain in the region of the tooth.
2. Swelling of the face on the affected side.
3. Increasing trismus.
4. Foetor oris.
5. Enlarged, tender, submandibular lymph gland.
6. Symptoms of acute pulpitis and even an acute
alveolar abscess in case of caries in the distal surface
of the second molar or third molar, itself, due to
impaction of food debris in between the aforesaid
teeth.
Fig. 4.1: Showing from top to bottom as follows: a. Class–I type
A – mesioangular, vertical, horizontal distoangular. b. Class–II 7. Buccal migratory abscess.
type B – horizontal, mesioangular, vertical, distoangular. c. 8. Submeseteric or infection involving other
Class–III type C – distoangular, vertical, mesioangular, anatomical spaces of the face.
horizontal. d. Rare positional or uncommon impaction 9. Extraoral discharging sinus, etc.
 Synopsis of Oral and Maxillofacial Surgery
16
Radiographic Investigation Occlusal X-ray (intraoral): Advantage of this view is
that buccolingual relationship of the third molar can
For diagnosis and assessment of lower third molar,
be visible in this view.
detailed radiological investigation is needed for
efficient guidance of the operative procedures. Not Orthopantomogram (OPG): The use of panoramic
only the relative position angulations, root pattern, radiographs in the assessment of impacted and
apical variation of the impacted lower third molar is unerupted third molars have the advantage of
assessed but also the relation between the roots and examining and comparing both sides of the jaw on
the inferior dental canal, texture of the bone, root the same film. This enables the surgeon to classify the
pattern of the lower second molar need to be assessed type of impaction and predict the difficulty of removal.
radiologically. However, panoramic radiograph has it limitations
(Fig. 4.3).
Radiological Investigation of Lower Third Molar
Digital IO: Enlarged, colour image on screen in front
This includes the following varieties: of operating surgeon.
1. Periapical X-ray (I/O PA X-ray). P. A. projection
and intraoral radiograph for demonstrating the Radiographic Assessment
anatomy of the tooth and the adjacent supporting
A standard periapical radiograph of the mandibular
bone.
third molar region is mandatory.
2. Lateral oblique X-ray (preferably 30o)
Interpretation of the standardized intraoral
3. Occlusal X-ray (intraoral)
radiograph was done in terms of following points:
4. Orthopantomogram (OPG)
1. Access
5. Digital.
2. Position and depth
Periapical X-ray (I/O PA X-ray): This view is most 3. Angulation
suitable because it gives the accurate picture of that 4. Obliquity
region for detail assessment needed for diagnosis and 5. Pattern
management. According to the report of the Howe and 6. Crown shape
Payton (1960) intraoral periapical X-ray is the best 7. Inferior dental canal and
radiograph to predict relationship of the inferior 8. Bone texture
dental canal and root of the third molar. But the 9. Root pattern of the lower second molar
disadvantage of this X-ray as suggested by the many 10. Any pathology present or not.
workers was inability to perform this X-ray in case of
trismus (Figs 4.2A and B). WAR Lines of Winter (Fig. 4.4)
Lateral oblique X-ray (preferably 30o): It is considered The position and depth of the impacted tooth within
to be a suitable substitute of periapical X-ray when the mandible was determined by Winter’s line. These
periapical X-ray facility is not available or periapical were three imaginary line described as ‘white’, ‘amber’
radiograph cannot be taken due to trismus. However, and ‘red’ lines respectively. ‘White’ line was drawn
this X-ray cannot give an accurate picture like the along the occlusal surfaces of the empted mandibular
periapical X-ray.

A B
Figs 4.2A and B: (A) I/O periapical X-ray shows mesioangular Fig. 4.3: OPG X-ray shows bilateral mesioangular impactions
impaction. (B) I/O periapical X-ray shows horizontal impaction of the mandible and distoverted impaction of the left maxilla
 Impaction
17
lingual side or to both sides so that it may
completely surround the canal.
3. Narrowing of the root: This sign appeared when
the inferior alveolar canal crossed the apex and was
identified by the double periodontal membrane
shadow of the bifid apex.
4. Interruption of the white line(s): The white lines
are the two radio-opaque lines that constitute the
‘roof’ and ‘floor’ of the inferior alveolar canal. These
lines appeared on a radiograph due to the rather
dense structure of the canal walls. The white line
was considered to be interrupted if it disappeared
immediately before it reached the tooth structure,
either one or both lines might be involved. The
interruption of the white line(s) was considered to
Fig. 4.4: WAR lines of Winter. W for white line, indicate deep grooving of the root if it appeared
A for amber line, R for red line
along or perforation of the root if it appeared with
the narrowing of the inferior alveolar canal
molars and extended positively over the third molar
(Seward 1963, Howe 1985). The interruption was
region. This line indicates the depth of the impaction.
considered by some to be a ‘danger sign’ of a true
The second imaginary line (‘amber line’) was drawn relationship between tooth root and canal.
from the surface of the bone lying distal to the third 5. Diversion of the inferior alveolar canal: The canal
molar to the crest of the interdental septum between was considered to be diverted if while crossing the
first and second mandibular molars. It indicates the mandibular third molar, there was a change of its
margin of the alveolar bone enclosing the tooth. direction (Seward 1963, Kipp et al. 1980;) attributed
‘Red’ line was a perpendicular line drawn from the an upward displacement of the inferior alveolar
amber line to an imaginary ‘point of application’ for canal to the contents of the canal passing through
an elevator, a maximum convexity of impacted tooth. the root ascend during eruption of the third molar,
Howe opined that 1 mm increase length of the ‘red’ the contents are dragged upwards with it. Rud 1983
line caused three times difficult. reported a 1 percent incidence of an upward
Several factors relating to anatomy, i.e. position, deflection of the canal where it overlapped the root
classification, and angulation of the third molar helps and 4 percent when the root was grooved.
the surgeon to predict the difficulty of removal. 6. Narrowing of the inferior alveolar canal: The
Generally the deeper the impaction in bone, the more inferior alveolar canal was considered to be
difficult it is to remove. narrowed when the root of the mandibular third
Seven radiological signs had been suggested by molar was crossed by it and there was a reduction
Howe and Payton (1960) as indicative of a close of its diameter (Poyton). This narrowing could be
relationship between the mandibular third molar tooth due to the downward displacement of the upper
and the inferior alveolar canal. Four of these signs were border of the canal or the displacement of the upper
seen on the root of the tooth and the other three were and lower borders towards each other with the
changes in the appearance of the inferior alveolar hourglass appearance (Cogswell 1942, Rud 1983).
canal. Following signs are explained below: 7. The hourglass form indicated a partial encircle-
1. Darkening of the root: When there was impinge- ment of the canal or a complete encirclement or it
ment of the canal on the tooth root, there was loss might mean either or these alternatives. Howe and
of density of the root. The root appeared darker. Poyton (1960) reported 33.7 percent of teeth in a
Howe and Poyton (1960) reported that 93.1 percent true relationship with the canal to have this sign.
of the teeth in “true relationship” to the canal 8. “Bull’s eye” appearance in impacted lower third
showed this sign. molar.
2. Deflected root: Deflected roots or roots hooked
around the canal were seen as an abrupt, deviation Surgical Modalities
of the root, when it reached the inferior alveolar The various techniques of surgical removal of lower
canal. The root may be deflected to the buccal or third molar were recommended by several authorities
 Synopsis of Oral and Maxillofacial Surgery
18
like Sir William Kelsey Fry, Sir Terrance Ward. There have a posterior and an anterior limb with or without
are various methods of incision and flap design (Figs an intermediate limb. The incision should not be
4.5 and 4.6). extended too far distally to avoid:
Three main types of incision were used: i. Bleeding from the buccal vessels and anastomising
1. ‘L’-shaped, branches of lingual and facial arteries.
2. Bayonet-shaped, and ii. Careful to avoid damage to the temporalis muscle
3. Envelope incision and envelope flap. to avoid postoperative trismus.
iii. Herniation of buccal pad of fat into the operating
‘L’ -Shaped Flap: Cited from Macgregor AJ 1985 field.
This most commonly practice flap extends from a
Difficulty index of impacted lower third molar
posterior limit just lateral to the ascending ramus to
the sulcus. Incision distal to the second molar angled Angulation Depth Ramus relationship/
laterally along the ascending ramus on the bony space available
support by carrying it from the lateral margin of the MAI 1 Level A 1 Class I 1
distolingual cusp of the second molar. The total length HI/TI 2 Level B 2 Class II 2
of the distal incision is around 2 cm. VI 3 Level C 3 Class III 3
Anterior limb is the vestibular extension at the level DAI 4
of second molar. If wider exposure is desired, it can From the above table difficulty index may be calculated as
be extended anteriorly upto the first molar. The follows:
junction between the limbs may be curved and the More the number more difficult extraction
incision made in one sweep or it may be angled. This Example: DAI-4, Level B-2, Class II-2, Total score 8 that means
8 is the difficult extraction. Another example HI-2, Level C-3,
incision almost totally commits the operator to a
Class III-3, Total score is 8, so difficult extraction.
buccal approach, as it is now difficult to raise a lingual
flap.

Bayonet-Shaped Flap: Cited from

Macgregor AJ 1985
The bayonet-shaped incision has three parts – distal;
intermediate/gingival and anterior. In other words,
it goes round the gingival margin of the second and
even the first molar before turning into the sulcus.

Envelope Incision and Envelope Flap Figs 4.5A and B: (A) Design of buccal flap for lower third molar:
the distal extension follows the external oblique line of the
In its posterior part, this incision tends to be placed mandible. (B) Use of scissors to extend the incision up the
more lingually. It joins the gingival margin of the external oblique line
second molar anywhere from the lingual to the buccal
side.
The flaps should provide maximum visual and
mechanical access. Variation in flap design include
technique of detaching the buccal free gingival fibers
around all the teeth forward to include the first molar
and separating the large flap buccally.
The envelope flap design is reported to be very
much satisfactory and convenient, and which is
recommended by Walter Gurallnick 1968. It is also
claimed this flap is easier to repair and has less
postoperative complications.
Many types of flap design have been advocated Figs 4.6A and B: Showing most commonly used envelope
by Archer 1975, Koemer 1994. Basically, all of them incision and the design of envelop flap
 Impaction
19
Ward’s Incision lingual and buccal plate. Therefore, Ward 1956
advised to give a vertical stop cut at the mesial end of
Sir TG Ward 1968, made some modification of the
incision. The anterior line of the incision runs from the portion of the bone to be removed to prevent
the distal aspect of the second molar curving accidental splitting of buccal alveolar plate enclosing
downward and forward to the level of the apex of the the lower second molar.
distal root of the first molar. The second type of Late Homer C Killey and LW Kay 1985 explained
incision is used when a linguoverted tooth impaction a slightly modified view and advised to establish to
is present. The posterior part of the incision is the same vertical stop cuts, one at the mesial limit of the bone
but the anterior part commences as the junction of the to be removed and the other at the distant limit which
anterior and middle thirds of the second molar and was made at a similar depth.
runs down to the apex of the distal root of the first A chisel has a bevel and a flat surface, which affects
molar. the direction in which the instrument cuts through the
bone. In most instances, the chisel is used with the
Incision Used in Lateral Trepanation Technique or bevel towards bone to be sacrificed. However, in some
Removal of Developing Lower Third Molar by cases, ‘the use of bevel’ may be different to overcome
CB Henry, 1969 the difficulty of access in the lower third molar region.
Chisel provides a quick clean method of removing
‘S’-shaped incision was advocated from the retromolar
young elastic bone provided that the instrument is
fossa, across the external oblique ridge curving down
sharp and used skillfully. Incidence of postoperative
through the attached mucoperiosterum to run along
complications like infection, acute alveolar osteitis,
the reflection of the mucous membrane to the anterior
oedema etc. is less with the use of chisel. Healing of
border of the first permanent molar. Literature
indicated to leave a cuff of attached mucoperiosteum the bone is good Srinivasan 1994.
5 mm in width distobucally to the second molar. However, the chisel technique has certain
disadvantages. It is different and patient’s compliance
Removal of Bone (Fig. 4.7) is poor when used under local anesthesia. Chances of
mandibular fracture are relatively high with the use
Surgical removal of an impacted mandibular third of chisel. Furthermore, use of chisel may be restricted
molar involves bone, removal and there are two in case of deeply-buried impaction, impaction in
methods by which this is achieved using (a) chisels edentulous jaw and in elderly patients Killy and Kay
and mallet or (b) a surgical drill. Method of bone 1975 and Srinivasan 1994.
removal was developed by George B Winter and The other method of bone removal is with the help
Glenn Bell, Boyd Gardner, T. Austin were among those of a bur, the bone may be removed either piecemeal
who provided refinement to the technique of chisel with a large bur size No 12 round bur or vulcanite
instrumentation as an aid to dento-alveolar surgery burs or by the postage stamp method. In this
from Kurt H Thoma. technique, a small round bur No 3 is used to make a
In the mandibular third molar region, the grain of series of holes outlining the portion of the bone to be
the bone runs in an anteroposterior direction in both sacrificed and then joined up by either a bur or chisel
cut. That is a neat ad precise method of bone removal.
Cited from Prof G L Howe.
Another method of bone removal with the help of
a bur, is “Guttering”. This is done with the help of a
No 6 round bur or No 10 rose head bur. A gutter is
created in the bone along with the crown of the
impacted tooth starting from the distolingual corner.
This is an extremely useful technique for removal of
the tooth or root as it leaves a ridge of buccal bone to
serve as a fulcrum for an elevator during the delivery
of tooth. Harris, Killey and Kay.
Fig. 4.7: Removal of buccal bone by chisel. Bone removal with bur is a precise, efficient and
Decapitation of the tooth by bur useful technique—Thoma.
 Synopsis of Oral and Maxillofacial Surgery
20
Lingual Split Bone Technique
The lingual split bone technique for removal of lower
third molar was invented and introduced by Sir
William Kelsey Fry who taught this method to many
operators including Sir Terence G Ward who was a
noted exponent and improviser and popularized this
technique throughout the world.
The technique is based on special anatomical
features of the third molar region. First, a vertical stop
cut about 5 mm in height is made with a 3 mm width
chisel in the buccal cortex immediately distal to the
second molar. A second vertical stop cut will be made
about 4 mm disto-buccal to the third molar crown.
The two cuts will then be joined, and the buccal plate
covering the crown will be removed.
When completed, the rectangular window should
have a depth sufficient to permit insertion of an
elevator beneath the mesial aspect of the impacted
tooth. Any bone over the superior aspect of the crown
will be then removed. Then the chisel will be placed
on the inner side of the lingual plate at an angle of 45o
to the upper border with its cutting edge paralle to Fig. 4.8:
the external oblique line and the bevel facing lingually. a. Outline of incision for raising a third molar buccal flap
A light tap with a mallet will split off a portion of the b. Modification to create an envelope flap
lingual cortex, which will then be removed. A. Vertically-impacted third molar
The above technique is modified by Davis et al 1983 B. Horizontally-impacted third molar
and Lewis in 1980. Davis’s technique mentions not to C. Mesioangular impaction of a third molar
separate the mucoperiosteom from lingual area of D. Distoangular impaction of a third molar (Diagram from Prof
bone. The bone was released in segments to allow Moore)
tactile control of osteotome to prevent penetration of
the osteotome into soft tissue. More than one
osteotome per impaction was usually used to ensure
sharp cutting edge. Wedging the osteotome between
tooth and bone should be avoided to prevent fracture
of the mandible (Figs 4.8 and 4.9).

Lewis Modifications
Flap: A limited buccal envelope flap was raised to
avoid unnecessary stripping of the periosteum to
avoid periodontal pocketing distal to the second
molar.
Bone removal: A lingual stop cut was given
immediately distal to the second molar with the help
of a chisel. The chisel was advised to be held as parallel
as possible to the long axis of the second molar (an
angled chisel was preferred in terms of convenience).
Bowdler Henry 1969 described this method to Fig. 4.9: The lingual split bone technique originally described
remove any partially formed unerupted third molar by Sir William Kelsey Fry. Improvised and popularized all over
from patients of 9 to 18 years of age. This technique is the world by Sir Terence G Ward for removal of mandibular
known as lateral trepanation. third molar
 Impaction
21
After reflection of this flap (incision described Outline of Removal of Different Lower Third Molar
earlier) the soft tissues lying behind and below the
incision were reflected from the bone, and held away
with a Bowdler Henry retractor. A round together
bone bun in a straight hand piece was used to make a
vertical cut through the external plate at the anterior
margin of the crypt. A second cut was made at the
posterior end of the crypt at an angle of 45o from the
row of trephine holes. Then a chisel was used to
remove the buccal plate and the crypt was removed
with the help of a Warwick James elevator.
The advantages of the technique described were
excellent bone healing and no loss of alveolar bone
around the second molar.

Different Surgical Modalities Fig. 4.10: The top diagram shows an envelope flap incision for
lower left third molar depending upon the depth. It may be
This includes: finished at one or other of the two arrows anteriorly. The bottom
1. By buccal approach using chisel technique with or diagram shows the incisions for two-sided flap
without decapitation.
2. By buccal approach using bur technique with or
without decapitation of the tooth.
3. By lingual split bone technique with or without
decapitation of the tooth (in case of decapitation
of tooth bur is used or combination technique).

Outline of the Surgical Procedure

1. Incision and creation of the mucoperiosteal flap.
2. Removal of adequate amount of bone and
establishment of point of application for elevator. Figs 4.11A to D: Removal of DAI of lower third molar (A) The
3. Delivery of the tooth from its socket with or crown is uncovered and the distal part split of with an osteotome.
without decapitation. (B) This permit to access the distal bone, previously hidden by
4. Trimming of the bone by a bone file or vulcanite the bulbous distal part of the crown. (C) A straight elevator
bur. applied mesially to tilt the third molar clear of the second. (D)
Buccal application of an elevator drives the tooth upwards and
5. Toileting of the socket with normal saline or
forwards out of the socket
povidone iodine solution.
6. Control of bleeding.
7. Closure of the wound by sutures.
8. Postoperative advice and prescription.

Incision and Creation of the Mucoperiosteal Flap

The incision having three parts:
Limb A: The anterior incision started from a point
about 6.4 mm down in the buccal sulcus approxi-
mately at the junction of posterior and middle third
of the second molar, passes upwards extended upto
the distobuccal angel of the second molar at the Fig. 4.12: Removal of MAI of lower third molar with curve
gingival margin. roots by section of the distal root
 Synopsis of Oral and Maxillofacial Surgery
22
Limb B: It was carried along the gingival crevice of
the third molar extending upto the middle of exposed
distal surface of the tooth.
Limb C: Started from a point where intermediate
gingival incision ended and was carried laterally
towards the cheek at mucosal depth.
In case of unerupted tooth when intermediate
gingival incision was not needed. Then limb ‘A’ was
extended upto the middle of the distal surface of the
second molar.

Retraction of the Flap

1. Buccal and lingual flaps were reflected and then Fig. 4.13: Removal of MAI of left lower third molar. (A) Bone is
removed below the greatest diameter of the crown and below
suitably retracted. Special care was taken to avoid
the mesial convexity to make a point of application for a straight
any injury to the lingual nerve. elevator. (B) Bone is removed distally to permit the tooth to be
2. Removal of adequate amount of bone (discussed tilted. (C) It is elevated distally and then upward first by mesial
previously in detail). application of a straight elevator and then buccal application of
3. Delivery of the tooth/root: The delivery of the a curved one
tooth or root was achieved with the help of a
suitable elevator.
4. Trimming of the bone by a bone file or vulcanite
bur.
5. Toileting of the socket with normal saline or
povidone iodine solution.

Control of Bleeding
The wound was packed with moist gauze for few
minutes. After withdrawal of the pack if no active
bleeding was detected (when haemostasis was
achieved) the wound to be considered as ready for its
closure. Fig. 4.14: Removal of a HI of lower third molar. (A) Bone is
removed to expose the crown. With later mesial elevation it would
Closure of the Wound by Sutures rotate about the distal apex, but the mesial cusp would not clear
the distal surface of second molar. (B) The tooth is divided
All wounds were closed with two 000 black-braided longitudinally between the roots. The angle needed to tilt the
silk sutures, one placed immediately distal to the distal half clear of the 2nd molar is determined and appropriate
second molar and one placed midway between the bone removed distally. (C) The distal half is elevated out. (D)
The mesial half will now rotate about the mesial apex and clear
second molar and the end of the distal incision.
the distal surface of the 2nd molar

Postoperative Advice
If bleeding occurs :
1. Patients were advised to bite the pressure pack for 1. Apply gauge pressure pack and bite it firmly.
one hour. 2. Rest, sitting in an upright position.
2. Cold and soft diet for first 24 hours. 3. Tablet Ethampsylate 500 mg twice daily about 24
3. Avoid vigorous mouthwashing for 24 hours, hot to 48 hours.
drinks, hot food and alcohol. Violent exercise or 4. If bleeding is not controlled by these measures
effort. contact concerned surgeon.
4. Application of ice extraorally for one hour after 5. Hot saline mouthwash frequently after 24 hours.
surgery. 6. Removal of upper third molar if present in future.
 Impaction
23
Surgical Steps of Prof Kapadia’s Cunicular or Paragingival Single Flap,
Distal End Incision for Impacted Lower Third Molar (Figs 4.15 to 4.24)

Fig. 4.15: Incision continued. Paragingival

across from left second and first molar to
distal of second molar if third molar not
visible or distal third molar partly visible. The
knife blade now changes to BP No 15 or
can be continued with same No 11 blade,
obliquely at an angle of 45o, down to and Fig. 4.20: Showing guttering of buccal plate
across the external oblique ridge of the of bone from end of stop-cut incision to distal
mandible, down to the bone of impacted third molar crown

Fig. 4.16: Showing completion of incision, Fig. 4.21: Showing continuation of buccal
which on reaching the end of the external bone gutter to distal of third molar, but
oblique ridge then continues into soft tissue stopping short at the distolingual cusp of
for about ½ to 1 cm into the soft tissue, but second molar, without injuring the lingual
only at mucosal depth nerve

Fig. 4.17: Total reflection of single buccal

flap, and the spatulate end of the Howarth’s Fig. 4.22: Showing elevation of third molar
periosteal elevator relaxing the lingual with Coupland’s elevator, from buccal
gingiva around impacted third molar to aspect, taking support of the bony ledge of
protect and retract the lingual nerve intact bone, left at distal of second molar

Fig. 4.18: Complete exposure of operative Fig. 4.23: Showing empty socket following
field. Lingual nerve seen removal of third molar

Fig. 4.19: Buccal stop-cut dimensions,

depth of 2 to 3 mm and length 5 to 7 mm Fig. 4.24: Wound closure of the single flap,
depending on depth of roots of impacted distal end or cunicular incision with two
third molar as seen in the x-ray sutures
 Synopsis of Oral and Maxillofacial Surgery
24
Prescription Class–IV : When the impacted canine located in the
alveolar process between the lateral incisor
1. A course of suitable antibiotics to prevent infection
and first premolar and its axis is usually
before surgery or postsurgery. Preferably cap.
vertical.
Amoxycillin 500 mg three times daily day before
Class–V : When the impacted canine is located in the
surgery to be continued five to seven days. In case
edentulous maxilla.
of allergic to above drugs tab Erythromycin 500
Class–VI : When the canine is placed in abnormal
mg four times daily.
position, antral walls, infraorbital region.
• Tablet metronidazole 400 mg twice daily after
food for five days.
• Chymoral forte one tablet three times daily half Another Classification of
an hour before meal for at least three days to Impacted Maxillary Canine
avoid postoperative oedema. 1. Labial position
2. For relieving pain a suitable anti-inflammatory a. Crown is in intimate relationship with incisors
analgesics (preferably NSAI Drugs) at least 24 to b. Crown well above the apices of the incisors.
48 hours. 2. Palatal position
a. Crown near surface in close relationship to roots
Classification of Impacted Upper Third Molar
of incisors.
Classification based on the long axis of the tooth within b. Crown deeply embedded in close relationship
the bone in relation to the second molar: to apices of incisors.
1. M for mesioangular. 3. Intermediate position
2. D for distoangular. a. Crown between lateral incisor and first
3. H for horizontal. premolar roots.
4. V for vertical. b. Crown above those teeth with crown labially
5. DV for distoverted. placed and root palatally placed or vice versa.
6. BV for buccoverted. 4. Unusual position
7. Inverted. a. In nasal or antral wall.
b. Infraorbital region.
Another Classification Based on the Position of the
Impacted Tooth and the Maxillary Air Sinus
Diagnosis
The outline of maxillary air sinus looks like W and Y
1. On inspection, impacted canine may be visible
of Ennis.
partially or completely covered by mucosa or bone.
1. If the tooth is situated near to the sinus it is called
2. Absence of canine in the arch.
sinus approximation (SA)
3. Bulge and or discharging sinus.
2. If the tooth is situated away from the sinus it is
4. X-ray as IO parallax method.
called no sinus approximation (NSA)
5. Intraoral vertex occlusal X-ray.
Classification of Impacted Maxillary Canine 6. Extraoral true lateral oblique view.

Class–I : When the impacted canine is located in the

X-ray as IO Parallax Method
palate.
It may be again Two periapical X-rays of the same area are taken by
• Vertical moving the incident ray mesially or distally, by 5
• Semivertical degree angle. The interpretations are, the movement
• Horizontal of canine along with tube, the canine is placed
palatally.
According to Axial Inclination The movement of canine opposite the tube. A
Class–II : When the impacted canine is located in the canine placed labially or buccally.
labial or buccal surface. Intraoral vertex occlusal X-ray: In this process, the
Class–III : When the crown is situated in the palate and central ray passes through the long axis of the central
root is labial/buccal surface. incisors. The cross-sectional views of the teeth are seen.
 Impaction
25
Extraoral true lateral oblique view: The crown of the
impacted tooth lying in front of anterior surface of
roots of central incisors—it is placed labially.
It lies behind the anterior surface of the roots of
central incisors—it is placed palatally (Fig. 4.25).

Classification of Mandibular
Impacted Canine
Classification is based on the finding of Field and
Ackerman 1935. The mandibular impacted canine Fig. 4.25:
classified as vertical normally oblique and horizontal. (A) The palatal flap, outline (in heavy print) of the incision for a
Rarely found canine impacted palatal flap raised to expose a buried maxillary canine.
1. Lower border of the mandible. (P) Position of the palatine arteries (Diagram from Prof Moore)
2. Bilateral canine impacted.
3. In mental protuberance area.
4. Migrated to the opposite side. Bone Removal
The bone over this tooth is usually quite thin and can
Surgical Modalities for Removal be removed with burs or with a sharp chisel used with
of Upper Third Molar gentle pressure by hand to avoid accidentally pushing
the tooth into the maxillary sinus. The placement of
Assessment elevator should be gentle after creation of a point of
Accessment is made difficult by the position of the application of the elevator. The other steps are same
upper third molar behind the second molar, the as mentioned before.
presence of the zygomatic buttress and the way which Surgical Modalities of Impacted Canine
the coronoid comes forward when the mouth is open.
Fortunately, in the majority cases, the molar is placed Impacted Canine
buccally covered by a thin layer of bone. The roots • Exposure for orthodontic reason, discussed in
are often small and elongated and chances of fracture separate chapter
are easily. The roots or the whole tooth sometimes may • Removal of canine
be close to the maxillary sinus. This may pushed into
the sinus or deeply placed disto angular teeth may Buccally-Placed Canine
create same problem as being pushed into the
These are extracted through a buccal incision, which
tuberosity.
is made in a long curve about 3 cm in length and at
In most of the cases, if the tooth and roots are favou-
least half a centimeter above the gingival margin of
rable, placement and application of a straight
the standing teeth. The thin layer of bone over the
Coupland elevator or straight Warwick James elevator
tooth is removed and the canine elevated from the
are sufficient to remove the upper third molar.
socket by a Cryer’s elevator and if it is disimpacted
The incision and flap sometimes require to start
then it can be extracted with forceps.
from the distul aspect of the maxillary tuberosity
forward to the middle to the distal aspect of the second
Palatally-Placed Canine
molar crown. This part of the incision should be kept
over towards the palate to expose the third molar The approach is via a palatal flap. The incision is made
without raising a second palatal flap which is often in the gingival crevice round the next of the standing
difficult to retract and may cause retching in some teeth. For right-impacted canine it extents from the
patients. The incision is then taken round the neck of upper left canine to the upper right first molar. The
the second molar to midway along the buccal of its raising of the mucoperiosteal flap is done without
crown from which point it is carried obliquely forward damaging the vessels, and the structure passing
into the buccal sulcus. The flap is reflected and held through the incisive foramen are preserve if possible.
back with the periosteal elevator. This may be divided if the access is restricted.
 Synopsis of Oral and Maxillofacial Surgery
26
In case of bilateral canines to be removed. One, 8. Impacted lower third molars have the potential
large flap is made from first molar to first molar. to spread infection in many directions: sub-
mandibular space via lingual plate, pterygo-
Bone Removal mandibular space, lateral pharyngeal space and
down the neck. Spreading laterally infection from
Bone is to be removed very accurately or carefully with
the third molar may give severe trismus with an
a medium size rosehead bur (5–9) keeping to the
extension into the sub-meseteric space.
palatal side of the buried tooth. Bone is removed until
9. a. Vessels of the palate that can be severed during
the crown is found. Then creation of a point of
operations in this region. Ligation of the
application of elevator, for removal of the tooth.
vessels by means of a “stick tie” through the
Sometimes decapitation of tooth may be necessary for
entire mucoperiosteum will arrest bleeding
removal. Care about not to damaging the greater
(Fig. 4.26).
palatine artery, in case of injury to the vessels a
b. Vessels located in the mucoperiosteum covering
measure recommended by late Quentein Royer known
the lingual surface of the madibular alveolar
as stick tie should be taken.
ridge. The “stick tie” method will arrest bleeding
Some Analytical Observations from a torn vessel in this region as
Regarding Impaction recommended by late Quentein Royer.
10. Recurrent pericoronitis: The pericoronitis as an
1. Avoid the injury to the nutrient vessels present in infection or imflammation involving the soft
the bony bed. In case of surgical trauma and tissues surrounding the crown of a partially
consequent bleeding, crush the over lying bone erupted tooth commonly seen in a mandibular
with a blunt artery forceps as well as burnishing third molar. Affected male female ratios are same.
the bone and application of Horsley’s bone wax. Age mostly 18 to 25 years.
2. Careful about accidental slippage of tooth or root
during per-operative period to lingual pouch, post- Pericoronitis
pharyngeal space or accidental inhalation of tooth.
• Acute
3. Interrupted suture is mandatory distal to second
• Sub-acute (importance migratory abscess of buccal
molar to prevent formation of a distal pocket, distal
sulcus)
to the second molar, postsurgery.
• Chronic
4. Placement of Bevel towards the bone to be
The above-mentioned classification is based on the
removed, otherwise Bevel’s head causes Ischaemic
severity to moderate infection of the disease.
Necrosis of the sound bone, and ultimately causes
a. Severe throbbing intermittent pain which
postoperative complications after removal.
aggravated with mastication radiating to the
5. Vertical stop cut is a mandatory dictum during
adjacent area.
bone removal of mandibular teeth. Saline or cool
b. Difficulty in swallowing (dysphagia).
water irrigation necessary during removal of bone
c. Difficulty to open the mouth (trismus).
by bur to avoid the charring of bone.
d. Regional lymph adenopathy.
6. Submeseteric space infection is more common in
disto-angular impaction, as the insertion of the
masseter muscles as the intermediate part is
floating or loosely attached below (Bransby and
Zachary), cited from Shafer. The infection and pus
may tract the least resistance path under the
masseter, which is attached to the lateral surface
of the ramus of the mandible.
7. Migratory abscess of buccal sulcus is a compli-
cation of sub-acute pericoronitis. Pus may track
buccally along the inner aspect of the buccinators
and cause a discharging extraoral sinus in relation
to the first molar and second pre molar. Fig. 4.26
 Impaction
27
e. Halitosis with milegrade of fever. 2. Davis, et al. Modified distolingual technique for removal
f. Ulceration or erosion may present in the area of of impacted mandibular third molar. JOS 1983;56:128.
gingival pad with cheek biting. 3. Harris and Seward, et al. Outline of Oral Surgery, Part–I,
1987.
Treatment Modalities 4. Henry CB. Excision of the developing mandibular third
milar by lateral trepanation BDJ, 1969;127:111-18.
a. Irrigation with warm normal saline.
5. Henry BC. Extraction of the developing mandibular third
b. Grinding of the offending maxillary third molar. molar by lateral tripanation. BDJ 1963; August 5:111–18.
c. In case of pus, drainage, 30 to 40 percent trichlor 6. Henry HB. Prophylactic Odontectomy of the developing
acetic acid used as chemical cauterization for the mandibular third molar American J Orthodontics and Oral
covering operculum. Care should be taken the Surgery 1938;24:72.
surrounding area must be guarded by cotton. To 7. Howe GL, Royton HG. Prevention of damaged to the
prevent the seepage of the chemical agent. inferior dental nerve BDJ 1960; November 1:355–66.
Sometimes the TCA may cause a burning sensation 8. Howe GL. Minor Oral Surgery, 3rd edn, 1985;109.
to the surrounding tissues. In that case, glycerine 9. Killey HC, Kay LW. The Impacted Wisdom Tooth, 2nd
will act as a soothing agent. edition, 1975.
d. Suitable pain relieving medicine, and an antiseptic 10. Kruger GO. Textbook of Oral Maxillofacial Surgery. CB
Mosby Publication.
mouthwash (preferably chlorhexdine).
11. Lewis JES. Modified lingual split bone technique for
e. Suitable antibiotics.
removal of impacted third molar. JOS 1980;38:578.
f. Sometimes after obtaining local anesthesia removal 12. Mason DA et al. Symptoms from impacted wisdom teeth.
of operculam is necessary (Operculectomy). BJOMFS, 1994;32(6):380-83.
g. Removal of offending partially erupted or 13. Moore JR et al. Oral surgery procedures for general practice.
impacted third molar. BDJ 1968;125:402-05.
14. MacGregor AJ. Impacted Lower Wisdom Tooth. Oxford
BIBLIOGRAPHY University Press 1985;53:62-63.
1. Archer WH. Textbook of Oral and Maxillofacial Surgery 15. Ward TG. The split bone technique for removal of lower
Vol. I, 5th edn, 1975;260. third molars. BDJ 1956;297-304.
FIVE
Common Precancerous Lesions
and Oral Cancer
• Lesions Mention Briefly—Definition, Clinical Features, Probable Etiology
and Management • Concepts of Tumor Immunology • Features of Oral Cancer
• Radiological Appearance of Oral Cancer • Types of Intraoral Malignancies
• Perioral Malignancies • TNM Classification • Recent Treatment Modalities

COMMON PRECANCEROUS Epidemiology reports available from studies

LESIONS/CONDITIONS conducted in different parts of India reveals the
1. Leukoplakia. prevalence rate of leukoplakia from 0.2 to 8 percent.
2. Carcinoma in situ.
Treatment Modalities of Leukoplakia
3. Oral submucous fibrosis.
(Figs 5.2 to 5.5)
4. Erosive oral lichen planus.
5. Querat’s erythoplakia. 1. Maintenance of oral hygiene.
6. Chronic interstitial glossitis in syphilis. 2. Oral prophylaxis.
7. Sideropenic dysphagia (Plummer–Vinson 3. Grinding of sharp and knife-edge tooth/teeth.
syndrome/Kelly Patterason syndrome). 4. Removal of septic tooth, roots and oral sepsis.
5. Antioxidant.
Leukoplakia 6. High doses of isotretinoin (13–cis–ratinoicacid, a
Leukoplakia is defined as a raised white patch or form of vitamin A) followed by a course of low
plaque, which cannot be scraped off easily and cannot dose isotretinoin or beta carotene have been
be attributed to any other diagnosable disease reported to reduce eliminate some leukoplakic
clinically or pathologically (Fig. 5.1). lesions. The capsule Selece-F is recommended.
Pre-leukoplakia, a precursor stage of leukoplakia 7. Surgical ablation superficial surface to be removed
is a grey or greyish-white area with a slight lobular (Burtlin’s operation).
pattern and indistinct borders.

Fig. 5.2: Ice crystal formation following application of liquid

Fig. 5.1: Leukoplakia of cheek nitrogen cryotherapy
 Common Precancerous Lesions and Oral Cancer
29
8. Mucoabrasive Surgery.
9. Surgical diathermy.
10. Cryosurgery and laser surgery.

Carcinoma in situ
This is a severegrades of epithelial dysplasia may
merge into the lesion customarily designated as
‘Carcinoma in situ’– a lesion in which the whole
thickness of the epithelium shows malignant cellular
features. Prognosis is good in case of early detection
and treatment.

Treatment Modalities CA in situ

Fig. 5.3: One hour after cryotherapy 1. Total excision, in case of small area.
2. Postsurgical management of lip lesions should
include prescribing effective actinic blocking
agents. The topical fluorouracil therapy has also
been used successfully.
3. Laser excision, in case of wide spread areas
recommended.

Oral Submucous Fibrosis

This is an insidious, chronic, complex disease affecting
the mucosa of any part of the oral cavity.
Epidemiology prevalence of the diseases varies
from 0.2 to 0.5 percent in India. The disease occurs
almost exclusively among Indians, Pakistanis,
Bangladeshis and Myanamaries, but sporadic cases
have been deserved in China, Nepal, Thailand and
Fig. 5.4: Necrotic slough after five days South Vietnam.
of liquid nitrogen cryotherapy The etiology of the diseases is still obscure but the
following factors do have some conditioning effect on
the oral mucosa:
1. Chewing of betel nut along with tobacco sometime
with sweetners and condiments, rapped in betel
leaf, the slaked lime act to realize and alkaloid
(arecaidine) from the areca nut which ultimately
causes mucosal rigidity of varied intensity.
Nutritional deficiency increases the risk and
severity of fibrosis.
2. Use of tobacco and lime.
3. Eating of excessive chilies (Capsaicin)
4. Protein and vitamin deficiency—specially vitamin
A.
5. Autoimmune phenomenon.

Clinical Features
Fig. 5.5: The healing site after 45 days of 1. Age: Patients between 20 to 40 years mostly.
liquid nitrogen cryotherapy 2. Sex: Females are affected more than males.
 Synopsis of Oral and Maxillofacial Surgery
30
3. Site: Cheek, soft palate, lips, tongue, faucial pillars, without the presence of inability to open the
pharynx and even oesophagus. mouth.
4. Continues discomfort with burning sensation 2. Early stage: Characterized by initial stage of
during consuming meals and hot spicy foods. inability to open the mouth (oral opening is more
5. Excessive salivation or dryness of the mouth. than two fingers width) along with the above
6. Altered gustatory sensation. subjective features.
7. Difficulties in chewing, swallowing, and speaking. 3. Moderately advanced stage: Characterized by
8. Progressive reduction of the oral opening. moderate degree of inability to open the mouth
9. Blanched opaque oral mucosa. (oral opening is less than two fingers) along with
10. The uvula shrunk and appears as a small fibrous the above mention symptoms with difficulties in
nodule. mastication.
11. Atrophy of the papilla of the tongue. 4. Advanced stage: Characterized by development of
12. Stomatitis, vesicle formation and/ulceration of the complete pseudoankylosis.
oral mucosa—especially of the soft palate.
13. Small, slightly elevated, irregular, leukoplakic Treatment Modalities of OSMF (Based on Modified
(white) spots on the lesion. Dictum of Prof Ravindra M Mathur)
14. Occasional tenderness—especially in the ulcerated
zones marks reduction in the movement of the soft 1. Removal of all pre-disposing factors, (omit spicy
palate and tongue. food, smoking, alcohol, pan parag, pan masala,
15. Inabilities open the mouth of varying degrees (not khainy, gutka, betal nut chewing etc.).
trismus but pseudoankylosis according to Rowe’s). 2. Removal of upper and lower third molars.
16. Presence of multiple fibrous bands involving 3. Removal of septic tooth, roots and all oral sepsis.
cheek, soft palate, lips, and anterior facial pillars. 4. Grinding of sharp edges of teeth.
17. The mucosa may be dry, firm or leathery inconsis- 5. Antioxidants, i.e. vitamin B complex with beta-
tency. carotina, selenium and zinc (one capsul daily).
6. Septilin 2 tabs three times a day (clinical experience
Clinical Classification of OSMF shows encouraging results).
7. Aquasol A (water soluble vitamin A) once a day.
Oral submucous fibrosis may be classified into the 8. Injection placentrex (extract from human placentra.
following clinical stages depending on the degree of Fitalov’s biological stimulant concept).
inability to open the mouth according to Rowe’s 9. Placentrex gel application recently used.
Pseudo-ankylosis (Fig. 5.6). Most satisfactory results obtain by intralesional
1. Very early stage: Characterized by discomfort or injection of triamcinolone (macromolecule steroid
burning sensation or ulceration in the mouth helps long acting locally, the function mainly
fibrolytic).
Recent studies showed that intralesional injection
of Interferon gamma improved maximum mouth
opening, reduced mucosal burning, increase
suppleness of the buccal tissues.

Erosive Oral Lichen Planus

This is a chronic complex dermatologic disease with
oral manifestations. It may occur in oral mucosa even
in the absence of skin lesions (Fig. 5.7).

Epidemiology
The prevalence of oral lichen planus in India varies
Fig. 5.6: Oral submucous fibrosis with nodular leukoplakia from 0.1 to 1.0 percent.
 Common Precancerous Lesions and Oral Cancer
31

Fig. 5.7: Erosive oral lichen planus

Etiologic Factors
1. Anxiety.
2. Over work. Fig. 5.8: Querat’s erythroplakia
3. Traumatism.
4. Malnutrition.
2. Anxiolytic tranquilizer:
5. Poor oral hygiene.
• Diazepam 5 mg at bedtime.
6. Chronic infection.
• Alprazolam 0.25 mg at bedtime.
7. Immunologic factors.
3. Corticosteroids topical application—
This disease commonly affects the oral mucosa and
Triamcinolone/betamethasone.
lesions may occur in the mouth even in the absence of
4. Intralesional injection—Triamcinolone.
skin lesions. Females are affected more than the males,
5. Antioxidant may routinely used (selenium zinc
usual site, cheek, lip, anterior 2/3 of the tongue and
and beta-carotina with vitamin B complex).
soft palate. Usual age third to fifth decade of life with
complain of irritation, itching, burning sensation
Querat’s Erythroplakia
during taking meal. Mucosal lesions, which are
usually multiple, generally are seen as minute white This is a well-defined plaque or patch with a bright-
papules that gradually enlarge and coalesce to form red, velvety surface which cannot be corroborated
different patterns such as the reticular, annular, clinically or pathologically to any other precancerous
plaque-like and atrophic or erosive types. This also lesion. Oral Querat’s erythroplakia is an uncommon
appears as white or yellowish-white lines arranged disease in contrast with oral leukoplakia. This lesion
in a lace-like or filigree pattern. The characteristic also occur in addition to vagina and penis. Oral
features is the striae of Wickham, oral lichen planus is manifestation seen in cheek tongue and lip, etc.
a prevalent disease in India. In some areas in South Querat’s a French dermatologist reported first the
India 1.5 percent of the population suffer from this above mentioned lesion (Fig. 5.8).
disease. The predilection site among Indians appears
to be the posterior part of the buccal mucosa. Treatment
Malignant transformation has been established in
It is a rare lesion sometimes needs excision.
some cases of oral lichen planus.
Chronic Syphilitic Interstitial Glossitis
Treatment Modalities of Erosive Oral Lichen Planus
The chronic inflammation of the tongue (syphilitic
1. Antiseptic mouthwashes—chlorhexidine, glossitis) which associated with arteritis (inflammation
povidone, iodine. of the arterial wall). Arteritis leads to proliferation of
 Synopsis of Oral and Maxillofacial Surgery
32
the intima and narrowing or occulision of the lumen • Spicy food
with resultant ischemia. The lingual papillae, • Smoking
therefore, atrophy leaving a bald tongue. Syphilitic
glossitis is often associated with leukoplakia, and ORAL CANCER
transformation to malignancy is high. The clinical features of oral cancer are as follows:
Painless swelling or pain may be later, easily bleeds
Treatment
in advanced case restriction movements of tongue
Treatment includes confirmation of diagnosis of dysphagia, deysgesia (change in the test) changes in
syphilis and treatment of syphilis along with anti- sensation (hyperasthesia, paresthesia, dysasthesia,
oxidant and vitamins. paresis or any sorts of altered feelings). Symptoms of
distant primary tumor. Inability to open the mouth
Sideropenic Dysphagia (Plummer–Vinson either partially or totally (Trismus). The regional
Syndrome/Kelly Patterason Syndrome) lymph nodes tender palpable even fixed. The
The oral manifestation atrophy of the papillae and appearance of malignant ulcer is rolled out everted
bald spot of the tongue. Tender tongue with cheek margin. The patch or plaque in form of red or reddish-
difficult and swallowing (dysphagia), a feeling of food white exofytic (rough surface) ulcerated or non-
sticking in throat and leukoplakia of the oesophagus. ulcerated red, white, pink, brownish, bluish or black
It is commonly seen a middle aged women with iron lesion.
deficiency anaemia. This symptom complex is called
Plummer-Vinson syndrome. Radiological Appearance of Oral Cancer
Radiolucency with ragged and vague borders band
Treatment like widening of the PDL. Combination of radiolucent
This includes: and radiopaque lesion with vague pattern.
1. Correction of iron deficiency anaemia. Radiopaque with vague border shows the sunburst
2. Iron with vitamins. appearance from the bone. Another important
3. High-protein diet and periodic check-up. significance is the onion skin appearance from the
border of the bone.
Some Important Predisposing Factors
for Precancerous Conditions Types of Intraoral Malignancies
These are summarized as follows: 1. Verrucous carcinoma (Akermann’s tumor)—This
6S is a clinicopathologic entity exhibiting low-grade
• Sharp tooth/teeth squamous cell carcinoma and having a striking
• Sepsis association with the habit of chewing tobacco or
• Syphilis (syphilitic glossitis) using snuff and with a better prognosis than a
• Spirit (alcohol) squamous cell carcinoma (Figs 5.9 and 5.10).

Fig. 5.9: Verrucous carcinoma (Akermann’s tumor) Fig. 5.10: Squamous cell carcinoma
 Common Precancerous Lesions and Oral Cancer
33
2. Squamous cell carcinoma (90-95 percent) Carcinogenesis
3. Malignant salivary gland tumor. The generic term for malignant epithelial tumor is
4. Mesenchymal, osteogenic sarcoma and chondro- carcinoma, and the common term used for all
sarcomas. malignant tumors is cancer.
5. Melanoma. (Greek: Karkinos = A crab)
6. Intra-alv-epidermoid CA (Shear) retitle by WHO A satisfactory definition of tumor or a neoplasm
primary intraoral CA. would be “A mass of tissue formed as a result of
7. Malignant ameloblastoma. abnormal, excessive, uncoordinated, autonomous and
8. Ameloblastic CA. purposeless proliferation of cells” – Willis.
9. Systemic: Carcinogenesis means induction of tumors.
a. Metastatic CA. Agents, which can induce tumors, are called
b. Multiple myeloma. carcinogens. The ultimate mechanisms, which caused
c. Lymphoma and leukemia. cancer, that is, allow cells to proliferate continuously,
d. Kaposi’s sarcoma. break through normal bounds and invade tissues,
10. Perioral malignancies: remain unknown. The agents are usually:
a. Cervical lymph node metastasis. • Chemical carcinogens
b. Salivary MT of parotid, submandibular gland • Radiation
c. Basal cell CA of the face. • Viruses
d. MT of the maxillary air sinus.
Theories of Carcinogenesis
TRIAGE OF LESIONS The Genetic Theory
• Low-suspicious treat and follow to observe This is the most popular theory, which suggests that
disappearance within two weeks, upgrade if cells become neoplastic because of alteration in the
appropriate. DNA. The mutated cells transmit their characters to
• Moderate-suspicious index: Referred immediately. the next progeny of cells. Evidence in support of this
• High-suspicious index: Referred emergency theory comes from all types of aetiologic agents in
measures. carcinogenesis.
Oral cancer is an epithelial neoplasia, thought to
be developed in the antecedent mucosal epithelium. The Multistep Theory
It generally begins near the basement membrane as a This is the other well-accepted and documented
focal clonal overgrowth of latered stem cells, which theory. According to this theory, carcinogenesis is a
expands upwards and laterally, replacing the normal multistep process. Example:
epithelium. In chemical carcinogenesis, there are two essential
The neoplastic process is a continuum beginning features in proper sequence: initiation and promotion
with normal epithelium progressing through: (propagation). Most cancers arise after several
Hyperplasia → Dysplasia → Carcinoma in situ → mutations, which have been acquired in proper
Invasive carcinoma (Sirnath) sequence.

Table 5.1: Triage of lesions

T N M
Primary tumor Lymph node status Distant metastases
T0 No evidence of primary tumor N0 No nodes involved clinically M0 Absent
T1 Greatest diameter < 2 cm N1 Single ipsilateral node < 3 cm diameter M1 Present
T2 Greatest diameter < 2 cm N2 Single ipsilateral node > 3 cm and
< 6 cm Multiple ipsilateral nodes < 6 cm
T3 Greatest diameter > 4 cm N3 Bilateral nodes or ipsilateral nodes > 6 cm
T4 Tumor > 4 cm with gross local invasion
 Synopsis of Oral and Maxillofacial Surgery
34
Some cancers progress stepwise: An initial dysplastic 1. Tumor-specific antigens (TSA) are present only in
change that may progress on to carcinoma in situ and tumor cells. Virally-induced tumor cells generally
then into invasive carcinoma. have antigens, that are shared by all tumors
induced by same virus, whereas, tumors induced
Immune Surveillance Theory by chemical carcinogen have antigens not shared
by other tumors induced by the same chemical
This hypothesis suggests that an immune competent
even in the same animal.
host mounts an attack on developing tumor cells to
2. The other type is a tumor-associated antigen, that
destroy them while an immune incompetent host fails
is present in tumor cells and also in normal tissues,
to do so.
e.g. oncofoetal antigens. Oncofoetal antigens are
Monoclonal Hypothesis present during normal foetal development but are
absent or very difficult to detect in normal adult
Currently there is growing evidence that most cancers tissues. Some of these antigens can be detected in
arise from a single clone of transformed cells. some malignancies and other diseases. Examples
However, no single theory can be implicated and of these antigens are:
in many tumors, more than one mechanism is a. Carcinoembryonic antigen is found on normal
involved in carcinogenesis. foetal intestine and human colon cancer,
Molecular approaches to cancer diagnosis can be smokers, and patients with cirrhosis. It is most
considered from several different perspectives and useful in monitoring the activity of disease in
molecular tests can also be discussed in terms of the recurrent colorectal cancer.
variety of molecular markers that can be assessed for b. Alpha-foeto protein is normally made by yolk
diagnostic purposes, and in terms of the different sac and liver cells of human foetus. It is also
techniques used for detecting these markers (cited found in the serum of liver cancer patients and
from Principal and Practice of Oncology by Jeffrey is a sensitive maker for disease activity.
Sklar). However, it is not specific and can be elevated
Thus, the accuracy, sensitivity and inherent in viral hepatitis.
advantage of using molecular markers can be summed Immune response to tumor antigens: The major
up as follows: mechanism of tumor cell lysis is NK cells and cytotoxic
Molecular markers are used: T-cells. However, macrophages and antibodies also
1. For primary diagnosis of cancer. participate.
2. For sensitive staging of cancer. Three major types of antibody associated with
3. For informing prognosis of a case. tumor immunity are: Cytotoxic Ab, blocking Ab, and
4. For the biologic behaviour expected of a particular unblocking Ab (the last two are controversial).
tumor. According to the concept of immune surveillance,
5. For monitoring residual disease after therapy. the immune system detects tumor cells and destroys
6. For detecting possible predisposition for deve- them before a tumor can form. The evidence
loping certain cancer. supporting this theory is provided by the obser-
7. The molecular markers commonly used in oral vation that, immunodeficient persons have a higher
squamous cell carcinoma: incidence of lymphosarcomas and leukaemias.
a. c–mye oncogene However, the occurrence of cancers in otherwise
b. The proliferating cell nuclear antigen (PCNA). immunocompetent humans indicates existence of
escape mechanisms from immune system. Some of
TUMOR IMMUNOLOGY these are as follows:
Apart from loosing control of cell division, a malignant Immunosuppression, especially in tumors of
cell may develop other abnormalities including lymphoid system is common.
formation of new or altered proteins. These proteins Blocking antibodies, large amount of tumor
may be recognized by the host’s immune system as antigens, immune complex (ab+tumor antigen) may
foreign antigens. Two types of tumor antigens can be block the host’s immune response against tumor
seen on tumor cells. antigen.
 Common Precancerous Lesions and Oral Cancer
35
There may be loss or reduced expression MHC alcoholism, however, are believed to play a role in its
antigen. production. Smoking is believed to be an important
It is thought, that, a better understanding of the factor not only in the production of oral cancer, but
interaction of cancer cells and host immune system also in the development of a second tumor after the
will lead towards effective immunotherapy of cancer. first one has been cured.
Several methods are being studied now and that
includes: Border’s Classification
1. Immunostimulation by BCG, interferons, Border classified the tumor (Squamous cell CA or any
interleukins, lymphokine activated cells (LAK), other cancer) according to the degree of differentiation
tumor infiltrating lymphocyte (TIL). of malignancy in an ascending order.
2. Passive immunization with monoclonal conjugated • In Grade- I tumors, 75 percent or more of the cells
with cytotoxin. are normally differentiated.
3. Active immunization with cancer cells. • In Grade-II tumors, 50 to 75 percent are normally
differentiated.
Immunological perspective of oral sq cells CA—shows
• In Grade-III tumors, from 25 to 50 percent are
wide range in the inflammatory response. The
normally differentiated.
plasmolymphatic response of the stromal reaction
• In Grade-IV tumors, from 0 to 25 percent are
together with the mode and stage of invasion and
normally differentiated.
vascular invasion (all are representing tumor host
As a rule, carcinomas of the lip are better
relationship) have been combined with features of
differentiated than those within the month. Of the
tumor cells population (appearance, keratinization,
latter, the carcinomas of the tongue and of the floor of
nuclear differentiation and mitosis).
the mouth are least differentiated. Squamous cell
It is also been demonstrated (1) that blast transfor-
carcinoma of the oral regions metastasizes to the
mation of peripheral blood lymphocytes, as well as
regional lymph nodes and only later to the distant
the percentage of T-cells in peripheral blood, is
organs.
significantly, lowered in patients with oral carcinomas
The erosion is shallow crater involving the surface
compared to normal subjects, and (2) that serum from
epithelium and the ulcer is deep crater damaging the
tumor patients had an inhibiting effect on trans-
whole surface epithelium and involving the under-
formation of lymphocytes in normal subjects (Bier
lying the connective tissue.
et al, 1977).
Classic Features of Malignant Ulcer
Diagnostic Procedures
1. Nodular
1. Oral exfoliative cytology
2. Lobulated
2. Toluidine blue test
3. Papillary
3. ** Biopsy
4. Fungative
• Incisional
5. Ulcerative
• Excisional
6. Deep after infection of tissues
• Punch
7. Rolled out everted margins
• Drill
8. Pain, referred pain to ear
• Fine needle aspiration cytology
9. Pain during swallowing
• Frozen section (In case of cryosurgery)
10. Salivation
11. Dysphagia
Etiopathological Observation of
12. Is able to articulate
Oral Squamous Cell CA
13. Halitosis
The cause of oral squamous cell carcinoma is 14. Local spread via lymphatic
unknown. Ill-fitting oral prostheses, actinic radiation, 15. A lump in the neck, which is palpable and tender
smoking, jagged teeth, syphilitic glossitis, and may or may not be fixed.

** Discussed in detail in subsequent chapter six.

 Synopsis of Oral and Maxillofacial Surgery
36
Treatment Modalities of Oral Cancer Various Incisions Recommended for
Surgery, which includes: Radical Neck Dissection are Follows
1. Blade 1. Crile T incision
2. Laser 2. Martin double Y incision (one is straight and other
3. Electrocautery (Surgical diathermy) is inverted)
4. Cryosurgery 3. Mcfee double ladder incision (exposure is good
5. Surgery with block dissection. repair also good)
The importance of lymphatic drainage of tongue 4. Ward Y incision
for metastasis of carcinoma via the cervical lymph 5. Hockey stick incision or reversed J incision (it is
nodes the following diagram will help to understand combined parotidectomy and block dissection).
the drainage system of the tongue and involvement
of cervical lymph nodes and spread (Fig. 5.11). Chemotherapy (Seldom Use Alone)
Common chemotherapeutic agents used:
Radical Neck Dissection 1. 5-Flurouracil
Remove the cervical lymphatic channels and in order 2. Cisplatin
to eradicate regional metastatic disease as originally 3. Methotrexate
described by Crile dissection was usually perform 4. Cyclophosphamide
after the tumor was controlled by radiation therapy. 5. Adriamycin
However, theory today dictates that resection of 6. Bleomycin
the primary cancer and neck dissection occur Chemotherapy via superior temporal artery by
simultaneously either in continuity or enblock. perfusion technique recommended by PY Holoye.
Composite resection and commando operation. Bleomycin for four days infusion, then after 24 hours
Radiation therapy either pre or postoperatively as an rest followed by cyclophosphamide vincristin
adjunct to surgical treatment. (Oncovin) methotrexate and 5-flurouracil (BCOMF)
another alternative BCMF, surgical adjunct
Clinical Staging of Cervical Lymph radiotherapy.
Nodes Metastasis by Anderson
Irradiation (External or Interstitial)
N0 : Negative Radiotherapy by external beam :
Nx : Single excise 1. Cobalt
N1 : Single node < 3 cm 2. Caesium
N 2A : Single node > 3 cm Interstitial irradiation technique with 137caesium
N2 B : Multiple unilateral nodes 192
iridium hairpins and looped are used.
N 3A : Unilateral fixed nodes External and interstitial therapy the dose
N3 B : Bilateral nodes reciprocity relationship to tumor size.
Tumor Radiation Implant
diameter dose (c Gy)
External Beam
<1 cm 0 7,000 – 7,500
>1 cm but < 2 cm 3,000 4,000 – 4,500
>2 cm but < 3 cm 4,500 2,500 – 3,000
>3 cm 5,500 0

Assuming 275 to 300 c Gy per fraction 5 fractions

per week according to Stfford and Waldron 89.

Surgery with Radiation with Neck 4000 – 4500 r

Before radiation 11 percent carbamide per oxide
Fig. 5.11: Lymphatic drainage of tongue dissolved in 9 percent mepivacaine HCl intratumoral
 Common Precancerous Lesions and Oral Cancer
37
injection to improve the oxygenation of tumor cells- 6. Cox SC, et al. OSMF. A review. Aust Dent J 1966;41:294-99.
(Bragg method) Pizer. The idea prior to radiation the 7. Daftary DK, et al. Risk Factors and risk Marker for Oral
above treatment may help better acceptance of Cancer in high incidence area of the world. Oral Cancer
1991;Vol. II: 29-63.
radiation. Co – 60 needle @ 200 r in one treatment
8. Govan’s Illustrated Pathology, 2nd Ed.
tissue dose repeated two to three weeks. 9. Grushka M, et al. Burning mouth syndrome. Dent Clin
North Ameri 1991;35:171-84.
Immunotherapy (Clinical trial) 10. Hague MF, et al. Interferon gamma may reverse OSMF. J
Oral Patho Med 2001;30:12-21.
Major Complication of Oral Cancer Treatment 11. Harshmohan. Theories of carcinogenesis. Essential
1. Surgical defects lead to aesthetics and functional Pathology, Chap 21, 242-50.
12. Lai DR, et al. Clinical evaluation of different treatment
problems. methods for OSMF. J Oral Patho Med. 1995;23:65-69.
2. Radiation caries and dental infection, osteomyelitis 13. Martin, et al. Application of Toluidine blue as diagnostic
and osteoradionecrosis. adjunct. Triple O with Oral Radio and Endod. 1998;85:444-
3. Soft tissue infection may be bacterial fungal and 46.
viral. 14. Pindbog JJ, et al. A follow up study of 61 oral dysplastic
4. Mucositis. precancerous lesions in Indian villagers. Triple O
5. Xerostomia (Dryness of the mouth). 1977;43:383-90.
15. Pindborg JJ. Oral Cancer and Precancer.
16. Silverman S, et al. Oral leukoplakia and malignant transfor-
BIBLIOGRAPHY mation. Cancer, 1984;53:563-68.
1. Bishop JM. Molecular themes in oral onchogenesis. Cell 17. Sankaranarayanan R, et al. Chemoprevention of oral
1991;64:235-48. leukoplakia with vit A and beta carotene: An assessment
2. Bouquot J, et al. Leukoplakia, lichen planus and other Oral Oncol 1997;33:231-36.
keratosis cysts. Triple O 1986;61:371-81. 18. Sanyal Bipradas. Tumor Immunology. Personal Communi-
3. Bouquot J, et al. Reviewing oral leukoplakia clinical cation.
concepts. JADA 1991;1222:80-82. 19. Schildt EB, et al. Oral snuff, smoking habits and alcohol
4. Bouquot, et al. Erythroplakia, the dangerous red mucosa. consumption in relation to oral cancer. Int J Cancer, 1998;77:
Pract Perio Aesth Dent 1995;7:59-68. 341-46.
5. Brgdehi M, et al. Burning mouth syndrome, prevalence and 20. Vander Wall T. The Burning Mouth Syndrome.
associated factors. J Oral Patho Med 1999;28:350-54. Copenhegen, Munksgaard, 1990.
SIX
Biopsy
• Definition • Various Types • Principles • Instruments • Importance as a
Diagnostic Aid in Oral and Maxillofacial Surgery

DEFINITION Incisional Biopsy

Biopsy is the histopathological study of tissues remove Incisional biopsy used when the lesion is large and
from leaving body, for confirmative diagnosis for irregular, and there is a need to study the border zone
evaluating the cancerous or pre-cancerous nature of a of the lesion. An incision biopsy should always include
lesion. It can be of various types: tumor tissue, border zone and adjacent normal
1. Incisional biopsy mucosa.
2. Excisional biopsy
3. Aspiration biopsy Excisional Biopsy
4. Drill biopsy It is the removal of the lesion into, for histopathologic
5. Punch biopsy examination. Lesions of 1 cm or less are ideal for this
6. Exfoliative cytology type of procedure.
7. Fine needle aspiration cytology
Aspiration Biopsy
Principles of Biopsy It is useful in deep-seated inaccessible sites. This is
performing by using a large caliber needle and a glass
1. Select most suspicious area, which may turn into
syringe. It is used for cystic lesions to identify the true
malignancy.
nature of the contents of the fluid.
2. Avoid necrotic ulcerative area of the lesion.
3. Local anesthesia to be injected the surrounding Examples: Straw colour of fluid in case of dentigerous
areas. cyst. Shining appearance of the keratin fluid and
4. Include normal tissue margin, should be straight peculiar smell and viscosity of the same, in case of
not beveled. odontogenic keratocyst. Wine colour of the aspirated
fluid suggested the cystic ameloblastoma and the
Instruments for Biopsy aspirated frank blood suggested hemorrogeic lesiosn
like aneurysmal bone cyst AVS hemorrhagic bone cyst
The instruments required for procedures are: or central haemangioma.
1. Non-serrated tweezer
2. Curved scissor Drill Biopsy
3. Bard Parkar blade no. 11
4. Bard Parkar handle no. 3 It is rarely done in case of central lesions that mean
5. Five mm biopsy punch the pathology within the bone. The incision was made
6. Disposable syringe with needle 26 G on the overlying mucosa and makes a window by use
7. Two percent Lignocaine HCl with 1: 80000 of drill to collect the tissue for the histopathological
Adrenaline HCl (3–5 ml) study.
8. Suture material 000 black silk
Punch Biopsy
9. Needle (½ inch, ½ circle curve cutting needle)
10. Ellis artery forceps It is advocated when the lesion is uniform in
11. Fixative solution (10% Formosaline). appearance, the area to be biopsied is not very large
 Biopsy
39
and when the adjacent normal tissue is not required Class III : The cells wider atypia may be suggested
for histologic examination or for comparison. cancer
Class IV : Suggestive cancer
Exfoliative Cytology Class V : Positive for cancer and biopsy is mandatory.

It is the study of superficial cells, which have been Fine Needle Aspiration Cytology
either exfoliated or shaded naturally from mucous Advocated by Ward in 1912, simple, safe, fast,
membrane. It is quick lab procedure to evaluate mass inexpensive, atraumatic, dependable and effective
screening of oral cancer. Exfoliative cytology easy method of tissue sampling for pre paroperative
quick procedure, local anesthesia not required. diagnostic technique, with Silverman needle. It is
Common staining can be applied. Unsuitable for possible to get a strip of intact tissue 1.5 mm width
diagnosis for malignancy. No significant complication. and 1.5 cm long which can be sectioned and studied
Evaluates vesicular lesion study of the oral like normal biopsy. A 21-gauge needle is inserted into
epithelium changes followed by chemotherapy. the lesion and cells aspirated and smeared in a slide.
Contraindication: Deep-seated lesion and fibrous Rapid and effective acid cells fixation, stained and
lesion. examine very quickly. For deep lesions, ultrasound
or radiological guideline may be insured that the
Papanicolaou and trum stain: Interpretation of needle enters the lesion.
exfoliative cytology as follow:
Advantage: The needle divided the structures than
• Non-keratinised deeper cells—blue
cutting through them. Lever and Trott in 1985 have
• Non-keratinised superficial cells—yellow
given another useful extension FNAC or biopsy which
• Keratinised cells—red.
is transoral aspiration cytology, in sebaceous lesions
Exfoliative cytology interpretation oral cavity and destructive jawbone lesions.
Class I : Normal cells Immunostaining procedure: Quite encouraging
Class II : Presence of minor atypia method for histological diagnosis.
SEVEN
TM Joint and Its Diseases
• Anatomical and Physiological Aspects • Discussions of Various Diseases
Involving TM Joint • Hypermobility • Subluxation • Luxation • Dislocation
• Arthritis • Arthrosis • TMJDS/MPDS/Facial Arthomyalgia • Trismus and
Ankylosis of TM Joint • Classification of Trismus and Ankylosis • Comparative
Studies and Its Importance • Rational Management Including Medicinal, Surgery
and Arthroscopy

ANATOMICAL AND PHYSIOLOGICAL 3. Sphenomandibular ligament.

ASPECTS OF TM JOINT 4. Stylomandibular ligament.
5. Mandibular-malleolus ligament or ligament of
Anatomical Consideration Pinto.
TM Joint is a unique joint according to structural 6. Fibrous capsule surrounding articular tubercle
anatomy and function. Though it is a two joints (R circumferential mandibular fossa and lateral and
and L) but when it act as a unit of joint. squamatymphanic fissure below it is attached with
According to Harry Sicher, it is called a cranio- neck of the mandible. Fibrous capsule is loose
mandibular joint. It is like an atlanto-occipital joint. above the disc and tight below it.
Again the one side of the joint is divided into two joints 7. Lateral ligament: It reinforces and strengthing the
by the meniscus or articular disc. fibrous capsule. It is attached in the articular
1. Temporal meniscus joint. tubercle in the roof of the zygoma. Below it is
2. Mandibular meniscus joint. attached posterior and lateral aspect of the neck of
The TM joint is a joint, which is formed by head of the mandible.
the condyle and glenoid fossa of the temporal 8. Sphenomandibular ligament: It derives from first
bone. According to Cunninghum, it is called branchial arch. It is arises from the spine of the
glynglimoarthroidal joint (sliding hinge joint). TM sphenoid. It is attached below inferiorly in the
joint type condyloid subtype synovial structurally and lingualae of the mandible.
modified hinge joint functionally. 9. Stylomandibular ligament: Arises from the lateral
The component of TM joint: The articular disc or aspect the styloid process of temporal bone. Below
meniscus. Articular disc previously called as fibro- it is attached inner surface of the ramus and angle
cartilagenous disc. Nowadays it is called as fibrous of the mandible.
capsule. Sometimes it is considered as extention of the 10. Arterial supply: Superior temporal artery of ECA
lateral pterygoid muscle. It is an oval shape thick in branch.
the periphery, thin in the centre. Upper border is 11. Mesenteric branch of maxillary artery.
concavo-convex and the lower border is concave to 12. Nerve supply: Auriculotemporal nerve of posterior
accommodate to the head of the condyle. It is division of mandibular nerve.
surrounded by synovial membrane and the synovial 13. Mesenteric nerve of anterior division of
fluid provides nutrition, lubrication and act as shock mandibular nerve.
absorbers of the joint.
The following ligaments are essential components Physiological Concept
of TM joint. A reflex arc mechanism is present involving sensory
1. Fibrous capsule. nerves of the capsule and posterior attachment of the
2. Lateral ligament or temperomandibular ligament. meniscus and motor fibers of the muscles of
 TM Joint and Its Diseases
41
mastication, primarily the external pterygoid muscle. The terms ‘luxation’ and ‘dislocation’ are
It is thought that prematurities or decreased vertical synonymous.
dimension cause the condyle to exert pressure on the Laskin (80) defined dislocation as, it is a deran-
sensitive loose connective tissue attached to the gement between the articulating components of a joint
posterior aspect of the articular disc. This results in that is not self-reducing.
triggering a reflex nerve arc to relieve the pressure, As stated by MG Lawlor (82) dislocation is defined
which may results in dislocation (Schwartz, Miller and as a displacement of the condyle in front of the
Murphy et al). articular eminence where it is held by spasm of the
Wyke’s concept is that all the synovial joints of the muscles of mastication.
body are provided with a quadruple array of Dislocation of the temporomandibular joint occurs
corpuscular (mechanoreceptors) and noncorpuscular when the condylar head travels anterior to the
(nociceptor) receptor endings with individually articular eminence on maximal incisal opening and
characteristic properties of behaviour and different becomes locked in front of the eminence such that the
distributions in the articular tissues. TMJ also has four patient is unable to close the mouth.
receptor systems. Type I, II and III are mechano-
receptors and Type IV is nociceptive. According to Clinical Classification
Mariano Rocabado (83) Type I mechanoreceptors
William Irby, the famous American authority
assisted by type II contribute to reflex regulation of
classified the various abnormalities associated the
postural movement and to perpetual awareness of
excessive forward movement of the condylar heads
mandibular position.
which as follows:
1. Hypermobility (subluxation) without pain.
Hypermobility
2. Hypermobility (subluxation) with pain.
According to Ralph G Merrill (92), hypermobility of 3. Habitual dislocation (can be reduced by the
temporomandibular joint is characterized by excessive patient).
anterior movement of the condyle in all directions. 4. Fixed dislocation (can not be reduced by the
As mentioned by Mr Zetz and HB Kaufman (80) the patient).
term “hypermobility” is very much confusing when 5. Acute or initial dislocation (the first dislocation,
used to the TMJ. Because it is more likely a normal which generally can not be reduced by the patient).
condition rather than pathology for a large segment 6. Chronic or recurrent dislocation (dislocation that
of population. As stated by DM Laskin (80), radio- tend to recur on a periodic basis and generally can
graphically the condyle may be translated anterior to not be reduced by the patient).
the eminence as far as 5 mm. This radiologic feature 7. Permanent or prolonged dislocation (dislocation
may not be diagnostic of any pathology, i.e. of the condyle or condyles that has persisted for a
subluxation or dislocation. According to Laskin (80), significant period of time without reduction).
Zetz and Kaufman (80), because the individual Millar Murphy et al and Tiecke consider certain
showing this sign may absolutely asymptomatic. predisposing factors for TM joint dislocation.
1. Birth-related forceps delivery and congenital
Subluxation weakness of the articular ligaments.
Subluxation defined as a self-reducing derangement 2. Traumatogenic.
between the articulating components of a joint that is 3. Iatrogenic. Which includes:
associated with symptoms of pain, clicking or a. Prolonged dental procedures.
momentary locking, Laskin (80). b. Traumatic dental extractions.
Subluxation as a partial dislocation of the joint with c. Injudicious use of mouth prop.
temporary locking of the jaw which is self-reducing d. Manipulation under general anesthesia.
Langdon et al (91). e. Improper use of laryngoscope or bronchoscope.
According to Merrill (92), in subluxation of the 4. Drug: Reserpine and henothiazines.
temporomandibular joint the articular surfaces 5. Physiologic:
maintain partial contact and the condyle is able to a. Yawning.
return to the glenoid fossa voluntarily or aided by self- b. Sneezing.
manipulation. c. Extreme opening.
 Synopsis of Oral and Maxillofacial Surgery
42
6. Systemic: Epilepsy and other involuntary muscle
contractions.
7. Long-term over-closures secondary to loss of
dentition as a result of loosening of the joint
capsule.
Radiographic evaluation: OPG demonstrates
dislocation as the condylar head is anterior to the
articular tubercle after maximum oral opening
(Lawlor, 80).
Lateral oblique transcranial radiograph and lateral
tomograms (Merrill 92) are important in identification
and documentation of dislocation. The condyle
becomes superior and anterior in luxations and
subluxations.
Fig. 7.1: The resected triangular flap,
Treatment Modalities capsular plication procedure

Conservative Method
1. Reduced condyle by Hippocrates recommended
measures. Dislocation can usually reduced by
inducing downward pressure by both thumbs on
the posterior teeth and subsequent upward
pressure on the chin by remaining fingers. Simul-
taneously pushing posteriorly of the entire
mandible. The operator should stand in front of
the patient.
2. Rest of the joint. Sometime immobilization may be
needed.
3. External heat.
4. Vapocoolant spray.
5. Short-wave diathermy.
6. Analgesics, muscle relaxants and sedatives. Fig. 7.2: The wound of the TMJ capsule after
7. Occlusal adjustment by grinding the tooth resection one of the triangular flap
(according to Law of Bull, i.e. buccal cusp of upper
and lingual cusp of lower).
8. Physiotherapy in the form of exercise.
9. Intra-articular injection of corticosteroid
(sometimes recommended).

Surgical Methods
Operation for recurrent dislocation (Figs 7.1 to 7.9):
1. Capsule tightening procedure.
a. Chemical capsulorrhaphy: Use of injection, 5
percent sodium psylliate or sodium tetradecyl
sulphate.
b. Surgical capsulorrhaphy: Tightening the
capsule by sutures.
2. Lateral pterygoid myotomy (Laskin 1973, Miller Fig. 7.3: Radiographic appearance of the anterior translation
and Murphy 1976). of the left condyle after capsular plication procedure
 TM Joint and Its Diseases
43

Fig. 7.4: Picture shows the expose articular Fig. 7.6: Picture shows the bur holes
eminence following surgical dissection drilled in the articular eminence

Fig. 7.5: The radiographic appearance shows the anterior Fig. 7.7: The radiographic appearance of the movement of
translation of the left condyle after articular eminectomy the right condyle following articular eminectomy

3. Plication of TM joint ligaments (Hudson and Spire). Injury to the TM Joint Causes
4. Raising the hight of the articular eminence by down Complications as Follows
fracture of the zygomatic bone (Dautrey 1975,
Lawlor 1982). Arthrosis
5. Eminectomy and meniscectomy (Myrhaug 1951) Non-inflammatory conditions characterized by
allow to condyle to move freely. According to clicking or locking joint due to damage of the articular
William Irby (80), the Norwaian surgeon Myrhaug disc and capsule. The suggested cause are a
operation still popular, simple and highly traumatogenic occlusion with cuspal interference on
successful. Wanderkwast Scandinavian Authority closing; over-closure of the vertical dimension of the
recommended this technique still today. bite due to extraction of the posterior teeth or recession
 Synopsis of Oral and Maxillofacial Surgery
44

Fig. 7.9: The picture shows the smoothening of the bone in

the resected articular eminence area with vulcanite bur

Fig. 7.8: The picture shows the eminence

is being separated by a flat chisel articular surface of the joint. X-ray shows sometimes
condylar lipping and the narrowing of the joint space.
It is affected in older age group. The TM joint suffers
of the alveolar ridges in denture wearers; and bad destruction of the cartilage on the condyle and the
habits such as grinding the teeth or abnormal chewing meniscus, with resorption of the bone of the condyle
on one side only. head, articular fossa and the articular eminence.
Diagnosis: The chief symptoms are cracking or
grating in the joint during movement and pain often Rheumatic Arthritis
referred to the temporal, cervical and occipital regions. Commonly affected middle age females about 35 to
It is usually worse on chewing or when the patient is 40 years old. Polyarthritis of the joint swollen and
tired. The affected condyle is tender to palpation, has painful joint with rise of temperature and ESR atrophic
restricted movement and an abnormal pathway on skin generalized lymph adenopathy.
opening or closing. Radiographs show no obvious
changes except possibly restriction of movement on Treatment: Salicylates and steroid as palliative
opening. Electromyography has been used recently measures.
as a diagnostic aid but interpretation of the results is Diagnosis: The symptoms are stiffness and crepitus,
still inconclusive. accompanied by occasional pain. Radiographs show
Conservative treatment eburnation and flattening of the condyle head and the
1. Rest. artiular eminence with occasional loose bodies in the
2. Rehabilitation of the occlusion. joint.
3. External heat. Conservative treatment includes:
4. Short-wave diathermy. 1. Physiotherapy.
5. NSAID. 2. Short-wave diathermy.
6. Operative treatment. 3. Antibiotic, anti-inflammatory and analgesic.
7. Arthroscopy. 4. Operative treatment.
8. Meniscectomy. 5. Arthoplasty by arthroscopy technique.

Arthritis TMJDS/MPDS/Facial Arthomyalgia

Inflammation of the TM joint: Osteoarthritis or FAM, facial arthomyalgia (Harris) is the latest
traumatic arthritis may result from damage to the terminology of TM joint pain dysfunction syndrome
 TM Joint and Its Diseases
45
(Schwartz), myo-facial pain dysfunction syndrome Clinical Features
which was also called in past as “Costen” syndrome.
1. Cusp interference were noted on closure from rest
The principal causes of TMJPDS/MPDS/FAM are
position on retruded closure, on lateral excursions
emotional, anxiety distress perspective rather than
in empty mouth and during unilateral chewing.
physical cause (Laskin and Harris).
2. Missing or displaced teeth, which suggested the
According to Bell, the FAM/TMJPDS is initially a
like-hood of unilateral chewing and cause of cuspal
problem of the masticatory muscles rather than arthro-
interference.
pathy.
3. Facets on the teeth indicating a para-functional
Pain mechanism probable release of P P substance
grinding habit were common.
due to intermuscular vasodilatation of the facial
4. Clicking noise during jaw movements was often
muscles.
the chief complaint.
Laskin described the typical clinical panaroma of
5. Deviation of the mandible to the affected side.
TMJPDS explain as four cardinal signs and two
6. Confirmed the diagnosis of a tissue disorder.
negative components.

Cardinal Signs Treatment Procedure

1. Unilateral joint pain. Counselling: This consists of explaining the condition
2. Muscle tenderness. in simple lucid manner by understandable lay term
3. A clicking and popping noise in the TM joint. with “reassurance” that recovery is likely if the advise
4. Limitation and/or deviation of mandibular is follows.
movement. Toller study (74) shows, simple reassurance and
explanation—produced improvement 80 percent at
Diagnosis 3 months with anxiolytic and muscle relaxant action
The symptoms are pain, muscle tenderness clicking like benzodiazepines. Diazepam 2 mg and 5 mg three
and locking or popping noise of the joint. Clicking is times a day for 2 to 3 weeks.
due to the condyle riding over the meniscus and
Occlusal splints: Full occlusal coverage maxillary
coming sharply into contact with the bone of the
splint to give higher, positive response (Greene and
articular fossa. It occurs late on opening if the meniscus
Laskin ’72).
is detached anteriorly, and late on closing if it is
1. The possible mechanism of beneficial effects of
detached posteriorly. Locking is due to the detached
splint reduces the muscular overactivity explained
or torn meniscus jamming the smooth action of the
by Jarabak 56, Solberg 75, Clerk et al 79 by their
condyle.
EMG studies.
There must be two negative components:
2. Splints render the premature occlusal contacts.
1. No radiographic changes in the TM joint.
3. Opening of the bite prevents terminal closure and
2. No tenderness of the TM joint when palpated
may reduce stimulation of post, part of the joint
through external ear canal.
capsule (Posterior auricular nerve).
Hamish Thompson, 87 outline the syndrome and
clinical described by the patient attended the clinic Physical therapy
from 54 to 83 of TMJPDS as follows: a. In the form of moist heat (Hydrocollator neck
1. Pain in the preauricular region during and type) 30 min/day both joints.
following mastication usually in one side only. The b. Short-wave diathermy.
pain was sometimes referred to the frontal, parietal, c. Interferential therapy (Recent addition of
and occipital neck region. Physiotherapy) (Ultrasound 3 MHz head is
2. Tenderness over ear in front of the mandibular used).
joint.
3. Limitation of opening. Therapeutic exercises
4. A clicking noise within or other joints. a. Straight opening exercise.
5. Spasm of the closing muscles on waking with b. Suprahyoid exercise.
consequent clenching of the teeth. c. Finger and thumb dilation exercise.
 Synopsis of Oral and Maxillofacial Surgery
46
4. Use of intra-articular injection of corticosteroid: capsule for selective sectioning the post-auricular
Excessive hypermobility and tendency to nerve.
subluxation of TM Joint associated with recurrent 7. A new form of conservative therapy is TM
pain dysfunction syndrome treated successfully joint arthroscopy (Sanders 86, Murakami 86,
after the acute phase is over by sclerosant therapy. Harris 88).
Paul Bradley recommended the use of one ml 8. Laser under arthroscopy control: A quartz fibre
STD (3% Sodium tetradecyl sulphate) to inject into probe is indicated when a laser is used under an
the lateral aspect of joint capsule. A single injection arthroscopy. Burning, evaporation and coagulation
is sufficient to reduce the interincisal clearance by all occur, while the physiologic saline solution is
about 2 to 3 mm. perfused for cooling the surgery region. The Nd-
5. Harris recommended the use of arthrocentesis (that YAG laser is the most suitable for this technique,
is lavage or irrigation of the upper joint cavity, since it can pass through fibres. They mostly uses
which improve the elimination of joint inflam- laser fibres of 1.5 mm outer diameter at 10 – 20 W
mation, and subsequent relives pain, and return for surgery of the joints. Tissues can be burned,
to normal function (by arthroscopy procedures). evaporated and coagulated on mere contact—no
The condylar shave, the removal of fibrous tissue mechanical force is required. As no bleeding is
affecting the joint by previous method. involved, and since visual fields are secured, the
Arthroscopy was performed with the patient under laser technique is the most suitable for arthroscopic
general anesthesia via nasoendotracheal intubation surgery.
and neuromuscular relaxation. Dexamethasone 0.5 9. As Harris ’84 believed that the pain mechanism is
mg per kg body weight and suitable antibiotic were FAM is released of P substance due to
given parenterally. Normal saline was used for vasodilatation of the facial muscles by tension,
irrigation and distention. Double or triple superior anxiety and depression (P substance hypothetical
posterolateral and anterolateral puntcher factor described by Lewis’s the substance which
technique as described by Moses ’89 was used. A produce by ischemic muscles causes pain).
systemic arthroscopic examination of the superior The use of anxiolytic tricycle antidepressants such
joint compartment was performed. After the as nortriptyline and motival is of great value of
examination arthroscopic surgery was proceed. treating these cases. Here, the use of medication for
Depending on the finding during inspection, the its centrally-acting muscle relaxant and analgesics
following procedures were carried out using effect, not as an antidepressant.
triangulation technique as per Macain ’89, which
may have the following stages or phases. Rowe’s Proposed the Limited Mandibular Mobility
a. Capsular release, lysis or resection of adhesions. into the following Categories
b. Coagulation or hypervascular tissues and retro-
1. Trismus (muscle spasm).
discal tissues, and mobilization of the disc.
2. Pseudoankylosis (mechanical interference)
c. Physiotherapy started on the first day of post-
3. False ankylosis (extracapsular in origin).
operatively.
4. True ankylosis (intracapsular in origin).
6. Denervation procedures: Thilander demonstrated
well, the rich enervation of the posterior aspect of Trismus
the capsule by the posterior auricular nerves
arising from the auricular temporal nerve. She has Definition
also shown there is also a nerve supply from the The word ‘Trismus’ is derived from Greek word
nerve to the massetor and frequently post-deep “Trismos” meaning gnashing or lockjaw.
temporal nerves. Poswillo ’75 described injecting Upto seventeenth century it was used almost exclu-
small volume of STD sclerosant close apposition sively when referring to tetenus. In the year of 1718,
to the posterior attachment of the TM Joint capsule the famous German Surgeon ‘Lorenz Heister’ gives
to achieve neurolytic action. the first scientific entity of ‘Trismus’ describing a case.
Bradely ’87 suggested a simple conservative ‘Trismus’ term is boldly used for inability to open the
surgical approach to the post aspect of the joint mouth. But in the year of 1963, IJ Berlove of UK defines
 TM Joint and Its Diseases
47
Trismus, “A condition of spasm of the jaw muscles 2. The antibiotics are most effective in trismus of
causing them to the rigid, and preventing the opening odontogenic infection involving muscles of
of mouth either partially or totally, temporarily or mastication directly, or via facial planes.
permanently”. 3. Surgical interference is mandatory according to
In 1973, Nally and Eggleston define trismus simply necessity (Removal of offending tooth or teeth,
and lucidly, “inability to open the mouth due to reflex drainage of abscess).
muscle spasm”. 4. Infraray therapy helps in localization abscess in
But, probably best in all aspect trismus is defined earlier stage and in relieving spastic condition of
by Sir Norman L, Rowe in his famous William Guy muscle due to inflammatory process.
lecture in 1981. 5. Muscle relaxant property of diazepam is widely
Trismus is mediated by the “Servo feed back” of used in practice.
arthokinetic reflex arc from proprioceptive nerve 6. Use of Brisment force. Mechanical appliance
endings in the periodontium, the muscle spindles and (Fergusion’s mouth gag, acrylic screw) is found to
the mechanoreceptors of the joint capsule via the brain be helpful in relieving trismus in post-extraction
steam to the muscles, which activate the closure of cases.
the lower jaw. 7. Trismus is not always associated with pain.
Once the existing stimulus is removed, the 8. Trismus is a reversible condition mostly and irre-
condition disappears. versible partly.
Ankylosis can be defined as stiffness or immobility
of the joint due to fibrous adhesion or bony fusion Etiology of Pseudoankylosis
within the joint or between two bones.
Trauma Depressed fracture of zygomatic bone or
arch (mechanical obstruction of coronoid
*Modified Rowe’s Classification of Trismus
process)
1. Odontogenic – MPDS (myofacial pain dysfunction Hyperplasia True developmental hyperplasia of
syndrome), malocclusion, erupting teeth. coronoid process. Relative hyperplasia due
2. Infection – Periodontitis, pericocoronitis, to short ramus in acquired deformity of the
submasseteric, temporal, peritonsiller space condyle
infection, parotitis. Neoplasia Chondroma/osteoma/osteosarcoma of
3. Traumatic – Fracture of the mandible, fracture of coronoid process
the zygoma impinging the coronoid. Miscellaneous Myositis ossificans
4. Neoplastic – Tumors involving the jaw muscles, Congenital anomalies (very rare)
retromolar fossa, tonsillar fossa, nasopharynx Submucous fibrosis
(Trotter’s syndrome).
5. Pharmacological – Some phenothiazines. Etiology of Extracapsular Ankylosis
6. Psychological – Hysterical trismus (Thoma, Kurt
Trauma Periarticular fibrosis (wounds or burns)
H)
posterior or superior dislocation (rare).
7. Neurotoxic – Tetanus. Chronic dislocation of long duration
8. Neurological – Central and peripheral lesion.
Rowe’s classified OSMF, myositis ossificans in Infection Chronic periarticular suppuration
(pyogenic/mycotic/tuberculous)
separate heading designated as pseudoankylosis (will
be discussed later). Neoplasia Fibrosarcoma of capsule (rare) Chondroma
from ectopic tissue (rare)
Some analytical observation on clinical perspective:
Radiation Periarticular fibrosis/osteoradionecrosis.
1. Treatment of trismus is primarily based on
Inhibition of condylar cellular activity
aetiological factors, clinical panaroma, and degree (child)
of myospsam.
 Synopsis of Oral and Maxillofacial Surgery
48
Etiology of Intracapsular Ankylosis 2. To achieve a functional joint.
Trauma Intracapsular comminuted fracture.*
3. To reconstruct the joint and restored the vertical
Penetrating wounds (gunshot and/or height of the ramus.
infected) 4. To improve patient’s nutrition and oral hygiene.
Forceps delivery 5. To restore normal facial growth pattern (which is
Infection Otitis media/mastoiditis
based on the functional matrix theory). An
Osteomyelitis of the jaws analytical notes. The functional matrix theory
Haematogenous concept of Melvin moss on growth and develop-
ment explain the doctrine of functional matrix
Systemic- Still’s disease (juvenile
arthropathy osteoarthritis)
complementary to the original version of functional
Ankylosing spondylitis (Marie-Strumpel component of Vander Klaaus. The functional
disease) matrix concept attempts to comprehend the
Osteoarthritis relationship between form and function. The
Rheumatoid arthritis functional matrix hypothesis claims that the origin,
Neoplasia Chondroma/osteochondroma/steoma form, position, growth and maintenance of all
Sarcoma/fibrosarcoma (rare) skeletal tissues and organs are always secondary,
Metastasis to condyle compensatory and necessary responses to chrono-
Miscellaneous Chondromatosis (“melon-seed”) loose
logically and morphologically prior even or
bodies process that occur in specifically-related non-
skeletal tissues, organs or functioning spaces.
* Particularly when bilateral, under the age of five years, or
Moss’s claims that the growth of the skeletal
associated with prolonged unconsciousness.
components, whether endochondral or intra-mem-
Universally-accepted Dictum or Protocols for the branous in origin is largely dependent on the
Management of TM Joint Ankylosis growth of functional matrices.
Recommended by Kaban, Perrot and Fisher 90 6. To improve cosmetics and rehabilitation of the
patient.
1. Should obtain the easy visual access and sufficient 7. To prevent recurrence.
exposure for early surgical intervention.
2. Resection must be sufficient, achieve a gap of at
Surgical Modalities
least 1 to 1.5 cm.
3. Ipsilateral coronoidectomy and temporalis Various authorities of TM joints surgery have
myotomy recommended. advocated various methods recommended and
4. If incisal opening is <35 mm then contralateral described from time to time. Ultimately the following
coronoidectomy is sometimes necessary. surgical techniques mostly adopted.
5. The rigid fixation of graft with the ramus is required 1. Condylectomy. Originally described by Henny,
for early mobilization and active physiotherapy to excision of the condyle in case of fibrous ankylosis,
be started after 2 weeks of IMF to prevent soft tissue where articular space is still persisting, along with
contractors. removal of fibrous bands which restricted the
6. Lining of the glenoid fossa region with temporalis movements.
fascia. 2. Gaparthroplasty is the operative technique
7. The reconstruction of the ramous preferably with described as to bony cuts by two horizontal
a constochondral graft. osteotomy and removal of a bony wedge to achieve
8. Regular long-term follow up. a gap between the glenoid fossa and the ramous
9. When the growth of the condyle of the patient is of the mandible. The gap should be at least 1 cm to
completed at the later stage a cosmetic surgery may prevent reankylosis. Gaparthoplasty sometimes
be needed for symmetry. performed with coronoid ectomy that means the
removal of the coronoid process.
Aims and Objectives of Surgery as 3. Interpositional arthroplasty with costochondral
Summarized by Rowe graft (interpositional arthroplasty according to
1. Removal of ankylosed mass and creation of a gap Topazin Brothers involves the creation of a gap and
mobilized the joint. placement of a barrier which may be outogenous
 TM Joint and Its Diseases
49
or alloplastic materials inserted between the cut 4. Preauricular incision the basic incision for TM Joint
bony surfaces to prevent recurrence and to ankylosis (Fig. 7.12).
maintain the vertical height of ramus). 5. The Egyptian oral maxillofacial surgeon Adil-
The most of the surgical procedure exposure of TM Alkyat 79 and English oral maxillofacial surgeon
joint area the following incisions recommended for Paul Bramely recommended a question mark
operative technique. incision for maximum visual and mechanical
1. Blair used an incision resembling and inverted L, access (Fig. 7.13).
commencing of the temporal airline and curving 6. (A) Sub-mandibular or Risdon’s approach and (B)
downwards in close proximity to the anterior postramal or hind approach (Fig. 7.14).
auricle (Fig. 7.10). 7. Popowich and Crane modification of Adil-Alkyat
2. Dingman and Moorman recommended an incision and Paul Bramely’s question mark incision 82 (Fig.
the sectioning the minor fibrous attachment of the 7.15).
lamina of tragus and superior aspect and reflecting The approach claims the extension of the incision
this cartilage anteriorly and down over itself (Fig. slightly less than the previous question mark incision.
7.10). The dissection can be achieved through the
3. The Blair incision slightly modified by Rowe’s avascular area and reduction of total operating time,
slightly extending the superior limb of inverted L. and postoperative edema and discomfort and good
This incision also resembling the original cosmetic results.
preauricular incision of Thoma (Figs 7.10 and 7.11). In early 80s Prof Janardhanan and Prof.
Sunderrajan in India, first performed costochondral

Figs 7.10A to C: The variation of preauricular incisions.

(A) Blair’s inverted hockey-stick incision. (B) Rowe’s extended
Blair’s incision or Thoma’s angulated incision. (C) Dingman’s
and Moorman’s incision A

B
Fig. 7.11: Blair incision modified by Figs 7.12A and B: (A) Preauricular incision,
Rowe’s. Dingman’s incision (B) Modified preauricular incision
 Synopsis of Oral and Maxillofacial Surgery
50
graft surgery by Adil-Alkyat and Paul Bramely’s
approach in ankylosis of TM joint.
For better adaptation of chondral graft as growth
centre of condyle to the ramus of the mandible via
Risdon approach, they improvized a technique the
mortise of outer cortex of the ramus as well as inner
aspect of the chondral graft for better result (the
mortise means the roughing of the inner aspect of the
chondral graft and the outer cortex of the ramus by
vulcanite bur).
The costochondral graft act as initiator of condylar
growth centre. Janardhanan has also shown in animal
experimental study (dog) a chondral graft placed in
Fig. 7.13: Question mark incision the dog mandible, after the mortise the graft and the
mandible.
After sometimes the mandible of the dog removed
and series of section showing on H.P. examination the
encouraging adaptation of the graft. Prof Phillip J
Boyne also supported this method.
An appraisal of TM joint ankylosis over 15 years
review of management by Prof Harris as follows :
The condylar growth centre contributes approxi-
mately 20 per cent of ascending ramus height and
width, and its loss does not affect mandibular body
growth if function is restored before puberty.
Therefore, a simple gap or interpositional arthroplasty,
Figs 7.14A and B: (A) The incision is given about 1cm below even in the first decade, will give minimal asymmetry
angle of the mandible. It extends forward parallel to the lower at rest and on opening in adult life with good
border and curves backward slightly behind the angle of the
adjustment or the occlusion. Asymmetry can be
mandible. This approach provides the poor access to the
condylar head region. (B) Excellent cosmetic procedure avoided by grafting a costochondral growth centre
recommended by Hind, for surgeries involving the condylar neck before puberty, but may produce an ipsilateral hyper-
and ramus area plasia if the costal cartilage growth exceeds the ramus
requirement.
Prolonged ankylosis extending through puberty
will impair total mandibular growth leading to micro
and retrognathia. This requires both excision of the
ankylosis and reconstruction of ramus height, which
may be achieved with a variety of techniques.
Ankylosis occurring in adult life after the
completion of growth with no loss of ramus height,
merely requires the separation of the fused bony parts.
This can be done with a silicone elastomer (Silastic)
membrane.
Figs 7.15A to C: (A) Preauricular incision the basic and usual
approach of TM joint originally described by Blair. (B) It is a
modified Adil-Alkyat and Paul Bramely’s incision recommended Relapse may be Attributable
by Popowich and Crane. The incision slightly larger than the to Three Factors
former incision. This incision provides excellent visual and
mechanical access. (C) It is a Rowe’s modified preauricular 1. Inadequate removal of bone at the site of the
approach explained as reverse extended ‘L’ incision ankylosis.
 TM Joint and Its Diseases
51
2. Failure to recognize postankylosis contracture 11. Guralnick WC. “Ankylosis.” Surgery of the Tempo-
formation in both temporalis tendons requiring romandibular Joint. In David A Keith, (Ed): (2nd ed)
bilateral coronoidectomy or myotomy. Blackwell Scientific publication 1992;p-125.
12. Hudson HNG, Miller, Murphy, et al. ‘External pterygoid
3. Failure to recognize that exuberant bony fusion
myotomy for recurrent mandibular dislocation (Review of
especially in the adult, is probably a manifestation the Literature and Report of a Case). OS, OM, OP Dec.
of fibrodysplasia ossificans, which can be preven- 1976;42,6:705-16.
ted by diphosphonate therapy, e.g. disodium 13. Hansson LG, Karl-ake Omnell. In Radiology of the TMJ. In
etidronate (Didrobnel) 700 mg a day for three William B Irby (Ed): Current Advances in Oral Surgery.
months or 350 mg a day for six months. The CV Mosby Co 1980;3.
14. Hill SC. Surgical management of internal derangement of
BIBLIOGRAPHY the temporomandibular joint. In William H Bell (Ed):
1. Al-Kayat A, Bramley P. A modified preauricular approach Modern Practice in Orthognathic and Reconstructive
to the temporomandiular joint and malar arch, BJOS, Surgery 1993.
1979;17:91. 15. Irby WB. Surgical correction of chronic dislocation of the
2. Boudreaux Raymond E, Spire Edward D. Plication of the temporomandibular joint not responsive to conservative
capsular ligament of the temporomandibular joint. A therapy. J Oral Surgery, 1957;15:307.
surgical approach to recurrent dislocation or chronic 16. Irby WB. Surgical Treatments of TMJ Problems. Current
subluxation, JOS, 1968;26:330-33. Advances in Oral Surgery. The CV Mosby Co. 1980;3.
3. Blair GS, Chalmers IM. Radiology of the temporo- 17. Kojetzny GE. Miller, Murphy et al. External pterygoid
mandibular joint. A comparison of circular tomography myotomy for recurrent mandibular dislocation (Review of
with orthopantomography and lateral transcranio-oblique the Literature and Report of a Case). OS, OM, OP Dec.
radiography. J Dent 1972;1:69. 1976;42:6,705-16.
4. Bradley P. Injuries of the condylar and coronoid process. 18. Laskin DM. Myotomy for the management of recurrent and
In Maxillofacial Injuries by Rowe and Williams Vol. I, protracted mandibular dislocation. Transactions of the IVth
reprint of 1st ed, 1986;354. International Conference on Oral Surgery, Amsterdam,
5. Boaring. Quoted by RG Merrill in ‘Mandibular Dislocation’. May, 1971.
(Surgery of the Temporomandibular Joint. ‘Edited by David 19. Laskin DM. Pathologic condition involving the TMJ. In
A. Keith, 2nd ed, 1992. Blackwell Scientific Publication). Temporomandibular Joint Problems: Biologic Diagnosis
6. Courtmanche AD, Son-Hing QR. Cited in MA Pogrel, and Treatment. Solberg and Clark, Quintessence Publishing
Articular eminectomy for recurrent dislocation. Br. J Oral Co., Inc 1980.
Maxillofacial Surgery 1987;25:237-43. 20. Last RJ. Anatomy, Regional and Applied. Reprint of 7th ed
7. Dingman RO, et al. Surgical correction of lesions of the 1985;384-85.
temporomandibular joint. Plast Constr Surg 1975;55:335- 21. Myrhaug H. A new method of operation for habitual
40. dislocation of the mandible: Review of former methods of
8. Feinman C, Harris M. Psychogenic facial pain. Part–I: The treatment. Acta Odontol, Scand, 1951; 9:247-61.
clinical presentation. Br Dent J 1948B;156:265-68. 22. Malcolm Harris. Facial pain. Huntarian Lecture, 1984.
9. Feinman C, Harris M. Psychogenic facial pain. Part–II: 23. Sir Normal L Rowe William Guy Lecture. Ankylosis of TM
Management of prognosis. Br Dent J 1948B;156:205-08. joint. J of Royal College of Surgeons, Edin. Part–I,
10. Greene and Laskin, et al. Spring therapy of the MPDS. A 1982;27:67-69. Part–II, 1982;27:167-73. Part–III, 1982;27:209-
comparative study ADA 1984;p-624. 18.
EIGHT
Odontogenic and
Non-odontogenic Cysts of Jaws

• Definition of Cyst • Classification • Concept and Etiopathogenesis of its Growth

and Development • Detail Discussion of Dentigerous Cyst • Odontogenic Kerato-
cyst (Primordial) • Periapical Radicular Cyst • Certain Analytical Observations
of Odontogenic Keratocyst • Various Treatment Modalities of Management of Cysts

DEFINITION OF CYST Simple Classification Recommended

by Harris and Seward
Cyst is an abnormal cavity having fluid, semi fluid or
gaseous contents which is not created by the A. Of odontogenic epithelium:
accumulation of pus (*Modified Kramer, Ivor RH). It 1. Derived from the dental lamina:
is frequently but not always, lined by epithelium, *and a. Keratocysts:
expanded by the process of osmosis. i. Solitary or primordial cysts
ii. Pseudofollicular or extrafollicular
Modified Classification Recommended dentigerous cysts.
by Shear and Kramer b. Calcifying odontogenic cysts (Gorlin’s cyst).
2. Derived from reduced enamel epithelium:
a. Eruption cyst.
b. Follicular or dentigerous cysts:
i. Periocoronal
ii. Lateral
iii. Residual.
3. Derived from epithelial debris of Malassez:
a. Inflammatory periodontal (radicular):
i. Apical
ii. Lateral
iii. Residual.
B. Of non-odontogenic epithelium (Fissural):
1. Nasopalatine
2. Nasolabial.
C. Bone cysts:

}
1. Solitary bone cyst. Cyst without epithelial
2. Aneurysmal bone cyst. lining or pseudocysts
by Cawson.
Classification of Odontogenic Cyst
Recommended by Charles A Waldron
from Neville et al

Developmental
1. Dentigerous cyst.
2. Eruption cyst (Eruption hematoma).
 Odontogenic and Non-odontogenic Cysts of Jaws
53
An Analytical Observation
1. Cawson considered the cystic ameloblastoma and
calcifying epithelial odontogenic cyst (Gorlin cyst)
as neoplastic cysts.
2. The terms odontogenic keratocyst and primordial
cyst were used synonymously. In 1972, WHO
classification used the designation primordial cyst
as the preferred term for this lesion. In 1992, WHO
classification, however, lists odontogenic kerato-
cyst as the preferred designation.
3. Orthokeratinized odontogenic cyst is not a specific
type of odontogenic cyst but more of histological
concept.
4. Gingival cyst of the new born are also called as
Epstein’s pearls and Bohn’s nodules. This cyst is
derived from remnants of the dental lamina, and
commonly seen in newborn babies. However, they
disappear spontaneously by rupture into the oral
Fig. 8.1: Cysts of the jaws cavity.
A, Fissural cysts: Top left, Diagram of the face of a human 5. Gingival cyst of the adult is an uncommon lesion.
embryo at 6 weeks. Top right, Diagram of sections through the It is considered to represent the soft tissue
developing nasal pit showing how the nasal fin is breached by counterpart of the lateral periodontal cyst and the
maxillary and pre-maxillary mesoderm. a, Site at which other name is Botryoid odontogenic cyst.
nasolabial cyst develops. b, Site at which globule maxillary cyst
6. Glandular odontogenic cyst (Sialo-odontogenic
develops. c, Nasal pit. d, Lateral nasal process. e, Naso-optic
or nasomaxillary groove. f, Nasal fin. g, Olfactory placode. h, cyst) is a rare and recently recognized type of
Bucconasal membrane. Bottom left. Diagram of the developing developmental odontogenic cyst that can show
palate. Bottom right. Sites of fissural or non-odontogenic aggressive behaviour. They clinically occur
developmental cysts. j, Primary palate or medial palatal process. commonly in middle-aged adults in the anterior
k, Lateral palatine process. m, Site of nasopalatine (incisive region of the jaws. The size of the cyst may vary
canal) cyst. n, Incisive canal cyst. o, Globulomaxillary cyst. p, from 1 cm to large destructive lesions involving
Nasolabial cyst. b, Periodontal cyst: A, Lateral, B, Apical, C,
most of the jaws, the small lesion may be asympto-
Residual, D, Residual (deciduous tooth). c, Primordial cysts:
Top: Replacing tooth. Bottom. Distal to 3rd molar. d, Bone cyst:
matic, but a large cyst often produces clinical
A, Stafne’s idiopathic cavity. B, Solitary bone cyst. e, Dentigerous expansion associated with pain or paraesthesia.
and developmental periodontal cysts: Dentigerous cyst – A, X-ray appears as an unilocular or multilocular
circumferential; B, pericoronal; C and D, Lateral. Periodontal radiolucency.
cysts – E, Lateral; F, Distal–Cited from Harris and Seward Treatment includes enucleation or curettage.
Some authors recommended en block resection for
3. Odontogenic keratocyst. the potential aggressive nature of the cyst.
4. Orthokeratinized odontogenic cyst. 7. The buccal bifurcation cyst an uncommon
5. Gingival (alveolar) cyst of the newborn. inflammatory odontogenic cyst commonly develops
6. Gingival cyst of the adult. on the buccal aspect of the mandibular first
7. Lateral periodontal cyst. permanent molar. The pathogenesis of this cyst is
8. Calcifying odontogenic cyst (Gorlin’s cyst). uncertain. This may be an inflammatory response,
9. Glandular odontogenic cyst. which may occur in the surrounding follicular tissues
that stimulates cyst formation during the eruption
Inflammatory of the tooth. Radiologically shows a well-
1. Periapical (radicular) cyst. circumscribed unilocolur radio-lucency involving
2. Residual periapical (radicular) cyst. the buccal furcation and root area of the involved
3. Buccal bifurcation cyst. tooth.
 Synopsis of Oral and Maxillofacial Surgery
54
Treatment includes enucleation. The extraction Concept of Mode of Formation of
of the associated tooth is not necessary. Various Types of Developmental
8. Kaneschiro and associates described a post- Odontogenic Cysts Cited from Lucas
operative maxillary cyst in Japan (Cited from 1. Cyst formation takes place in the enamel organ at
Peterson). This is due to delayed complication of an early stage, before the deposition of enamel. A
radical surgical intervention in the maxillary sinus primodial cyst results.
and documented histololgically. 2. Cyst formation takes place or occurs in the enamel
organ after the tooth has formed. A dentigerous
Growth and Development of Odontogenic Cyst cyst results.
3. A dentigerous cyst may in some case result from
The most popular concept of odontogenic cyst growth
cystic changes in remnants of the dental lamina
was delivered by Prof. Malcolm Harris in his
with subsequent development of the crown of the
Hunterian lecture in March 1974, the theories listed
tooth in the cyst.
as follows, lesion expands in a balloon-like manner
4. Cyst formation in the lateral part of the enamel
resorbing the surrounding bone, the expansile force
organ produces a lateral dentigerous cyst.
being created by an accumulation of intracystic
5. A laterally situated cyst may also arise from cyst
contents which may be listed as follows:
formation in epithelial rests.
1. Cyst epithelium and its products of autolysis.
6. Multiloculated cyst arising from cystification in
2. Plasma proteins derived from transudation,
buds forming from the enamel organ (Thoma and
exudation, and intracystic haemorrhage.
Goldman).
3. Tissue fluid drawn into the cyst owing to the high
osmolality created by (a) and (b). Primordial Cyst (Keratocyst)
4. Mucus secreted by the goblet cells, which are found
in some follicular, and nasopalatine cyst wall Philipson named the term ‘odontogenic keratocysts’
(Main, Toller and Browne). in the year 1956 and it is now quietly accepted.
Harris in his research has shown the bone resorbing Subsequently supported by Pindborg, Philipson and
prostaglandins (PGs) responsible for cystic bone Henriksen in 1962, Pindborg and Hansen in 1963
resorption. He also mentions the varieties of designated that keratocyst mean a cyst that contain
prostaglandins (PGEs and PGFs as well as PGE2) in keratin by a large extent. The several misleading
different cystic types for prostaglandins-induced bone implications lead to controversy regarding the name.
resorption. Considering the distinct entity of developmental
Harris also quoted the term name ‘Osteoclast- origin, arising from primodiam odonotogenic
activating factor’ (OAF) by Horton et al. Bone epithelium. Mervyn Shear prefers the term primordial
resorbing is activated by a variety of humeral agents cyst to the nonspecific histological term keratocyst.
(Raisz’70) which includes parathyroid hormone, Clinical Features
vitamin D, prostaglandins lymphokine produced by
stimulated B lymphocytes which has been named 1. Age: Common in second and third decades of life.
osteoclast-activating factor (Harris). 2. Sex: It is frequently seen in males than females.
3. Site: The mandible is more frequently involved
Cawson Summarized the Pathogenesis than the maxilla.
of Cyst Formation as Follows 4. Patient complains of swelling, discharge, or may
be pain. Some of the patients may develop a
1. Proliferation of epithelial lining and fibrous pathological fracture, because of being unaware of
capsule. the lesion. Some instance patient free from
2. Hydrostatic pressure effect of cystic fluid around symptoms until the cysts have reached to a large
the surroundings. size involving entired ramus. This is because the
3. Resorption of the surrounding bone. expansion of primordial cyst into the medullary
 Odontogenic and Non-odontogenic Cysts of Jaws
55
cavity early and bony expansion occurs late. The
cyst also produces the displacement of the teeth.
Concepts of Recurrences
There are several concepts of frequent recurrence of
primordical cysts as follows:
1. Occurrence of satellite cysts, which are, retained
during an enucleation procedure. There may be
formation of new cysts rather than recurrences.
2. The cystic linings are very thin and fragile, and
therefore difficult to enucleate, and part of the
lining may be left behind, and constitute the origin
of recurrences (Kramer Ivor R. H. 63 Fickling B.
W. 65).
3. Toller in 1967 suggested that epithelial lining of A B
Figs 8.2A and B: X-ray appearance of primordial cyst
cysts have an intrinsic growth potential and
(Keratocyst). (A) Mandible and (B) Maxilla
regards a primordial cysts as being a neoplasm.
4. Soskolen and Shear in 1967 suggested that patients
with naevoid basal cell carcinoma syndrome
having predisposition to form primordial cysts
from the dental lamina.
5. Stolelinga 1971 and Stolilinga Peters in 1973
proposed that the primordial cysts may arise from
proliferations of the basal cells of the oral mucosa
particularly in the third molar region and
ascending ramus of the mandible. They also
mentioned the adhesion of the cysts to the
overlying mucosa and should be excised to prevent
possible recurrence from the residual basal cell
proliferation.

Radiological Features (Figs 8.2 and 8.3) Fig. 8.3: X-ray appearance of primordial cyst
Primordial cysts may appear in X-rays as small round (Keratocyst), mandible (left side)
or ovoid radiolucent areas with well-demarcated
distinct sclerotic margins in case of slow enlarging
lesion. Majority of unilocular radioluscencies having
a smooth periphery. This is common in case of
maxillary lesions. Some of the unilocular lesions have
scalloped margins, and these may be misinterpreted
as multilocular lesions. There may be extensive
involvement of the body and ascending ramus of the
mandible, with little or no bony expansion.

Pathogenesis (Fig. 8.4)

The primordial cyst arises from odontogenic
epithelium prior to tooth formation, that means the
dental lamina or its remnants. It can be explained
lucidly—the tooth bud instead of forming a tooth Fig. 8.4: Histopathological appearance of primordial cyst
degenerating into a cyst (Main Soskolin and Shear 67 (Keratocyst). Typical thin parakeratinized epithelium with well-
and 70). defined basal cells
 Synopsis of Oral and Maxillofacial Surgery
56
Investigation: Electorphoresis Study 6. Radiotherapy (Cook 73 with little and questionable
value).
a. Estimation of soluble protein from aspirated cystic
7. Peripheral osteotomy.
fluid is a valuable aid in the preoperative
Paul Bramley recommended multilocular
diagnostic of primordial cysts. Toller’s study in
lesions should be treated by marginal excision with
1970 shows that if the protein level is <4 gram per
overlying mucosa. Some recommended excision
100 ml blood it indicated the diagnosis of primor-
with immediate bone graft, as the choice of
dial cysts. A value of over 5 grams per 100 ml of
operation.
blood would suggest a radicular, dentigerous or
fissural cyst or even ameloblastoma.
Dentigerous Cyst
b. Kramer suggested technique for preoperative diag-
nosis of primordial cysts by demonstrating Sir James Paget 1863 first coined the term dentigerous
keratinized squames of aspirating cystic stained cyst. It is the most common of all follicular
film, subsequent studies of Kramer and Toller in odontogenic cysts, comprising about 95 percent of
1973 reported the combined use of exfoliative these lesions and about 34 percent of all odontogenic
cytology and protein estimation in the preoperative cysts. It is slightly more common among males than
diagnosis of cysts. Smears are made by placing a females and usually occurs in the second or third
drop of cystic fluid on a clean glass slide and decade of life. About 70 percent of the lesions occur in
spreading with the edge of a dry cover slip. Two the mandible and 30 percent in the maxilla. Almost
smears of each specimen are allowed to air dry and 62 percent occur in the molar area, 12 percent in the
are stained respectively with haematoxylin-eosin canine area, and 12 percent in the premolar area, with
and by the Rhodamine B fluorescence method the remaining 14 percent occurring elsewhere in the
(Clausen and Dabelsteen, 69). A third is allowed jaws. The mandibular third molar and maxillary
to dry to a tacky state and fixed in a solution canines are the most frequently involved single teeth.
containing 75 percent ethyl alcohol and 3 percent The dentigerous cyst produces enlargement of the jaw,
acetic acid prior to staining with the Papanicolaou and in some instances, it is quite marked.
procedure.
Pathogenesis and Growth (Fig. 8.5)
Treatment
Dentigerous cyst may be of extrafollicular or intra-
The methods of treatment recommended which follicular origin. Shear’s rejects the extrafollicular
includes as follows (by Attenbourgh, 74 and Voorsmit, theory of origin of dentigerous cyst. Intrafollicular cyst
81) may develop by accumulation of fluid either between
1. Total enucleation and primary closer. the reduced enamel epithelium and enamel or within
2. Enucleation with chemical fixation. Voorsmit
recommended use of Cornoy’s solution after
enucleation from the bony bed to destroy the
satellite cysts lining. The Cornoy’s solution acts as
chemo-cauterization to prevent recurrence.
(Composition of Cornoy’s solution recommended
by Thoma Glacial acetic acid 1 cc, absolute alcohol
6 cc, spirit chloroform 3 cc and ferric chloride 1
grain). Liquid N 2 spray acts to destroy the
remnance of cystic lining. (Cryosurgical effect by
Paul Bramley). Intraluminal injection of Cornoy’s
solution prior to enucleation helps to removing the
cyst lining smoothly.
3. Marsupialization (Partsch technique).
4. Marsupialization followed by enucleation
(Waldron two stage technique). Fig. 8.5: Histopathological appearance of dentigerous cyst.
5. Resection. A partly-formed tooth as seen in bottom part of the field
 Odontogenic and Non-odontogenic Cysts of Jaws
57
the enamel organ. The above mentioned views mural ameloblastomas or some have been termed as
supported by Main 70 that pressure exerted by a preameloblastic lesion.
potentially-erupting tooth on an impacted follicle, Dentigerous cyst may be of central, lateral and
obstructs the venous out flow thereby induces rapid circumferential type. The eruption cyst in a child
transudation of serum across the capillary walls. The presents as a bluish fluctuant swelling in the mucosa
increased hydrostatic pressure of this pulling fluid immediately over an erupting tooth. This is also a
separates the follicle from the crown, with or without variety of dentigerous cyst.
reduced enamel epithelium. Gradually, capillary The eruption cyst (eruption hematoma) is the soft
permeability is altered to permit the passage of greater tissue cyst a variant of a dentigerous cyst. The cyst
quantities of protein above the low concentration of developing as a result of separation of the dental
the pure serum transuded. follicle from around the crown of an erupting tooth
that is within soft tissues overlying the alveolar bone.
Diagnosis and Investigation The cyst appears as a soft translucent swelling in the
gingival mucosa overlying the crown of an erupting
On palpation of the area of enlargement presents the
primary or permanent tooth, mostly seen in children
“typical eggshell crackling” due to expansion of the
and in a younger age. The surface trauma may result
cyst thinning of the overlying bone. X-ray shows an
in collection of blood in the cystic fluid showing a blue
unerupted tooth, a crown, which is surrounded by a
to purplish–brown colour. For this reason it is some-
clearly demarcated radiolucent area (Fig. 8.6). In a
times called as eruption hematoma. It does not require
large cyst of the mandibular third molar area, the
any treatment sometime a simple excision of the roof
radiolucent zone may extend to the ramus. The teeth
of the cyst permits speedy eruption of the tooth.
associated with the dentigerous cyst may be pushed
out of place, i.e. to the lower border of the mandible Treatment
or the floor of the nose in maxillary lesions.
Dentigerous cysts have a greater tendency than other 1. Marsupialization (Partsh surgery in case of
jaw cysts to produce the resorption of the roots of eruption cyst).
adjacent teeth (Struthers and Shear, 1976). 2. Enucleation with or without packing of defect
On aspiration the clear pale straw-coloured fluid (Waldron two stage technique).
is seen. On examination of the fluid cholesterol crystals Dental Cyst (Radicular Cyst, Periapical Cyst)
are sometimes seen. Total protein > 4 gm per 100 ml (Fig. 8.7)
on electrophoresis is of diagnostic importance.
Dental cyst is usually asymptomatic. Most commonly
Analytical Observation seen in the anterior teeth in the maxilla rather than
the mandible in the third decade of life.
Some authorities widely believe that ameloblastomas
frequently arise in dentigerous cysts and are called

A B
Figs 8.7A and B: X-ray appearance of dental cysts/radicular
Fig. 8.6: X-ray appearance of dentigerous cyst of the cysts or/periapical cysts. (A) Maxillary central incisor and (B)
left mandible. The third molar is impacted and tilted Mandibular first premolar
 Synopsis of Oral and Maxillofacial Surgery
58
There is a history of trauma, which leads to non- Marsupialization or partsch operation (Fig. 8.9)
vitality of the tooth or a deep carious lesion or long-
standing restoration. The patient may complain of Residual Cyst
pain, swelling discharging sinus, which reduces and If a tooth is associated with a radicular cyst is extracted
suppresses after antibiotic and analgesic cover. The but the cyst is left undisturbed, it may persist within
recurrent episodic attack is always present. the jaw. Such a lesion is called a ‘residual cyst.’
Residual cysts represent about 3.5 percent of all
Mechanism of Formation of a Dental Cyst periapical lesions. They occur in the maxilla more often
Pulpitis, from which the tooth fails to recover, leads than in the mandible and the majority of patients are
to inflammation and progresses to necrosis. in the fourth decade of life. Only by X-ray and history
The trauma causes collection of blood in the apical the presence of a residual cyst is detected.
region and the tooth becomes non-vital → Hematoma
gets organized → formation of granulation tissue → Treatment
fibrosis — as a result of inflammation the epithelium Surgical enucleation.
of periapical, area (epithelial rests of Malassez)
proliferates and by continuous proliferation forms a Calcifying Epithelial Odontogenic Cyst
large mass of cells. Since the epithelium has no blood (Fig. 8.10)
vessels of its own, its blood supply must come from Calcifying epithelial odontogenic cyst or Gorlin cyst
the surrounding connective tissue. Since the central is a very rarely reported cyst and has no sex
cells in the epithelial mass are farthest away from the predilection. It is common in children and adults about
blood supply, they degenerate and form a small cavity, the third decade of life. It was first described by Gorlin
which is lined by epithelium. This is the beginning of et al in the year 1962. It is commonly seen in the
the radicular cyst. Now the cystic cavity increases in anterior part of the mandible. Though it is a rare lesion
size. The epithelial cells are shed into the cavity. Since it discussed more in the various observer different
cells consist of protein material, the intracystic osmotic cystic studies. Clinically, the lesion is symptomless and
pressure progressively becomes greater than that in accidentally diagnosed during X-ray examination.
the surrounding tissues. Tissue fluids and edema fluid Expansion or swelling of the jaw is the most frequent
are therefore gradually imbibed into the cavity. This, complaint. Rarely, its patients complain of pain.
in turn, compresses the surrounding tissues and bone. Sometimes the expansion of bone may be extensive,
The bone is resorbed, and the radiolucency becomes
larger. In addition to this process, the granulation
tissue of the cyst wall also continues to proliferate,
destroying bone and thus enlarging the bone defect.
Finally, the third mechanism in the growth of the
radicular cysts consists of what may be called the
“sequestration” of the connective tissue wall. The
epithelial lining extends into the connective tissue of
the cyst wall and incorporates parts of it into the cystic
cavity.
X-ray: A radicular cyst is characterized by a more or
less clearly demarcated radiolucency associated with
the apical area of the affected tooth.
Figs 8.8A to D: Illustrating the enucleation of a cyst and primary
Treatment Method (Figs 8.8A to D) wound closure. (A) A three-sided flap is reflected, (B) Bone is
removed to uncover the cyst and the lining separated from the
1. Extraction of the offending tooth with apical bony cavity, (C) The lining removed. The apex of root-filled right
curettage. lower central incisor. Note the broad zone of bone around the
2. Apicectomy with R.C.T and obturation. opening, (D) The flap is sutured into place. Cited from Harris
3. Enucleation. and Seward
 Odontogenic and Non-odontogenic Cysts of Jaws
59
involving lingual as well as the palatal cortex. The cyst
may arise close proximity to the periosteum and
produce a depression like saucer-shaped in the bone.
The displacement of the teeth may also be seen.

X-ray Findings
The small cyst may be seen between the roots of the
teeth. The periphery well-demarked or an irregular
margin. The lesion may be unilocular or of a multi-
locular pattern.
Evidence of cortical perforation, may be present
irregular radio-opaque specks may be seen within the
cystic cavity as calcifications. The cyst may be
associated with a complex odontome or an unerrupted
tooth. Resorption of the roots of adjacent teeth also
may be seen.

Pathogenesis
The cyst has an odontogenic origin and may be
Figs 8.9A to E: Illustrating marsupialization of a cyst. (A) A U- derived from remnants of the dental lamina, stellate
shaped incision over the margins of the future cyst opening, reticulum and reduced enamel epithelium. The
(B) A mucoperiosteal flap reflected to reveal a perforation in multilocular variant may develop a thick capsule, into
the cortex, (C) Bone removed to uncover cyst lining which is which strands of epithelium resembling the dental
incised from within outwards flush with the bone edge, (D) The
lamina proliferate, forming daughter cysts.
lining is sutured to the edge of the mucosa. Often apex of the
tooth of origin protrudes into the cavity and may be amputated
flash with the lining. If unroot-filled, a retrograde root-filling can
Histological Features (Fig. 8.11)
be inserted, (E) The flap is turned into the cavity and packed Histologically the odontogenic type of lining
into place with ribbon gauze soaked in Whithead’s varnish. Cited epithelium is 6 to 8 cells thick and has a columnar or
from Harris and Seward.
cuboidal basal layer of cells with their nuclei polarized
away from the basement membrane. There can be a

A B
Figs 8.10A and B: X-ray appearance of calcifying odontogenic Fig. 8.11: Histological appearance of calcifying odontogenic
cyst (Gorlin’s cyst. A, Mandible and B, Maxilla with calcification cyst. “Ghost” epithelial cells seen
 Synopsis of Oral and Maxillofacial Surgery
60
superficial resemblance to a keratocyst in a small Ovarin cyst, lipomas, and meduloblastoma a malig-
biopsy. In patches the epithelium proliferates, the cells nant lesion of the brain, in advanced cases.
becoming swollen and then eosinophilic, due to a form Cawson describing the Gorlin and Goltz syndrome
of keratinization, but with persistence of pyknotic summarized the characteristic features as follows:
nuclei. These are called ghost cells. Later these cells 1. Facial with frontal and parietal bossing and broad
fuse and tend to calcify. If pyknotic nuclei are included nasal root.
in the calcified mass it may resemble cellular 2. Multiple keratocysts of the jaw.
cementum at first sight. It is the calcification in these 3. Multiple naevoid basal CA of the skin (milia).
epithelial cell masses, which forms the opacities seen 4. Skeletal anomalies usually bifid ribs and
in radiographs. abnormalities of the vertebrae.
5. Intracranial anomalies may include calcification of
Treatment the flaxcerebri and abnormally shaped sellaturcica.
Treatment is careful, simple enucleation.
Non-odontogenic Fissural Cysts

}
Botryoid Odontogenic Cyst 1. Median palatine Arise in areas of
2. Median alveolar fusion of facial
BOC cyst was reported by Weathers and Waldron in
3. Globulomaxillary processes; therefore,
1973, which is derived from the epithelial cell rests of
4. Nasoalveolar or collectively called
Malassez. It is thought to be a variety of the lateral
nasolabial fissural cysts.
periodontal cyst. The macroappearance of the lesion

}
5. Nasopalatine or Arise from
was explained as a bunch of grapes as it resemble are.
incisive canal remnants of
Hence, it is called botryoid. The cyst is commonly
cysts nasopalatine ducts.
seen in the mandible in the canine – premolar region.
X-ray shows polycystic lesions of radiolucency. Globulomaxillary, median mandibular, median
alveolar and median palatine cysts are also described
Multiple Cystic Lesions of the Jaws but their authenticity or even the actual existence of
some of these entities is in doubt (Harris).
Basal Cells Naevus Syndrome or
Gorlin and Goltz Syndrome Median Palatine Cyst
The jaw cysts are keratocysts and of the extrafollicular Usual location is midline of the palate. Commonly seen
dentigerous (Pseudofollicular) varieties. These cysts in the second to third decade of life. Male and female
start to develop at the time of eruption of the both are affected equally. Solitary area of radiolucency
permanent dentition. It may be present symmetrically in midline of palate behind incisive papilla,
in both maxilla and mandible, involving the unerrup- asymptomatic or may produce swelling in the palate.
ted tooth or may be scattered in different areas. Jarisch Histopathological examination shows cyst lined by
first reported the case and a detailed description was stratified squamous or respiratory epithelium.
given by Gorlin in 65. It is mostly genetic disorder.
The skull is often brachycephalic with frontal and Treatment: Enucleation.
parietal bossing and ocular hypertelorism. Ocular
abnormalities are apparent in childhood and a mild Median Alveolar Cyst
prognathism, due to a short cranial base may need Usually located anterior to the incisive papilla, and
orthodontic consultation. Skin lesions include the tiny commonly seen in second to third decade of life. Male
whitish epidermal cysts or ‘milia’ around the eyes and and female both are affected equally.
tiny circular patches of epithelium may be shed from Solitary circumscribed radiolucent area in anterior
the thick skin palms and tends to produce fitting. part of midline of palate; asymptomatic or may
Epidermal skin may develop under the skin in various produce swelling; neighbouring teeth vital.
parts of the body. Subsequently pinkish or white,
circular skin plaques are found on the face, check and Histopathological examination shows cyst lined by
trunk, which are basal, cell naevi. Complications stratified squamous or respiratory epithelium.
include transformation of basal cells carcinoma. Treatment: Enucleation.
 Odontogenic and Non-odontogenic Cysts of Jaws
61
Globulomaxillary Cyst Treatment: Careful surgical enucleation.
Usually located in the lateral incisor and canine area.
Cyst of the Papilla Palatine
Commonly seen second in the third decade of life.
Male and female both are affected equally. Pear- Usually located in the area of the incisive papilla.
shaped, solitary radiolucency between lateral incisor Commonly seen in second and third decade of life.
and canine, neck of “pear” toward crowns, and the Male and female both are affected equally. Clinical
cyst produces divergence of roots of canine and lateral and X-ray features swelling in area of incisive papilla,
incisor; may produce swelling on palatal or labial sometime produces radiolucency like incisive canal
sides; teeth vital. cyst.
Histopathological examination shows the above- HP examination shows the above findings already
mentioned findings. mentioned.
Treatment: Careful enucleation without damaging the Treatment: Enucleation.
adjoining the roots of the teeth followed by primary
closure. Median Mandibular Cyst
Nasoalveolar or Nasolabial Cyst The mandibular mesenchyme migrates medially from
each side and fuses beneath the epithelium to form
The nasoalveolar or nasolabial cysts are rare and arise
the mandibular arch. It is less common than the
above the buccal sulcus under the ala of the nose. This
fissural cyst. Commonly seen in the midline of the
cyst is slow growing, lifting the nasolabial fold
mandible. There is no sex predilection. The cyst is very
obliterating and it bulging into both the inferior
small in size about 1 to 3 cm in diameter. The asso-
meatus of the nose and the labial sulcus. A standard
ciated teeth are vital. A labial palpable swelling may
occlusal X-ray demonstrates the resorption of the
be present with divergence of teeth. X-ray shows a
anterior bony aperture. Normally the two inferior
well-demarcated circular or ovoid radiolucency with
nasal margins together with the buttress of the anterior
the intact laminadura of the involved teeth.
nasal spine produce a ‘bracket’-shaped line in this
view. A nasolabial cyst converts one half of this line Treatment: Careful surgical enucleation.
into a concave rather than a convex shape.
Histopathological examination shows cyst lined by Non-odontogenic, Non-epithelium, Cysts-
ciliated or squamous epithelium. like Conditions, the Traumatic or
Treatment: Enucleation. Haemorrhagic Bone Cyst

Nasopalatine or Incisive Canal Cysts (Fig. 8.12) This cyst is not fulfilling the criteria of cyst.

It is a true non-odontogenic cyst. Usually located

behind the maxillary anterior teeth. Commonly seen
in the second and third decade of life. Males are
affected slightly more than the females.
Solitary, circumscribed, often heart-shaped area of
rediolucency behind maxillary incisors, may produce
swelling in palate or may be asymptomatic, all teeth
vital in the area.
On aspiration: The viscous fluid may contain mucoid
material or even pus if the cyst has been infected. This
diagnostic aid may help to rule out the normal incisive
canal fossa radiolucency.
Histopathological examination shows cyst lined by
stratified squamous or respiratory epithelium;
connective tissue wall contains nerves and mucous Fig. 8.12: X-ray appearance of nasopalatine cysts showing
glands. the peculiar radiolucent heart shape area
 Synopsis of Oral and Maxillofacial Surgery
62
Etiopathological Concepts Etiological Factors
1. Trauma and subsequent haemorrhage, which fail 1. Trauma to the secretory acini.
to get organized. 2. Trauma to salivary duct, which is either impinged
2. Abnormal calcium metabolism. or severed.
3. Chronic low-grade infection. 3. Obstruction of a salivary duct.
4. Necrosis of fatty marrow secondary to ischaemia.
5. Spontaneous atrophy of the tissues in a central Site
benign giant-cell lesion.
6. Aberration in the development and growth of the Usually lower lip and tongue, but it may be seen any
localized osseous tissues. where in the oral mucosa. It usually presents as a
It is uncommon, and seen in the first and second small-circumscribed elevated lump, translucent and
decades of life, in between 10 to 20 years of age. Males bluish in color. The history of occurrence is usually
are affected more rather than females as they have week or more. Superficial lesions frequently rupture,
more exposure to trauma. It is rarely seen in the discharge a sticky mucoid material, and collapse. As
maxilla, mostly in the mandible is affected more above soon as they appear to have healed, they recur. This
the inferior dental canal. The lesion is usually repeated episodic cycle is continuous. Mucoceles are
asyamptomatic and accidentally-detected during formed because of a traumatic rupture of the excretory
radiographic examination. The thinning of the cortex ducts of minor salivary glands and the subsequent
and expansion occur at a subsequent stage. X-ray accumulation of the saliva in the tissues. The retention
shows as a unilocular cavity enlarging and pushing the phenomenon or retention cysts will be partly or
interdental bone and the teeth to produce a scalloped completely lined by stratified squamous or cuboidal
outline to the upper border around the roots of the teeth. or pseudostratified columanar epithelium.
On aspiration a deep yellow-coloured fluid may
be obtained which contains plasma, proteins and Treatment (Figs 8.14 and 8.15)
which will clot after sometime. A blood-stained fluid
or fresh blood may be obtained. Some cyst reported 1. Removal of the cyst along with the injured glands.
empty, might contain gases such as N2, O2 and CO2. Since the minor salivary glands lie close to the
surface, they usually are removed with the
Treatment: Surgical exploration and gentle curettage. mucocele.
2. Liquid nitrogen cryosurgery.
Soft Tissue Cysts of the Oral Cavity
Salivary gland retention cysts can be:
a. Mucocele
b. Ranula.

Mucocele
Two types of distinct entities are available. One is a
true retention cyst with mucous retention
phenomenon, which is lined by epithelium, and the
other, is a mucous extra-vasation cyst. A mucocele is
a mucous containing cyst that occurs in the salivary
gland bearing areas of oral cavity. The mucous
extravasation cyst, which occurs, has pooling of
mucous. It does not have any epithelial lining and is
surrounded by compressed connective tissues
(Fig. 8.13). Fig. 8.13: Mucocele preoperative appearance
 Odontogenic and Non-odontogenic Cysts of Jaws
63

Fig. 8.14: Ice crystals formation after application Fig. 8.15: Mucocele postoperative healing after one week
of liquid nitrogen cryotherapy by liquid nitrogen cryotherapy

Ranula 3. Possible relationship with the giant cell lesion.

A ranula is a large, soft mucus containing swelling in 4. Sudden venous occlusion.
the floor of the mouth. The term ‘Ranula’ known as It is a rare lesion and there is no sex predilection. It
frog’s belly. Ranula is identical to the mucocele except is seen in young, adults and children. Mostly seen in
that it is associated with a larger gland and is, the mandible than the maxilla and the posterior region.
therefore, of greater size. It is produced by a defect in The clinical features of the cyst exhibit firm and
the Wharton’s duct (sub-mandibular gland) or rapid enlargement. The teeth in the area may show
Bartholin’s duct (major sublingual gland). displacement and they remain vital. ‘Eggshell’
crackling may be present. The lesion is not pulsatile
Treatment and has absence of bruits.
X-ray appearance of the lesions is usually oval or
1. Partsh procedure (marsupialization) with pack or
spherical in shape, and leads to ballooning of the
without pack.
cortex. The lesions are usually unilocular or sometimes
2. Some preferred excision of the cyst along with the
may give a multilocular appearance resembling a
gland.
honeycomb or a soap bubble looks (Fig. 8.16).
Aneurysmal Bone Cyst
Most authors have described the central giant cell
granuloma and the aneurysmal bone cyst as distinct
entities. Clinical and therapeutic considerations for
these lesions are, however, similar, and in our opinion
(Osbon and Lilly), the aneurysmal bone cyst is a
histologic variant of the giant cell granuloma. The
aneurysmal bone cyst was first described by Jaffe and
Lichtenstein in 1942. Though often seen in the long
bones and spine, it is rarely seen in the jaws. In past it
has been described as a haemorrhagic osteomyelitis,
ossifying haematoma or benign bone cyst.

Etiology
Several concepts have been postulated from time to A B
time. Fig. 8.16: X-ray appearance the aneurysmal bone cyst
1. History of trauma. Note: Trabeculae traversing lesion. A. Frontal view, B. Lateral
2. Variation in the haemodynamics of the region. view
 Synopsis of Oral and Maxillofacial Surgery
64
On Aspiration, Dark Venous Blood will incision during closure following a maxillary surgical
come out from the Lesion procedure which includes maxillary osteotomies,
Caldwell-Luc or maxillary fractures which involved
Histologically the lesions are composed of a cellular the antrum.
fibrous connective tissues stroma containing The lesion is present in close proximity to the
numerous multinucleated giant cells and haemosi- maxillary sinus and there is no communication
derin pigments; vascularity is prominent in all lesions.
between them and it is proved by injecting radio-
opaque dyes.
Treatment
Surgical enucleation and curettage. Clinical Features
Patient may complain of a dull throbbing pain in the
Mandibular Salivary Gland Depression infra-orbital region. The X-ray shows well-defined
or Stafne’s Idiopathic Bone Cavity radiolucent expansion of the maxilla, with a radio-
The etiology as explained by Stafne, that such a opaque margin closely related to the maxillary sinus.
depression is a failure of the normal deposition of the
bone during development of the jaw. The defect, Histopathology
which is of developmental origin occupied by lobes
of sub-mandibular salivary gland. The cysts are lined by pseudostratified ciliated
It is very rare, uncommon, normally seen below columnar epithelium.
the inferior alveolar canal, near to the position of the
third molar tooth. It is generally unilateral but bilateral Treatment includes Enucleations by Snawdon’s
defects have been reported. Technique (Figs 8.17A and B)
Prof. Fickling in the Charlas Tomes lecture recounts
Clinical Features
and observes of Snawdon’s cases and comments the
Symptomless lesion discovered during routine radio- technique is symptomless and alveolar contour
logical examination. The lesions are non-progressive. excellent. The technique originally described by
X-ray shows the depression is rounded or oval about Snawdon by enucleating the lining and opening the
2 to 3 cm in size. The area of rarefaction is well- bony cavity into either the maxillary sinus or the nasal
demarcated by a dense radiopaque line. Histologically cavity.
contains normal salivary gland tissue, lymph node
tissue or abnormal glandular tissue.
Treatment: No surgical intervention is advised.

Cysts Associated with the Maxillary Antrum

Surgical, Ciliated Cyst of the Maxilla

These cysts are uncommon. They may also be called
as iatrogenic cysts, that mean the patient always gives
a history of some surgical procedure in the maxilla
and also in the maxillary sinuses opened surgically.

Etiopathogenesis Fig. 8.17A: A diagram illustrating the possible incisions, which

may be used; Snawdon’s incision is represented by the dot-
The cyst origin is from the epithelial lining of the dash line, Wassmund’s by the dotted-line and Seward’s by the
maxillary sinuses, which was entrapped in the surgical broken line.
 Odontogenic and Non-odontogenic Cysts of Jaws
65
14. Kramer IRH. Pindborg JJ, Shear M. WHO’s classification of
odontogenic cyst and tumor – 2nd edition, 1992.
15. Kramer IRH, Toller PA. the use of exfoliative cytology and
protein estimation in preoperative diagnosis of odontogenic
keratotcyts. Int. J. Oral Surgery 1973;2:143–51.
16. Lucas RB. Neoplasia in odontogenic cysts. Oral Surgery
1954;7:1227–35.
17. Main DMG. Epithelial jaws cysts: A clinicopathological
reappraisal. Br J Oral Surgery. 1970;8:114–25.
18. Main DMG. The enlargement of epithelial jaw cysts.
Odontol Rev 1970;21:29–49.
19. Margarate and Gordon R. Seward. Observation on
Snawdon’s technique for the treatment of cysts in the
maxilla. BJOS. P – 149-59.
20. Pindborg JJ, et al. Atlas of diseases of the jaws, 1974.
Fig. 8.17B: Snawdon was one of the first British authors to 21. Pindborg JJ, Rud J. Odontogenic Keratocysts: A follow up
describe the technique of treating large maxillary dental and study of 21 cases. J Oral Surgery 1969;27:323–30.
dentigerous cysts by enucleating the lining and then opening 22. Poyton HG, et al. The simple bone cyst. Oral Surgery
the bony cavity into either the maxillary sinus or the nasal cavity. 1965;20: 188–97.
(Cited from Margarate and Prof Gordon R Seward an 23. Seward MH. Eruption cyst: An analysis of its clinical
observation review article on Snawdon’s technique) features. J Oral Surgery. 1973;31:31–35.
24. Shafer WG, et al. A Textbook of Oral Pathology.
BIBLIOGRAPHY 25. Shear M. Primordial cysts. J Dent Assoc S Afr 1960;15:211–
17.
1. Ahlfors E, Larsson A, et al. The odontogenic keratocyst, a 26. Shear M. Cysts of the oral regions.
benign cystic tumor. JOMS 1984;42:10–19. 27. Sicher H. Anatomy and oral pathology. Oral Surgery
2. Blanas N, et al. Systemic review of treatment and prognosis 1962;15: 1264–269.
of odontogenic keratocyst. 5 O 1988;90:553–58. 28. Soskolne WA, Shear M. Observations on the pathogenesis
3. Bhaskar SN, et al. Aneurysmal bone cyst and other giant of primordial cysts. Br Dent J 1967;123:321–26.
cell lesions of the jaw. J Oral Surgery, 1959;17:30–41. 29. Stafne EC. Bone cavities situated near the angel of the
4. Bramley P. A treatment of cysts of the jaws. Proc R Soc Med mandible. J Am Dent Assoc 1972;29:1969–72.
1971;64:547–50. 30. Stoelinga PJW. Recurrences and multiplicity of the cysts.
5. Bramley P. The odontogenic keratocyct – An approach to In: Kay. L.W. (Ed.) Oral Surgery IV (Transaction of the
treatment. Int J Oral Surgery 1974;3:337–41. fourth International Conference on Oral Surgery).
6. Egyedi P, et al. Marsupialisation of large cysts of the maxilla Copenhagen.
into the maxillary sinus and/or nose. A follow up 31. Stoelinga PJW, et al. A note on the origin of keratocysts of
investigation. In: Kay. L. W. (Ed.) Oral Surgery IV the jaws. Int J Oral Surgery. 1973;2:37–44.
(Transaction of the Fourth International Conference on Oral 32. Snawdon JWE: Dent. Pract. 1950;1:105.
Surgery). Copenhagen 1973;81–84. 33. Toller PA. Experimental investigations into factors
7. Fickling BW. BDJ 1956;103:199. concerning the growth of cysts of the jaws. Proc R Soc Med
8. Fickling BW. Cysts of the jaw – A long term survey of types 1948;41:681-88.
and treatment. Proc R Soc Med 1965;58:847–54. 34. Toller PA. Origin and growth of the cysts of the jaws. Ann
9. Gorlin RJ, Goltz RW. Multiple nevoid basal cell epithelioma, R Coll Surg Engl 1967;40:306–36.
jaw cysts and bifid rib: A syndrome. N Engl J Med 1960;262: 35. Toller PA. Protein substance in odontogenic cysts fluids.
908–12. Br Dnt J 1 – 1970;8:317–22.
10. Harris M, et al. The production of a bone resorbing factor 36. Toller PA. The osmolality of fluids from the cysts of jaws.
by dental cysts in vitro. Br J Oral Surgery. 1973;10:334–38. Br Dnt J 1970;19:275–78.
11. Do. Prostaglandin production and bone resorption by 37. Toller PA. Newer concepts of odontogenic cysts. Int J Oral
dental cysts. Nature 1973;245:213–15. Surgery. 1972;1:3–16.
12. Howe GL. Haemorrhagic cysts of the mandible. Br J Oral 38. Voorsmit RACA. The incredible keratocysts: A new
Surgery 3, 55–75, 77–91. approach to treatment. Dtsch Zahnarzilz 1985;40:641–44.
13. Killey HC, et al. Benign cystic lesion of the jaws, their 39. Waldron CA. Sum observations on the jaw cysts in the basal
diagnosis and treatment, 2nd Edition Churchill Livings cell nevoid carcinoma syndrome. 4th Proceedings of the
Stone. International Academy of Oral pathology, 1969;page 220.
NINE
Role of Oral Surgeon in the Adjuvant
Management for the Orthodontic Treatment

• Therapeutic Extraction • Serial Extraction • Extraction of Carious Tooth or

Teeth • Wilkinson’s Theory • Surgical Exposure • Frenectomy • Pericision
• Transplantation of Tooth • Corticotomy • Placement of Implants

The following oral surgical procedures recommended method, the idea of treating by serial extraction
by the orthodontist prior to orthodontic treatment. procedure in mixed dentition period, to intercept the
1. Therapeutic extraction. development of malocclusion and facilitate the
2. Serial extraction. alignment of permanent teeth.
3. Extraction of carious tooth or teeth/super-
numerary tooth/impacted tooth/malformed Advantages of Serial Extraction
tooth. 1. Unerupted/erupted teeth can be guided into
4. Wilkinson’s theory. proper occlusion.
5. Surgical exposure or uncovering of teeth mostly 2. Avoids loss of alveolar bone.
canine. 3. Reduce the severity of malocclusion.
6. Frenectomy.
7. Pericision or circumferential supracrestal Aims and Objectives
fibrotomy. 1. To make treatment easier.
8. Transplantation of tooth. 2. To minimize the extent the orthodontic interven-
9. Corticotomy or cortical osteotomy. tion.
10. Placement of implant or bone screw for anchorage.
Indications
Therapeutic Extraction 1. Straight profile.
2. Tooth-size and arch-size discrepancies.
Extraction of teeth is necessary for orthodontic
3. Crowding with class–I malocclusion.
therapy, on the basis of sound diagnostic knowledge.
4. Crowding primary dentition.
The extraction of teeth is needed for orthodontic
5. Flaring of teeth.
treatment is designated as therapeutic extraction.
6. Abnormal erupted path and eruption sequence.
The premolars are the most-commonly extracted
teeth as part of orthodontic treatment modalities. Contraindications
Extraction should be atraumatic, care should be taken
to preserve the alveolus, not breaking any buccal, 1. Convex profile.
palatal or lingual bony part, it may jeopardize the 2. Severe crowding.
treatment. The main idea of therapeutic extraction is 3. Malformed teeth.
for creation of space, if there is any crowding. 4. Deep bite.
5. Impacted canine.
Serial Extraction Techniques or Procedures
B Kjellgren of Sweden in the year 1929 described serial A number of techniques or sequence of extraction have
extraction which is an interceptive orthodontic been reported from time to time.
 Role of Oral Surgeon in the Adjuvant Management for the Orthodontic Treatment
67
1. Dewel’s technique. Tweed’s Technique
2. Nance’s technique.
This method involves the extraction of deciduous first
3. Tweed’s technique.
molars at age of 8 years. This is followed by extraction
The Dewel’s technique proposed three stages
of first premolars and the deciduous canine.
extraction procedures.
Postserial extraction needs fixed appliance therapy
Stage 1 for the correction of axial and inclination and detailing
of the occlusion.
The deciduous canines are extracted to create space
for the alignment of the incisors. This stage is carried Extraction of Carious Tooth or Teeth/
out at 8 to 9 years of age. Supernumerary Tooth/Impacted Tooth/
Malformed Tooth
Stage 2
It does not require detailed discussion.
A year after the first stage, the deciduous first molars
are extracted so that the eruption of first premolars is Wilkinson’s Theory
accelerated.
Advocated the extraction of the first permanent molars
Stage 3 at the age between 8½ and 9½ years.
The erupting first premolars are extracted to permit The reasons of first molar extraction according to
permanent canines to erupt in their place. In some Wilkinson’s as because
cases a modified Dewel’s technique is followed 1. The first permanent molar is highly susceptible to
wherein the first premolars are enucleated at the time caries—extraction provides additional space for
of extraction of first the deciduous molars. This is eruption of the molar, the impaction of 3rd molar
frequently necessary in the mandibular arch where may be avoided.
the canines often erupt before the first premolars. 2. Crowding of the arch is minimized.

Nance’s Technique Surgical Exposure or Uncovering of

This technique involves the extraction of the deciduous Teeth Mostly Canine (Figs 9.1A to D)
first molars followed by the extraction of the first This is usually done in conjunction with an ortho-
premolars and the deciduous canines. dontist. Careful examination and history whether

A B C

Figs 9.1A to D: (A) Exposure of an impacted canine by excision

of the overlying palatal tissue, leaving a ‘window’ open for boding
and arthodontic attachment. (B) Exposure of an impacted canine
by raising a flap and bone removal. (C) Followed by bonding a
bracket with a twisted ligature wire. (D) Protruding through the
D soft tissue after the flap is sutured
 Synopsis of Oral and Maxillofacial Surgery
68
displacement of other teeth, the state of the primary The following criteria should be considered as
canine palpate to see any buldge in palatally or follows:
labially. a. The frenum should be merely be clipped. It should
Radiography I/o parallax assessment is manda- be totally excised to the bone level.
tory. Estimation of the depth of the canine within the b. Any palatally-attached fibrous tissues should be
bone, a lateral cephalogram may help. removed.
Operative treatment: If the canine placed palatally c. Fibrous tissue attached to the intermaxillary suture
the mucosa around the neck of the canine is to be area should be removed.
removed. If the canine placed labially same as above d. The mucosa of the lip is undermined to prevent
procedure. reattachment of the fibrous tissue.
The exposure of canine can achieve by removal of
bone with great care to avoid damaging the crown or Pericision or Circumferential
junction with the root. The whole of the greatest Supracrestal Fibrotomy
curvature of the crown is exposed and, or palatally- The surgical procedure provides to counter relapse
placed teeth, and area of overlying mucoperiosteum tendency stretched gingival fibers includes trans septal
is excised. A suitable haemostatic agent is used to alveolar crest group of fibers.
control of bleeding. Then orthodontists place a band To achieve and prevent to change the new tooth
around the canine for orthodontic movement in position or relapse. This method is generally used as
subsequent therapy for the placement of canine in an adjunctive retention procedure after the correction
aligns position. of rotation.
Fixation of orthodontic band: Attachments are
placed on the impacted canine to guide the erupting Method
tooth into the arch. The following attachments that • Obtain L.A.
can be placed on the impacted canine are: • No. 11 blade of B.P. knife passing through the
a. A metal crown with a hook. gingival sulcus around the tooth about a depth of
b. A celluloid crown with an attachment bonded to 2 mm apical to the alveolar crest.
it. • Control the bleeding by using pressure pack and
c. Bondable orthodontic brackets or buttons. haemostatic agent.
A ligature wire is placed in the crown around the
attachment and the other end tied to a removable or Transplantation of Tooth
fixed orthodontic appliance. The wire is gradually According to Wilkinson’s theory, the first lower molar
tightened at regular intervals to guide the erupting is very much prone to caries and this is the most
tooth.

Frenectomy
Frenectomy means cutting or removal of the frenum.
In general, frenectomy is indicated whenever a frenum
causes problems like phonation. High attachment of
frenum in which creates restricted movement of
tongue difficulty in chewing and opening the pocket
for food impaction. This may occur in premolar area.
A frenum also may cause a problem in the area
between the maxillary central incisors, thus contri-
buting to a median diastema. The fibers of the frenum
cross the height of the maxilla to the incisive papilla.
The papilla may blanch when the frenum is pulled. A
free gingival graft is performed in conjunction with
the frenectomy to prevent a recurrence of fiber Fig. 9.2: Surgical steps of frenectomy
attachment to the papilla. for removal of median diastema
 Role of Oral Surgeon in the Adjuvant Management for the Orthodontic Treatment
69
common indication for tooth transplantation. The first removed. The medullary bone is left undisturbed.
molar is automatically removed and the extracted Now it is possible to producing rapid orthodontic
third molar is placed into the first molar socket (lateral movement of the segment. Whenever there is
trepanation of third molar) that means the developing malocclusion with an abnormal basal bone relation-
third molar removed by Bowdler Henry 69 method. ship is highly temptating technique to achieve to align
Success of the transplant is most predictable when the the teeth. Cortical osteotomy the basic theme is an
apices of the roots of the tooth to be transplanted and osteotomy through the cortex of the alveolar bone at
one-third to one-half formed with open apices and the the base of the dentoalveolar segment, which serve
bordering bony plates are intact. the weaken the resistance of the bone to the application
of the orthodontic forces.
Corticotomy or Cortical Osteotomy
Placement of Implants or
This is a method of ensuring rapid movements of teeth
Bone Screw for Anchorage
with their investing bone by utilizing an orthodontic
appliance. Placement of implants or bone screw in the edentulous
In corticotomy, complete separation of alveolar area to work as an anchorage to accomplishment of
processes is not needed. Bony cuts are made in the orthodontic movements commonly used in posterior
cortical plate of bone and only the outer cortex is missing teeth area.
TEN
Pain, PTN and Facial Palsy
• Definition of Pain • Pain Theories • Concept of Facial Pain • Differential Diagnosis
• Treatment Modalities • Special Emphasis on PTN (Paroxysmal Trigeminal
Neuralgia) and Its Recent Update Overview • Some Observation of Facial Palsy
• Special Emphasis on Bell’s Palsy and Its Brief Management

DEFINITION OF PAIN Anatomy and Physiology of Pain

The word pain has been traced to ancient Greek The stimulus passes from the periphery via the sensory
means—a fine or penalty (Costich 1968). roots and spinal tract of the Vth nerve (also via the
According to Smith et al 1969, the term pain is cervical roots of VIIth, IXth and Xth) to the spinal
derived from the latin word ‘Poena’ meaning nucleus of Vth nerve from which the bultothalamic
punishment. tracts ascents to the thalamus (Figs 10.2 to 10.4).
Lord Buddha (around 500 BC) attributing to the Several theories have been postulated from time
universality of pain in the life to frustration of desires to time.
stated “Birth is attended with pain, decay is painful,
disease is painful, union with unpleasant is painful as Pattern Theory
also is separation from the beloved one”.
Specific theory of Von Fry: Specific receptors and
JJ Bonika 1975, the leading authority on this subject
specific pathway for pain sensation to pre-nerve
referred to pain as an emotional experience provoked
endings.
by the tissue injury or described by the patient in terms
of tissue damage or both.
Pain is defined as unpleasant sensory and
emotional experience associated with actual or
potential tissue damage or described in terms of such
damage. In this definition, the warning function of
pain is clearly identified.
Harris defined pain as it is an unpleasant emotional
experience suffered when hurt in either body or mind.
It is complex reaction involving all levels of nervous
system.

Concept of Basic Pain Physiology

Peripheral nociception: The term nociception derives
from Greek word “Nox” meaning harm or danger.
By nociception is meant all processes that originate in
the periphery and lead to pain sensation.
The peripheral pain receptor, which most often is
thin, unmyelinated (naked) nerve fiber, is thus termed
the nociceptor. All of the tissues in the body except
the brain and enamel of the teeth contain nociceptor.
The pain process is explained in Figure 10.1. Fig. 10.1: Pain process
 Pain, PTN and Facial Palsy
71

Fig. 10.2: The classic pain track from a tooth to the cerebral
cortex involving three neurons. The first neuron via the gs (that
means ganglion seminulare), then it passes to n-t-s-n-t (nucleus
tractus spinalis nervi trigemini) after reaching the nucleus the
synaptic junction of the second neuron, the gate is open and
transmit the second neuron to the thalamus. After that, the third
neuron transmits the pain perception to the cerebral cortex.
Then ultimately projecting the pain reaction

Fig. 10.4: Schematic drawing of the principle of the “gate” control

theory, where the gate is situated in the dorsal horn of the spinal
medulla
Explanation: A delta fibre stimulated by touch, vibration,
acupuncture or high frequency TENS. Non-specific pain-
transmitting gamma-fibre. Peripheral control. Descending central
control. Peri-aquaductal gray substance. Connections with
higher centres in midbrain and brainstem. Cerebral cortex.

• Small fibre—Inhibition of SG cells.

• Both large and small fibres stimulating T-cells.
Fig. 10.3: Chemical pain transmitter substance P. The electric • Presynaptic inhibition—SG cells.
pain message is in the synapsis transformed to chemical • Stimulation of large fibres—Gate is closed.
message as a chemical transmitter substance is released from • Stimulation of small fibres—Gate is open.
the presynaptic neuron, crosses the synaptic cleft, and affects 1. The cells of SG cells act as a gate.
the postsynaptic neuron, where the pain transmission continues
2. The control system, which modulates afferent
or is perceived
pattern before they influence T-cells.
3. T-cells activation the neural mechanism which
Gate control theory by Malzack and Well. It is quite comprised the action system for responsible for
accepted and popular theory of pain. Stimulus of the perception of pain.
skin leads to impulses going through to brain in three The electric pain impulse is transformed into a
pathways. chemical message in the synapses and back into an
• First pathway—Activation of SG cells (substantia electric action potential in the postsynaptic neuron.
gelatinosa of Ronaldo). The release of the chemical pain transmitter substance
• Second pathway—T-cells stimulates central trans- P can be blocked by naturally occurring morphine—
mission cells. like substance called endogenous morphines or
• Third pathway—Dorsal column stimulation, the endorphins. When endorphins are released from small
central system. interneurons close to the presynaptic neuron, they
• Large fibre—Stimulates the SG cells. attach to opioid receptors on the presynaptic neuron
 Synopsis of Oral and Maxillofacial Surgery
72
and block the release of substance P, thus blocking Pain Perception
further pain transmission. If this important pain
Pain perception is pain experience, which happens in
controlling system malfunctions, chronic pain can
the cerebral cortex. The perception of pain is a process
result. Some instances of chronic pain related to
that remains unexplained, we do know that the
depression have been shown to be characterized by
participation of consciousness is necessary. If
lower-than-normal concentrations of endorphins in
consciousness is removed by general anesthesia, the
the spinal fluid. The interneurons are especially found
brain will still perceive pain by the usual pain mecha-
in the substantia gelationsa of Ronaldo in the dorsal
nisms but the mind will be unaware of it. This
horn of the medulla spinalis and in the brain stem.
perception can be registered by monitoring blood
These interneurons probably can be activated by
pressure and pulse during general anesthesia.
both peripheral means and central means.
Whenever painful procedures are performed, blood
The peripheral control is activated when mechano-
pressure and pulse frequently rise, and it becomes
receptors are stimulated, e.g. by needle acupuncture
necessary for the anesthesiologist to administer more
or by electrical stimulation, or TENS (transcutaneous
general anesthetic in order to keep the patient quiet
electrical nerve stimulation).
and motionless. It is, therefore, wise to block the pain
The central control is activated from some cells in
tract peripherally, by administering local analgesia in
the area around the aquaductus cerebri (PAG =
the field of surgery, in order to minimize the central
periaquaductal gray substance). This area, in turn, is
input of painful impulses. Blocking the pain tract will
activated from the cortex cerebri, from the
decrease the risk of postoperative pain and edema and
hypothalamus, and from reflex loops from the
ensure a more even and smooth general anesthesia.
ascending pain tracts. Also, exogenous administered
opioids (morphine, meperidine) can activate the PAG
Pain Reaction
cells and thus the descending central pain control. The
convergence of both the peripheral and the central Pain reaction is the body’s reaction to pain perception.
control in the back horn is called the “gate”. Pain reaction is usually both—physiological and
If a pain tract is activated many times, pain tract psychological.
“printing” probably can take place. That is, the pain Physiological pain reaction is autonomic response
tract is easily remembered by the nervous system. and includes rise in blood pressure and pulse,
Next time something happens in the periphery close sweating, paleness, nausea, vomiting and motor
to the nociceptors of the printed tract, it is likely that withdrawal (pain reflex).
the specific tract is activated, and the patient Psychological pain reaction includes the crying,
experiences pain to stimulus that otherwise would be fear, or anger that may accompany pain perception.
subliminal. Pain tract printing is believed to be one Pain reaction varies widely from person to person, and
source of chronic pain arising in the periphery after also will vary within the same person depending on
acute pain, and also to be involved in postoperative the person’s will of mind and body, and time of the
pain. General anesthesia blocks pain perception in day.
cortex cerebri by removing the consciousness. The Pain reaction can be lessened by sedatives, nitrous
pain tract, however, is intact during surgery. The brain oxide, alcohol, morphine, hypnosis, and suggestive
remembers the pain tract after the anesthesia wears relaxation measures, and increased by fear,
off, and the patient experiences postoperative pain and depression, previous bad experiences, and unpleasant
discomfort in the area. Blocking the area of surgery behaviour of dental team members.
with analgesics apparently prevents the pain tract
printing. In experiments using analgesics for this Pain Threshold
purpose, patients without exception have experienced Pain threshold is an imaginary factor. It is defined as
less postoperative pain and swelling. being inversely proportional to pain reaction, i.e. the
more pain reaction the less pain threshold and vice
Components of Pain versa. When talking about the pain threshold it is
A. Pain perception, important to define the parameters. A patient is said
B. Pain reaction, and to have high pain threshold when he exhibits little or
C. Pain threshold. no reaction to a painful stimulus, whilst a patient with
 Pain, PTN and Facial Palsy
73
a low pain threshold is liable to react violently to an Doppler, transillumination, toothslooth (adjunct
identical or even lesser stimulus. In other words, pain for localizing cracked tooth).
threshold is inversely proportional to pain reaction.
The pain threshold also varies between individuals Differential Diagnosis of Orofacial Pain
and in the same individual at different times. Some
1. Pain arising from teeth and supporting structures.
factors which determine its level include:
2. Pain from neighbouring structures, like TMJ, ear,
1. Psychological make-up: Whilst it is readily
salivary gland, tonsils, eyes, elongated styloid
apparent that emotionally unstable persons have
process (Eagle syndrome).
a low pain threshold, it is easy to forget that each
3. Neuralgias—primary neuralgias, e.g. tic dou-
and every one of us is affected by our attitude
loureux.
towards the procedure, the operator, and our
Secondary neuralgias, e.g. mental nerve compres-
surroundings. In some patients previous painful
sion or entrapment, causalgias.
experiences have visual or olfactory association
Fray’s syndrome, nasopharyngeal carcinoma
which may lower their pain threshold on subse-
(Trotter’s syndrome), posttherapeutic neuralgias
quent occasions.
etc.
2. Fear and apprehension of dental treatment:
4. Vascular pain—migraine, facial migrainous
Nervous patients become hyper-reactive and tend
neuralgias, temporal arteritis.
to magnify pain out of all proportion. It is therefore
5. Psychogenic pain like atypical facial pain, atypical
essential to attempt to secure the patient’s
odontalgia (Idiopathic periodontalgia) by Harris.
confidence by all possible means and as early as
This can be designate as whole orofacial pain of
possible.
emotional perspective. The present author
3. Fatigue: As tiredness increases the pain threshold
influenced and elucidated by Prof. Harris about
is lowered.
orofacial pain concept also includes the T.M. joint
4. Age: Whilst order patients usually tolerate pain
dysfunction syndrome or myofacial pain dys-
well, children often have low pain threshold and
function syndrome and the recent term facio-
also find difficulty in distinguishing between pain
arthomyalgia (FAM).
and pressure.
6. Oral dysaesthesia—This group includes burning
tongue—glossodynia, dry mouth, denture
SUGGESTED READING
intolerance, phantom-bite syndrome, abnor-
1. WE Bell (1985). Orofacial pain, classification, diagnosis and malities of taste, including the obsessional fear of
management. halitosis or a conviction of a ‘discharge’ from a
2. MR Bond (1979). Pain, its nature, analysis and treatment. particular corner of the mouth (cited from facial
3. GL Howe (1983). Disorder of the masticatory apparatus.
pain lectures of Prof Malcom Harris).
Oral dysaesthesia or burning mouth syndrome
Diagnosis
affects females > males 7:1 ratio. They are classified
1. The history is very important for the diagnosis according to the clinical features:
which includes the nature of pain that is sharp, dull, 1. Type I: Usually asymptomatic on waking from the
throbbing, burning, stabbing or altered feelings of sleep and increases during the day with a good
oral cavity (oral dysasthesia) Duration—may be prognosis.
short or constant. Site and radiation—the history 2. Type II: Symptoms present on waking and
should indicate the primary site of pain and radiate continue throughout the day associated with
to other areas. Timing onset and frequency. significant anxiety or depressive mood. Prognosis
Provoking and relieving factors. is poorer than type I.
2. Clinical Examination includes (a) visual, (b) 3. Type III: Intermittent symptoms sometimes
probing, (c) percussion (tenderness on percussion involving the other side example floor of the
is very important feature in case of irreversible mouth-associated factors may be allergy.
pulpitis, periapical, periodontitis and periapical The most common presentations are:
access). 1. Burning tongue—glossodynia or glossopyrosis.
Special test includes vitality test. X-ray includes 2. Dry mouth in the presence of saliva ‘salivary sand’.
periapical and bitewing radiograph and OPG, laser 3. Denture intolerance.
 Synopsis of Oral and Maxillofacial Surgery
74
4. Phantom-bite syndrome is the situation where a 7. Correction and replacement of ill-fitting dentures.
patient cannot find position of comfort despite 8. If the mucosal infection like candidiasis then anti-
having worn dentures for many years. fungal therapy. Candid (Clotrimazole 1% W/V
5. Abnormalities of taste, including obsessional fear Sol.) mouth paint 10 to 20 drops gently applied the
of halitosis or a conviction of a ‘discharge’ from a affected area of mouth 3 to 4 times daily.
particular corner of the mouth. 9. Use of artificial saliva as glandosen or xerolub 4 to
6 times daily in case of xerostomia.
Factors Responsible for Burning 10. To reduce parafunctional activity suitable bite-
Mouth Syndrome or Oral Dysaesthesia guard or occlusal splint.
Include the Following 11. To reduce psychological factors Diazepam 5 mg at
bedtime may be adequate especially for cancer
1. Deficiencies of nutritional factors: Fe, Foliate and phobia. Antidepression, drug therapy is often
vitamin B1, B6, B12 helpful (please see the chapter drugs and the doses
2. Undiagnosed diabetes mellitus. mention in the treatment of FAM) Alprozolam 0.25
3. Ill-fitting denture, which may be unstable or hyper- mg to 0.5 mg at bedtime and or antidepressive
sensitivity to acrylic monomer. drugs recommended previous discussion.
4. Mucosal infection, which may be fungal 12. In case of allergy identification of the allergen and
candidiasis. treat accordingly.
5. Xerostomia (Treatment: artificial saliva. It is a 13. For the burning mouth Tantum oral rinse (0.15%
slightly viscous inert fluid, which has number of Benzydamine HCl). Prior to consume the main
additives, such as antimicrobial preservatives that meal rinse the mouth for better consumption of the
is fluoride, flavouring agent. The preparation food without complication.
available is Glandosane and saliva—orthana as 14. Kamillosan liquid contains Chamomilla oil 15 mg
aerosol sprays 4 to 6 times per day). in aqueous base. This can be used as paint 2 – 3
6. Increase parafunctional activity: clenching bruxism times daily or also used as mouthwash with water.
and habit of tongue-thrusting.
7. Psychological factors: anxiety depression and Pain Arising from Teeth and
cancer phobia. Supporting Structures
8. Allergy denture base material and food additives.
1. Pulpal pain: This may be reversible pulpitis (Pulpal
Investigation Includes hyperaemia). The clinical features include hyper-
sensitivity or pain aggravated to hot, cold or sweet
1. Total blood count. and sour. Pain is usually sharp and throbbing,
2. Assays of Fe, foliate and vitamin B12. difficult to locate and subside following removal
3. Estimation of blood sugar. of the stimulus. Exaggerated response to vitality
4. Smear for Candida. test for the pulp. There may be leaking restoration
5. Prosthodontic assessment for dentures. and carious cavity.
6. Evaluation of psychological status. Treatment: Removal of the cause includes caries
7. Patch test for allergic component. and placement of a sedative dressing (ZOE Paste)
with suitable restoration.
Treatment 2. Irreversible pulpitis: Duration of pain may last few
1. Reassurance (to explain the benign nature of the hours. Pain is aggravated hot and cold initially in
problem). later stage hot causes more pain. The pain is dull
2. Correction of underlying organic pre-disposing and throbbing, difficult to locate but if the
factors. inflammation spread to the periapical tissue the
3. Rich nutritional diet. tooth become more sensitive to percussion.
4. Iron rich, foliate with vitamins and minerals. Treatment: Includes removal of the pulp and RCT
5. Neuro-vitamins like B1, B6, and B12. and suitable restoration. Suitable antibiotics to
6. Controlled blood sugar and anti-diabetic treatment control infection and suitable analgesic to reliving
in case of diabetes mellitus. pain.
 Pain, PTN and Facial Palsy
75
Analytical observation: The pulp stone, the nodular associated with coagulation disorder, trauma,
calcification within the pulp chamber. This pulp hormonal disbalance, cancer chemotherapy, profound
stone may be composed of denticles, and the use of prednisolone and alcohol abuse. Osteonecrosis
nodular calcification free, attached or embedded. is not visualized in X-ray. Occasionally shows an
Sometimes pulp stone causes the neuralgic type of admixture of irregular sclerotic and radiolucent areas
pain referred to adjacent areas. X-ray may have the that means ischemic osteosclerosis with a faint central
diagnostic values (reported). sclerotic oval zone surrounded by a thick radiolucent
Treatment: Includes the extirpation of the pulp and circle which is, in turn, surrounded by a thick faint
the pulpectomy followed by suitable restoration. sclerotic ring (Bull’s eye lesion) may be identify by
3. Cracked or split tooth syndrome: A sharp pain or MRI or CT scan of bone.
biting of short duration, the tooth may have large Treatment includes initially antibiotics. Sometimes
restoration or history of biting hard substance, decortications and curettage may be necessary.
subsequently the pain started during chewing. 7. Other conditions: In these headings the pain may
Diagnosis is important for treatment point of view. be defuse or patient may localized the pain zone
Treatment: Includes restoration with coverage of in the following: buried roots, erupting third molar
the tooth if in case of vertical split extends upto which may cause pericoronitis or impacted tooth
roots, extraction of tooth may be required. and resorbed alveolar ridge where the mental
4. Periodontal pain: Dull continuous relieved initially foramen position changed from usual area to
by clenching but later aggravated. Primary superficially near to the upper border of the
irritation or secondary to pulpitis. Poorly localized alveolar ridge. The denture causes pressure
Tr. Oral prophylaxis, supra and sub gingival symptom on the mental nerve entrapment.
curettage and surgery. Treatment: According to the cause.
5. Acute periapical infection leads to periapical
abscess. The pulppal necrosis with periapical Pain from Neighbouring Structures, Like TMJ, Ear,
infection. The inflammatory changes characterized Salivary Gland, Tonsils, Eyes, Elongated Styloid
by with sever throbbing pain associated with Process (Eagle syndrome)
disturb sleep. The tooth and the supporting
structure tender on palpation. Tooth may be mobile Temporomandibular joint and masticatory muscles:
and extruded from the socket there may be Acute dysfunction moderate discomfort in joint
localized or defuse swelling. aggravated by chewing, talking, and yawning.
Associated trismus and deviation of jaw to painful side
Treatment: Includes drainage of pus by opening on opening. Tender effusion.
the canal, and suitable antibiotics if the supporting Etiology subluxation trapping meniscus or capsule
bone is favourable the RCT and or apical currattage or direct trauma.
if necessary.
6. Bone pain: Dull to severe throbbing (fractures, Treatment: Rest, soft diet, aspirin, short-wave diather-
alveolar osteitis, osteomyelitis, osteoradionecrosis, my.
neoplasia). Acute inflammatory rheumatoid arthritis (uncom-
Treatment: On the basis of history, diagnosis and mon). Treatment—Above plus steroids, etc. Infective
causative factors and treat the case accordingly. (rare). Treatment—Chemotherapy.
TM joint dysfunction syndrome or myofacial pain
Analytical Observation: NICO means neuralgia:
dysfunction syndrome or facioarthomyalgia
Inducing cavitational osteonecrosis. It is an ischemic
(discussed in detail in TM Joint Chapter). Dull ache in
osteonecrosis of bone characterized by intermittent
joint or associated muscles. Often long standing, e.g.
pain and degeneration and death of marrow with a
many years, intermittent usually without change in
slow abrupt decrease in marrow blood flow. This is
intensity.
commonly affected female of age 35 to 60 years. Males
and teenagers are also affected. The common sites are Timing: Two groups:
third molar region, walls of the maxillary air sinus 1. Wake in morning with pain and trismus, gradually
and the mandibular condyle. It is commonly subsides, are nocturnal grinders.
 Synopsis of Oral and Maxillofacial Surgery
76
2. Dull ache during day especially after meals of discharge. Tender over antrum. Pan sinusitis—
evening when tired. Diurnal clenchester. widespread facial pain.
May complain of clicking or sticking jaw joints. Radiograph: Opaque sinus often fluid level.
Tenderness present in masticatory muscles or joint.
Pain mechanism, probably release of pain substances Treatment
due to intramuscular vasodilatation.
1. Antibiotics, encourage drainage with steam
Etiology: An infinite range of combinations of inhalations (nasal decongestant).
emotional stress (see also psychogenic facial pain) and 2. Intranasal antrostomy (rarely).
malocclusion. At one end pure anxiety or depression 3. Ears: Occasionally otitis externa referred to
manifested as nocturnal bruxism with a normal mandibular area. Pain on rotating concha.
occlusion at the other a simple loss of occlusal support Etiology: Furuncle or impacted wax.
requiring partial dentures. (Including common exam- Treatment: Antibiotics etc.
ples such as clenching with or without pipes, pencils, 4. Salivary Glands: Dull pain associated with meals
pipettes, erasers, premature cuspal contacts, balancing and swelling. Establish nature of obstruction.
contacts, ill-fitting, over-closed or over-open dentures. Treatment: Antibiotics, surgery.
Also, reflex spasm from ipsilateral inflammatory 5. Tonsils: Quinsy, vincents angina, and acute
lesions or due to the avoidance of contra-lateral tonsillitis. Patient present with maxillary pain and
inflammatory lesions. some trismus.
Treatment: Quinsy (peritonsillar abscess) incise
Choice of Treatment and drain. Antibiotics.
6. Eyes: Rarely acute glaucoma presents as severe
a. Reassurance and abolition of stress induced habits. facial neuralgia. Associated disturbed vision and
b. Necessary dental care—minor malocclusion does high intraocular pressure.
not cause pain. Treatment: Pilocarpine and surgery.
c. Anxiolytic, e.g. diazepam 5 mg at bedtime.
However, the anxiolytic tricyclic drugs such as Elongated styloid process: Eagle syndrome. Rare pain
dothiepin 25–150 mg at night appear to be more on swelling and digital pressure in tonsillar fossa.
effective. Evident on radiograph.
d. Analgesics Mefanamic acid 500 mg or ibuprofen Treatment: Surgical (Carefully exclude glossopharyn-
325 mg with paracetamol 500 mg may be geal neuralgia and psychogenic pain regardless of
prescribed (Ibugesic Plus) after food. radiographs).
e. Devices to prevent bruxism, such as a temporary
acrylic or soft-bite guard (luciajig or shore Referred from Remote Structures
appliance recommended by Vambus and Morgan)
to be worn at night or in between meals. Angina Pectoris: Dull ache at angle of mandible on
f. Psychotherapy where indicated, i.e. intractable exertion. Ischaemia changes on E.C.G.
cases invariably have an over or latent psychiatric Treatment: Vasodilators, etc.
problem.
Chronic inflammatory: Osteoarthrosis. Cervical spondylosia: Referral neurologically possible,
difficult to prove clinically. However significant
Treatment correlation between TM joint dysfunction syndrome
and cervical pain, i.e. mechanism is reflex (muscle
a. Correction of occlusion by prophylatic selective spasm).
grinding.
b. Analgesics, injection intra-articular steroids. Subacute thyroiditis has been reported.
c. Rarely surgery, i.e. “condylar shave” and TM joint
Neuralgias
arthoscopy.
2. Sinusitis: Severe ache uni or bilateral. Maxillary Primary neuralgias, e.g. tic douloureux (Nicholaus
premolar and molar teeth may be periostitic. Worse Andre in 1756 coined the term) John Fothergill in 1773
on bending. Associated nasal obstruction and reported the first detailed description of PTN
 Pain, PTN and Facial Palsy
77
(paroxysmal trigeminal neuralgia) for that reason it 8. Viral lesions.
is also known Fothergill’s disease. 9. Pressure from adjacent structure.
The clinical features include intermittent Diagnosis of the affected branch of nerve can be
paroxysmal lancinating, stabbing, excruciating severe identified by the use of injecting local anesthetic
pain along the course of trigeminal nerve. The pain solution to the concern nerve.
never crosses the midline. The pain started as volleys
of jabs (bombardment and severe poker) having the Treatment Modalities
definite trigger zone duration of pain few seconds to Medicinal. Neurovitamins B1, B6 and B12 used routine-
less than minute. In between two bouts, there is no ly with little and questionable value.
pain at all. The patient showing the point of trigger Blom reported the response to anticonvulsants like
without touching the zone, the finger is half-inch away carbamazepine is highly effective for reliving pain in
the point of trigger as because the touching the area case of PTN. The carbamazepine can be given tailing
pain started immediately so this point is very or taper the doses may be start with 200 to 400 mg
important known as half-inch sign, positive. three times daily for 10 to 15 days according to the
Provocating factor includes touch movement, draft of severity of the cases. When the carbamazepine
air, talking, chewing and swallowing. (tegretol or mazetol) is contraindicated the
clonazepam 1.5 mg may be used daily. The side effects
CLINICAL PANAROMA AND DIAGNOSTIC include drowsiness, fatigue, lethaergy. Oxcarbazepine
CRITERIA OF PTN AT A GLANCE 1200 mg per day in divided doses. Side effects include
Site: Vth nerve mostly mandibular and maxillary diplopia, hyponatraemia. The recent less toxic agents
rarely ophthalmic division. like baclofen (lioresal) 30 mg in divided doses per day.
Duration: Paroxysmal—complete pain remissions in
between the attack of pain. Surgical Modalities of Treatment
Sign: Half-inch sign positive with definite trigger Injection 95 percent absolute alcohol 0.5 to 1 ml
zone. injected to the affected peripheral branches of the
Character: Sharp, shooting, electric shock like pain. trigeminal nerve. After obtaining the local nerve
Severity: Very severe, suicidal. blocked anesthesia. Intra-oral approach is normally
used.
Relieving factors: Sleep, local anesthetic. After obtaining local anesthesia 1 to 1.5 ml sterile
Associated factors: Weight loss, anxiety, and 99.9 percent anhydrous glycerol was injected slowly
depression. at the mandibular or intraorbital foramen, depending
Provoking factors: Non-noxious stimuli, e.g. eating, on the division of the trigeminal nerve affected.
washing and talking.
Peripheral Neurectomy or Nerve Avulsion
Examination: No gross neurological deficit.
Intraoral conventional approach by Ginwalla’s
technique. Incision is made along the anterior border
Etiology: Mostly Idiopathic
of ascending ramous extending lingually and buccally
Popular aetiological theories include according to by a reverse Y incision exposing the medial aspect of
Bayer and Stenger 1979. the ascending ramus by means of blunt and sharp
1. Lesions within trigeminal ganglionic end or its dissection exposing the mandibular foramen through
rootlets. which the inferior dental nerve passing through the
2. Cerebellopontine angle tumefaction. mandibular canal. Another incision is made in relation
3. Aberrant and arterosclorotic arteries. to mental foramen and the mental nerve is freed. Then
4. Hyperostosis of the petrous bone. from the mandibular foramen with the help of a
5. Demyelenation causing plaques at or near the hemostat gradually screwing the entire nerve is
trigeminal roots. avulsed from the canal. Wound is closed with suture.
6. Central brain lesion (thalamic cortical). Braun’s recommended transantral approach 1977,
7. Ischaemic to various portions of the trigeminal for the maxillary peripheral neurectomy via the
system. Caldwell Luc operation.
 Synopsis of Oral and Maxillofacial Surgery
78
Infraorbital neurectomy can be done intraorally via SURGICAL MODALITIES
the incision in the canine fossa region raising the muco- OF PTN AT A GLANCE
periosteal flap and exposing the intraorbital foramen
and the same method used before for avulsion of the The current trend in surgical treatment of PTN is to
infra-orbital nerve. use less-invasive procedures such as cryoanalgesia
Extraoral peripheral neurectomy recommended by (Lloyd et al. 1976; Barnard et al. 1981; Zakrzewska
Poppen and Thoma by extraoral Risdon incision and Nally, 1988), precutaneous retrogasserian
(rarely used). glycerol rhizotomy (Hakanson, 1981; Lunsford and
Cryotherapy or cryneurolysis for peripheral nerve: Bennett, 1984) radio frequency thermocoagulation of
Cryoprobe the temperature of (-) 60 o centrigad the trigeminal ganglion (Sweet, 1976), radio-
destroying the nerve sheath and destruction of the frequency thermoneurolysis of peripheral branches
nerve cells due to osmotic shock. of the trigeminal nerve (Gregg and Small, 1986) as
Thermocoagulation cordotomy, precutaneous well as the injections of affected peripheral branches
radio-frequency trigeminal neurolysis by Sweet and of the trigeminal nerve with different substances like
Wespek later modified and improvised by Gregg and Alcohol, Glycerol, Streptomycin/Lidocain (Kranzi
Small under LA fluoroscopic guideline a coaxial radio and Kranzl, 1976; Sokolovic et al. 1986; Stajcic, 1989;
frequency electrode is introduced through the skin Stajcic, 1990). Ginwalla, Poppen and Thoma
into foramen ovale and gasserian ganglion and described the surgical procedure of “peripheral
stimulation of nerve is carried on, and gradual neurectomy” at late sixties, of which Ginawalla’s
destruction is created under monitoring. technique is most popular in practice.
TENS or transcutenous trigeminal nerve
stimulation by O’nell. Secondary Neuralgias
Microvascular decompression by Jannetta and 1. Extracranial: Mental nerve compression by denture
Dandy a neurosurgical modalities via the retromastoid due to alveolar resorption easily elicited clinically.
approach. Old patient with radiological evidence of high
foramen.
Balloon compression: Under GA this mechanical
technique is used to destroy partially by advancing 4 Treatment: Relieve area or set down nerve surgically.
FG Fogarty Catheter about 1 to 2 cm within Meckel’s Mental nerve entrapment: Intermittent severe
cave and inflating the balloon at the ventral aspect of paroxysmal pain like tic doloreux in mental area. Old
the ganglion root via a 12 gauge spinal needle passed patient with radiological evidence of narrowed mental
into the foramen ovale and the balloon catheter is foramen. Occasionally due to Paget’s diseases.
passed through it after the placement of the balloon it
Treatment: Decompression of the mental nerve.
is inflated with X-ray contrast guidance remain the
inflated balloon for 1 minute. All above procedure Temporomandibular joint osteoarthrosis may be
mainly under the neurosurgical domaine. The difficult to distinguish from trigeminal neuralgia, and
intracaninal procedure is not discussed for the former in some cases appears to provoke it.
reason. Treatment: NSAI drugs with intraradicular injection
of steroid.
Differential Diagnosis of PTN Causalgia: Persistent burning pain usually well-
localized in the mandible with a history of traumatic
1. Facial arthromyalgia.
surgical intervention subsequent damage to the nerve.
2. Atypical facial pain.
3. Migranous neuralgia. Treatment: Neurovitamin and reassurance.
4. Hemifacial spasms. Frey’s auriculotemporal syndrome: Paroxysmal
5. Eagle syndrome. burning pain in the temporal area associated with
6. Atypical odontalgia (idiopathic periodontalgia, flashing and sweating on eating is due to parotid
phantom tooth syndrome). surgery or inflammation rarely due to condylar
7. Trotter’s syndrome. fractures.
 Pain, PTN and Facial Palsy
79
Treatment: Sometimes relieved by avulsion of nortriptyline) 1 tablet at night can be useful as
auricular temporal nerve. prophylactic measure.
Trotter’s syndrome: Nasopharyngeal carcinoma Facial migrainous neuralgia (Horton’s syndrome,
involving the V nerve leads to facial pain and Sluders syndrome, cluster headaches, histamine
paresthesia, conductive deafness and ipsilateral cephalgia, sphenopalatine neuralgia, alarm clock
elevation of soft palate with dysphagia and the headache, etc.)
affected medial pterygoid muscle leads to trismus. Intense pain in the periorbital region, usually at
night, associated with sensation of nasal obstruction,
Treatment: Radiotherapy and chemotherapy. and conjunctival hyperaemia. Attacks last about half
2. Intracranial: Postherpetic neuralgia—following an hour, and characteristically occur in groups, i.e.
shingles of VN or Ramsay Hunt syndrome (Herpes nightly or alternate nights for several weeks followed
zoster of geniculate ganglion which may spread by remission. Some patients provoked by alcohol.
to trigeminal distribution). Attacks of severe pain Occasional migraine patients also have features of TM
lasting for half an hour associated with scarred joint dysfunction syndrome, and should be treated for
areas of ciminished or increased sensation— anxiety or depression.
anesthesia dolorosa. Usually improves in six
months to two years. Treatment: Includes prophylaxis.
Indomethacin, beta blockers, methysergide 6 to 12
Treatment: Analgesic for relive of pain. Not amenable
mg orally daily and calcium channel blockers.
to surgery.
Incase of acute episode therapeutic oxygen and
Tumors of the posterior cranial fossa, e.g. Sumaptriptan.
cerebellopontine angle neurinomas (VII or VIII N)
Giant cell arteritis: Vascular pain syndrome of the
pain, deafness, ataxia.
temporal region, can affect other branches of the
Middle-cranial fossa lesions include pituitary tumors, external carotid artery. Severe localized pain in older
carotid aneurysms—pain with disturbances in vision age if internal maxillary branches involves, inter-
and extraocular movements. mittent claudication on eating in muscles or masti-
cation and tongue. Involvement of ratinal or cilliary
Vascular Pain—Migraine, Facial Migrainous vessels may cause blindness.
Neuralgias, Temporal Arteritis Investigation and diagnosis: Elevated ESR and C
reactive protein level during acute phase. Normo-
Migraine: Hemicrania. Visual disturbances, nausea,
chromic, normocytic anaemia in 50 percent of cases.
ataxia. May, however, be deep steady midline
Temporal artery biopsy demonstrates infiltration
throbbing pain accentuated by sneezing, coughing or
of artrial wall with giant cell. Early diagnosis and
head movement.
treatment is important on the prospective of
Mechanism: Spastic dilatation of cranial arteries. Some potentially serious ophthalmic complication.
patients unable to conjugate tyramine to avoid certain
Treatment: Includes systemic steroids immediately.
foods.
High doses are recommended with the consultation
Treatment: Paracetamol 500 mg with metoclopramide of medical specialist and ophthalmic surgeon.
5 mg 1 to 2 tablet at onset of attack followed by 1 to 2
tablet four hourly maximum 6 tablets per day. Psychogenic Pain
Ergotamine tartrate: 1 to 2 mg orally or by suppository. This pain like atypical facial pain, atypical odontalgia
0.36 to 0.72 mg by inhaler. (Idiopathic periodontalgia) by Harris. This can be
Severe cases: 0.25 to 0.5 mg ergotamine tartrate IM designates as whole, ‘orofacial pain of emotional
with 50 mg cyclizine lactate. Methysergide 6 to 12 mg perspective’. The present author influenced and
orally (side effects angina pectoris, retroperitoneal elucidated from Prof. Malcolm Harris about orofacial
fibrosis). pain concept also includes the TM joint dysfunction
In pregnancy and vascular disease Pro- syndrome or myofacial pain dysfunction syndrome
chlorperazime 5 mg short courses of a tricyclic and the recent term facioarthomyalgia (FAM) (This
antidepression, e.g. motival (Fluphenazine and topic is already discussed in TM joint Chapter).
 Synopsis of Oral and Maxillofacial Surgery
80
Atypical Facial Neuralgia • Paresthesia and abnormal and altered sensation,
whether spontaneous or evoked.
Dull or throbbing pain of long standing in non- • Paresis means partial dysfunction.
muscular parts of face or in jaws and teeth. Often • Anesthesia, loss of sensation.
associated with migrainous pains elsewhere. • Local anesthesia preferably termed as local
Unilateral, midline or bilateral–varies. Attacks may analgesia, loss of pain sensation in response to the
last weeks followed by remissions. Patient usually stimulus.
presents with a history of unnecessary extractions. • Dysaesthesia already discussed above.
Teeth may be tender to percussion even where non- • Hypokinesia means diminished movements.
carious and vital. Mucosa often hyperaemic. • Neuritis inflammation of the nerve.
Incompletely abolished by local analgesia of • Neuralgia transmission of pain impulse passed
trigeminal nerves. A significant number of patients along the distribution of the nerve or nerves.
have an underlying depressive illness. • Neuropathy—A disturbance of function or patho-
logical change in a nerve.
Cause • Nerve injury, which includes:
This has the characteristics of a vascular pain. Possibly — Neuropraxia is characterized by a conduction
local muscular activity such as bruxism produces nerve block, which is reversible.
painful vaso-dialatation which persists due to — Seddon and Sunderland proposed two classi-
inadequate catecholamine activity which is a feature fications related to nerve injury, which applied
of depression. Both pain and depression respond to to motor as well as sensory nerves.
tricyclic or meno-amine-oxidase inhibitor anti- — Tinel’s sign earlier indicates the initiation of
depression, e.g. dothiepin 25 to 75 mg night initially— nerve regeneration. Recently, electroneuro-
then increasing to maximum tolerated dose over 3–4 graphy diagnostic study shows for evidence of
weeks. NB relief may not be achieved for up to 8 reinnervation.
weeks. — Axonotmesis it represents the axtional injury
with subsequent degeneration and regene-
Mono-amine-oxidase inhibitors e.g. Phenelzine 15
ration. Tortion, compression and traction are
mg at 8, 12 and 4 pm and diazepam 5 mg nocte.
the most common cause.
Refractory cases should also be provided with a bite
• Neurotmesis – it is a severe disruption of the nerve
guard.
trunks with irreversible recovery. This injury
Unfortunately, some patients strongly resist a
caused by laceration, avulsion or chemical injury.
diagnosis of depression and psychiatric help but insist
Its damage to all components of the nerve trunk
on an organic diagnosis. Invariably this gives rise to
includes axon, endoneurium, perineurium and
fruitless operative procedures.
epineurium.
Atypical Odontalgia (Dental Migraine) Facial Palsy and Bell’s Palsy
Throbbing dental pain with hypersensitivity of one The facial nerve has a complex course from the
or more teeth to all stimuli – indistinguishable from brainstem through the temporal bone and the parotid
pulpitis. Often widespread or bilateral. Commonly gland, before innervating the muscles of facial
precipitated by dental treatment and made worse by expression. Running along side this motor nerve are
further intervention. Appears to be a hyperalgesia of sensory fibres conveying test from the anterior 2/3rd
the pulp and periodontal receptors due to vaso- of the tongue via the chorda tympani. The motor root
dilatation. supplies to the muscles of the face and associated
A careful history reveals significant emotional muscles. The preganglionic parasympathetic
problems in most patients. These patients are best (secretomotor) fibres to the submandibular, sublingual
considered to be a variant of atypical facial neuralgia. salivary gland, lacrimal gland and gland of the nose.
The temptation to devitalise or extract teeth mist be Damage to the facial nerve results in facial
strenuously resisted. weakness and a considerable cosmetic deformity. The
The various terms are used in neurological distur- neurological level of damage determine the clinical
bances, which are as follows: picture.
 Pain, PTN and Facial Palsy
81
The upper part of the face receives bilateral upper Etiology
motor neuron innervation from both cerebral
Bell’s Palsy: According to definition it is an idiopathic
hemispheres whereas the lower part of the face
condition. Various theories have been postulated from
receives upper motor neuron innervation from the
abnormal immunological response to reactivated
contralateral hemisphere. Thus, the upper motor
herpes simplex virus and infection in the geniculate
neuron affects only the lower part of the face on the
ganglion. There are various hypothesis from
opposite side while a lower motor neuron lesion
rheumatic ischaemic immunologic viral and cold
affects the whole of the face on the ipselateral side.
hypothesis of which cold exposure proposed by
Charles Bell and the viral infection and ischaemic
Upper Motor Neuron Lesion
hypothesis having the reasons on etiological point of
Acoustic neuroma, CVA, multiple sclerosis, lower view.
motor neuron lesion, Bell’s palsy, trauma may be
surgical or temporal bone fracture. Cerebellopontine Clinical Features
angle tumors then malignant parotid gland, middle
ear infection, sarcoidosis. Includes sudden onset usually early in the morning
after sleep. Loss of muscle control of one side of the
Clinical pictures consist of weakness of facial muscle
face. Inability to smile, close the eye or wink or raise
leads to paresis that means partial dysfunction.
the eyebrow on the affected side. Not able to close the
Loss of motor function (movements) is called facial
eye leaf. Attempt to close the eye, the eye–ball rolls
paralysis represent difficulty in consuming fluids and
upward this is known as Bell’s sign.
difficulty in masticatory function, there may be
Inability to wrinkle the forehead lacrimation,
drooling of saliva outside the mouth. Loss of
slurred speech, drooling of the saliva due to drooping
protection for cornea of the eye can lead to pain
of the angle of the mouth.
infection and visual disturbances due to corneal
ulceration. Facial asymmetry leads to cosmetic Investigation includes audiometry C.T. scan or MRI
disturbances. and EMG may be considered.
Management includes reassurance to the patient and Management includes referring and consultation with
sought the cause and removes the cause and treats ENT and Neurosurgeon as well as Ophthalmologist.
the consequence of the cause. Bell’s Palsy defines as Medicinal management includes injection, vitamin
unilateral idiopathic LMN paresis or paralysis of B1, B6 and B12. Prednisolone 80 mg daily for divided
sudden onset of the facial nerve described by Sir doses for 5 days, then gradually tailing off the doses
Charles Bell in the year 1828. consequent the next 5 days.
Women are more affected than the male. The Physiotherapy includes galvanism stimulation,
disease is more common in pregnant women. gentle massage and facial exercise. In chronic sequelae
Jackson et al in the year 1999; summarized the includes hyperkinesias or hypokinesias. In hyper-
initiating events or phenomenon a related to Bell’s kinesias offending muscles group are denervated by
Palsy: Clostridium botulinum toxin (botax) is a neurotoxin
• Acute otitis media. that temporarily interferes with acetylcholine release
• Atmospheric change of pressure (diving, flying). from motor nerve endplates, causing skeletal muscle
• Exposure to cold. paralysis. The affect last four to six months. Botax has
• Ischemia of the nerve near the stylomastoid been useful in the treatment of facial palsy by
foramen. weakening the contralateral side to allow centering
• Local and systemic infection (viral, bacterial, of the mouth to achieve symmetry of the face during
fungal). smiling.
• Melkersson – Rosenthal syndrome. Hypokinesia needs nerve transfer, muscle transfer
• Multiple sclerosis. or static slings. Other treatment includes nerve decom-
• Pregnancy (third trimester, early eclampsia). pression, internal and external decompression, nerve
• Diabetics. It can occur in any age. reanimation and nerve grafting.
 Synopsis of Oral and Maxillofacial Surgery
82
BIBLIOGRAPHY 18. Horton BT. Temporal arteritis. BMJ 1, 1966;105.
19. Jackson, et al. The facial nerve current trends in diagnosis,
1. ARIAS MJ. Percutaneous retrogasserian glycerol rhizotomy treatment and rehabilitation. Med. Clin. North Am.
for trigeminal neuralgia. A prospective study of 100 cases. 1991;83:179-95.
J Neurosurg 1986;65:32-36. 20. Loeser Jd. Tic douloureux and atypical facial pain. Textbook
2. Balla JI, et al. Periodic migrainous neuralgia, BMJ 1964;219. of Pain. Churchill Livingstone, 1984; 426-34.
3. Behrman S. Facial neuralgia BDJ 1949;April 14, 197. 21. Lord Cohen of Birkenhead facial neuralgia B.D.J. 1959;107.
4. Bell WE. Orofacial Pains; Classification, Diagnosis and 22. Melzack R, Wall PD. Pain mechanisms: A new theory.
Management. Chicago: Yearbook Medical Publishers Inc, Science 1965;150:971–79.
1985. 23. Miller H. Pain in the face, BMJ 2, 1968;577–80.
5. Blom S. Trigeminal neuralgia. In treatment with a new anti- 24. Perkins GD. PTN: Current treat options neurol 1991;1:458-
convulsant drug. Lancet 1962;1:839-40. 65.
6. Bond MR. Pain—Its Nature, Analysis and Treatment. 25. Sokolovic M, Stajcic Z, et al. Peripheral streptomycin/
Edinburgh: Churchill Livingstone, 1979. lidocaine injections in the treatment of idiopathic trigeminal
7. Bonica JJ. The Management of Pain, 1st Ed. Philadephia, neuralgia. JMFS 1986;14:8-9.
Lea and Febiger, 1953. 26. Sweet Wh, et al. Treatment of trigeminal neuralgia and other
8. Bonica JJ. Neuralgias of Face and Jaws. DCNA July 1959;451. facial pains by retrogasserian injection of glycerol
9. Bouquo TJ, et al. Neuropathic pain in maxillofacial neurosurgery 1981;9:647-53.
osteonecrosis. J. OMFS 2000;1003-20. 27. Smith DP, Billing LF, Pearson JS, Rushton JG, Goldstein
10. Costich ER. Facial Pain, Ed. Alling CC and Febiger, 1968. NP, Gibilisco JA. A psychiatric study of atypical facial pain.
11. Deleon EL. Facial pain of non-odontogenic origin. J Oral Canad Med Ass J 1969;100:285.
medicine 1968;23:119. 28. Textbook of Oral Maxillofacial Surgery by Gustaf Kruger,
12. Fromm GH, et al. Trigeminal neuralgia, current concepts CV Mosby, USA.
regarding etiology and pathogenisis. Arch Neurol, 29. William Irby. Recent advances of oral maxillofacial surgery
1987;41:1204-07. Vol. I and II.
13. Fried man RA. The surgical management of Bell’s palsy: A 30. Woda, et al. A unified concept of orofacial pain, clinical
review. Am J Otol 2000;21:139-44. features. J. Oro fac. Pain 1999;13:172-95.
14. Gonda JJ. Atypical facial pain and other pain syndromes. 31. Watt DM. Recording the sounds of tooth contact. A
Differential diagnosis and treatment. Neuro Surg Clinic diagnostic technique for evaluation of occlusal disturbances.
North Am 1997;8:87-100. Int Dent J 1969;221-39.
15. Graff–Radford SB. Facial pain. Curr OPI Neurol 2000;13: 32. Wilson DC. A typical facial neuralgia. JAMA, 1932;19:813-
291-96. 16.
16. Harris M, et al. Atypical odontalgia, BJOS 1979;16:212-18. 33. Zakrzewska JM, et al. Oxcarbazepine–A new drug in the
17. Henderson WR. Trigeminal neuralgia – the pain and its management of intractable trigeminal neuralgia. JNNP
treatment. BMJ 1, 1967;7–15. 1989; 52:472-76.
 ELEVEN
Diseases of Maxillary Antrum
• Anatomy and Physiology of Maxillary Antrum • Inflammatory Conditions of
the Maxillary Antrum • Clinical Features and Radiological Analysis with Special
Emphasis on Sinus Endoscopy • Removal of Displaced Root by Surgical Procedure
• Repair of Oroantral Communication and Oroantral Fistula by Various Surgical
Modalities • Classification of Malignant Tumors of the Maxillary Air Sinus and
Diagnosis • Brief Management (Cysts of the Maxillary Antrum Discussed in Cyst
Chapter)

ANATOMY AND PHYSIOLOGY Importance of Surgical Anatomy

OF MAXILLARY ANTRUM of Maxillary Air Sinus
Maxillary air sinus or antrum of Highmore can be 1. The distance is approximately 1 to 1.25 cm between
described as an air-space in the body of the maxilla. the floor of the sinus and root apices of the
Nathaniel Highmore first reported in the year 1651. It maxillary posterior teeth and it is also in close
is pyramidal in shape. Size, vertically 3.5 cm proximately with the roots of these teeth. The roots
anteroposterior, width 3.2 cm, transversely 2.5 cm. The of the second molar were closest to the floor of the
floor of the orbit forms the roof of the antrum; the maxillary sinus as per the study of Bornsdorff. It
alveolar process of the maxilla, which extends from was also supported by Paatero in the year 1939.
the second premolar to the molar teeth, forms the floor. 2. Lining of the maxillary sinus does not usually get
Anterior wall is formed by the posterior surface of the torn, if undue force of an extraction is applied.
anterior wall of the body of the maxilla. Posterior wall 3. Cracks and fractures in the bony floor of the
is formed by the anterior surface of the posterior wall maxillary sinus. There may be chances of an
of the body of the maxilla. Apex is formed by the oroantral communication or this may heal even if
zygomatic process. The medial wall of the body of the there is accompanying tear in the sinus lining.
maxilla forms base, where lie the maxillary meatus. 4. Periapcial infection: Infection in the form of chronic
abscess in teeth related to the floor of the sinus may
Function involve the maxillary antrum. The extraction of
1. Makes the cranial bone lighter (disapproved by such a tooth leads to an oroantral fistula by
Prof RJ Last). contamination from the infected blood clot.
2. Act as a resonant box. 5. Pressure of the nerves within the antrum. Acute
3. Regulates the temperature of the inspired air. maxillary sinusitis sometimes produces pus, which
4. Drainage. is unable to escape from the ostium into the nose
5. Pneumatisation. due to inflammatory reaction of adjoining muco-
The ostium draining the sinus enters the middle sal lining.
meatus. Ciliated epithelium lining the sinus wafts 6. Tumors involving or developing in maxillary
continuously to the exist. antrum. Tumors within the maxillary antrum also
Arterial supply: Facial, infraorbital greater palatine. penetrate floor of the maxillary antrum and present
as a palatal lump or expansion in the buccal sulcus.
Nerve supply: Infraorbital, anterior middle, posterior
The teeth in the area may get mobility due to
superior alveolar nerve.
destruction of surrounding bone. The tumor may
Venus drainage: Facial and Ptg. venus plexus. extend to the orbital floor and may cause
Lymphatic drainage into the submandibular nodes. paresthesia of the infraorbital nerve.
 Synopsis of Oral and Maxillofacial Surgery
84
7. The various foreign bodies within the maxillary reported by Maxwell and Maltz in the year 1925.
sinus. The foreign bodies includes tooth or roots They suggested sinus copy should be utilized for
fragments or any other objects, may change diagnosis, and explained the maxillary endoscopic
position with movement of the head. If the foreign sinusotomy via the inferior meatal and canine fossa
body does not move in consecutive radiographs roots. This method was improvised and developed
the chances are of foreign body hence trapped into by Messerklinger and Wigand in the year 1978.
thick antral mucosa or any polyp or it may present Subsequently Stamberger and Kennedy with the
between antral lining membrane and the bony help of CT scan and pluridirection tomograms
septa. improved the original technique described by
Messerklinger. In endoscopy of the maxillary sinus
Radiology of Maxillary Sinus topical anesthesia is applied to the sublabial zone
over the canine fossa. Then 2 percent xylocaine with
Extraoral 1: 80000 adrenaline, about 1 to 1.5 cc is injected in
1. 15 and 30o occipitomental. Reveal antral opacity, that area. A small stab incision is made with a BP
fluid level of the antrum or fracture maxilla. blade No. 11 over the mucous membrane. Then a
2. Occipitofrontal is recommended to detect multi- trocar is used to enter the upper lateral part of the
sinusitis and pan sinusitis. canine fossa. Care should be taken about the
3. Lateral skull. Confirms the presence of fluid level protection of the eye to fill the orbital rim and place
and cyst and localizing a tooth root when it is a finger on the rim during the puncture of the sinus.
located higher up in the sinus. The trocar and cannula are slowly-rotated while
4. Submento vertex. entering the sinus in the posterior direction. Then
5. Linear tomography. This method demonstrates the the sinus may be examined with a telescope. A
solid masses within the maxillary antrum such as biopsy can be obtained with an optical biopsy
antroliths and osteoma. This also shows early process via the cannula. The patient is asked to
erosion of the walls of maxillary antrum due to avoid blowing the nose for at least about a
involvement of malignancy of the maxillary week postoperatively to avoid subcutaneous
antrum. emphysema. The FESS technique was classified by
6. OPG for detection of lesions like odontogenic and Anand and Panje’s into V types of which type III
mucosul cyst of maxillary antrum. which includes the type II that is nasal endoscopy
7. Computerized axial tomography (CAT). This scan plus maxillary sinus antrostomy via the natural
is for better detection of a growth within the sinus osteium. Usually recommended in this
maxillary antrum and in blow out fractures. chapter.
Maxillary sinusitis can be explained as acute and
chronic varieties. The odontogenic sinusitis cause is

}
Intraoral The intraoral X-ray are of great value
in locating the foreign bodies such as due to infection from the tooth and associated
1. Occlusal tooth, roots and osseous fragments and structures. These may depend on the different phases
2. Lateral for treatment plan. It may help the of inflammatory conditions. The acute maxillary
occlusal different phases of opacities. However, sinusitis is considered as acute inflammation of the
it is impossible to diagnose purely by maxillary antrum. Patient complains of throbbing pain
3. Periapical.
radiological means. associated with severe headache with irritability, nasal
congestion running nose, sneezing may or may not
Special Diagnostic Tests in Addition
be present, and pyrexia, and sometimes, lacrimation
to the Radiological Methods
on the affected side. There may be a history of cold
1. Sensibility test (vitality). exposure. It may lead to throat and bronchial infection.
2. Transillumination test. Patient may complains of pain on the biting of the
3. FNAC affected side. This may be due to increase of
4. FESS (Functional endoscopics sinus surgery): The vasodilation of the periodontal ligament. Obstruction
main objective is to restore the normal function of of the maxillary opening or impairment of ciliary
the para-nasal air sinuses with mucociliary activity. activity due to intrusion of snuff. The antral cavity
The first description of endoscopic examination may form pus, and may discharge it via the nose or
methods of the nasal cavity and the antrum cavity involve the tooth inside the oral cavity.
 Diseases of Maxillary Antrum
85
X-ray Shows the Haziness in OMV/Water’s View in a successive radiograph after the patient has
Recommended by Water and Waldron vigorously moved his head, is confirmatory evidence
that the root is inside the antrum. However, such a
Infection may track from the oral septic focus or via
root often becomes in carcerated by a blood clot, and
the nasal cavity. Repeated episodic attacks of
is unlikely to shift in spite of vigorous movements of
prolonged sinusitis leads to the sub-acute or chronic
the patient’s head.
variety. The antral lining may be transformed to
Instead of being dislodged into the antrum a root
hyperactive plastic or atrophic variety ultimately to
fragment may be displaced into other tissue planes
form antral polyps or an antrolith. Patient complains
such as the extramucosal site, i.e. outside the antral
of halitosis with bad taste. There may be a purulent
mucosa, the subperiosteal plane, or intrabuccally, i.e.
discharge from the nose, accompanied at times by a
within the buccal soft tissue. Obviously it is extremely
postnasal drip.
X-ray shows thickening of the antral lining with
haziness or opacity of the affected antrum, and this
may be evaluated with a comparative examination of
both sides of the maxillary air sinuses.

Treatment
1. Tinc, Benzoin CO or carvol inhalation. The simple
steam inhalations containing the drugs mentioned,
to act as mucolytic agents.
2. Nasal decongestant like cetirizine.
Fig. 11.1: Diagrammatic coronal section of antrum showing
3. Nasal drops like 0.5 to 1 percent ephedrine sulfate
various positions of a displaced root. (A) Intra-antral, (B)
in normal saline 6 hourly. 0.1 percent xylometa- Extramucosal. (C) Subperiosteal, (D) Intrabuccal
zolin hydrochloride. This decongestant not only
shrinks the congested and inflamed mucosa but
also helps to minimize and eliminate the mucosal
discharge.
4. Selective course of suitable antibiotic to control
infection.
5. Maintenance of oral hygiene.
6. Paracetamol 500 to 750 mg. in case of pain, or
preferably NSAI drugs. Fig. 11.2: Outline of two-sided flap in heavy shade, X, retained
7. Omit the use of snuff. If the patient is using the root or similar. A line of additional incision to convert to a three-
habit. sided flap

Diagnosis and Management of the Displaced

Root in the Maxillary Antrum (Figs 11.1 to 11.3)
The accidental displacement of a tooth or a fragment
of a tooth or root into the maxillary sinus during
exodontias is a common experience. The diagnosis of
a recently displaced root in the maxillary sinus is
obvious as a rule. A history of sudden disappearance
of a root fragment from its socket during manipulation
together with a breach in the floor of the maxillary
sinus, is strongly suggestive of such a mishap.
In a periapical radiograph, the displaced root
fragment is usually seen to be lying near its socket Fig. 11.3: The figure shows the Lee transalveolar approach for
and is devoid of its normal surrounding periodontal removal of root from the maxillary sinus—The incision, and
membrane and lamina dura. Alteration of its position raising the mucoperiosteal flap
 Synopsis of Oral and Maxillofacial Surgery
86
difficult, if not impossible, to differentiate these Subsequent to the recovery of the root, dividing
various positions of the displaced root on radiographic the underlying periosteum of the buccal flap and
examination. advancing the flap in a manner originally described
by Rehrmann meticulously close the antral opening
Management together with the socket. Long tails of the sutures are
Whatever may be the position of a displaced root, it left so that they may be used to secure a small dressing
should be removed as an emergency procedure at the of ribbon gauze in Whitehead’s varnish packed over
time of a displacement or at the earliest opportunity. the tooth socket for its protection.
For removal of a root from the maxillary sinus two
surgical approached have been employed. Postoperative Instruction and Advice
1. Caldwell-Luc method via canine fossa.
1. Cap amoxycillin 500 mg three times daily for five
2. The approach at the site of the tooth socket by
to seven days or Tab erythromycin 500 mg four
enlarging the existing antral perforation and
times daily five to seven days.
recovering the root via the enlarged opening in the
2. Non-steroidal anti-inflammatory analgesic usually
tooth’s socket.
ibuprofen 400 mg with paracetamol 300 mg for first
3. FMS LEE recommended a technique of approach
24 hours three times daily and this may be
of the antrum from the buccal aspect, immediately
continued for another 48 hours, and instead of three
above the tooth socket. According to Lee this
times, twice daily or suitable analgesic may be
opening gives the operator a maximum visual and
given.
mechanical access as well as a better view of the
3. Nasal decongestant drops 0.1 percent xylometa-
floor of the antrum adjacent to the tooth socket,
zoline hydrochloride may be used three to four
and it is also less likely to lead to the formation of
times daily.
an oroantral fistula. This simple technique was
4. Chymoral forte 1 tablet half an hour before meals
described by Lee as transalveolar approach under
or one hour after the meals three times daily for
local anesthesia. A trapezoid incision is given on
three to four days to reduce the postoperative
the buccal aspect of the respective tooth socket. A
edema.
mucoperiosteal flap is raised, and the buccal plate
of the alveolar bone is first removed with a rongeur.
Removal of bone is extended beyond the apical Advice
limit of the socket, which immediately exposes the 1. Not to blow air via the nose. Avoid sneezing,
antral mucosa. An exposure of about 1cm in vigorous coughing and smoking.
diameter is adequate as a rule. If there is any 2. Saline mouth bath after 24 hours.
indication that the displaced root may not have 3. Ice application from outside for first 1 hour to
penetrated the antral mucosa, e.g. if the antral reduce the hematoma.
mucosa has not been breached, then the other tissue 4. Soft semisolid diet for first 24 hours.
planes should be carefully explored at this stage. 5. Remove the pack after 1 hour.
Otherwise the antral mucosa is incised across the 6. Report after 10 to 14 days for removal sutures.
full extent of the bony window exposing the antral 7. In case of emergency, contact the concerned
cavity. If the root has not been displaced far from surgeon.
its socket, it may come into view, in which case it
can be removed under direct vision on the tip of a Oroantral communication can be defined as
suction nozzle or with any other suitable instru- an accidental opening between the oral cavity and
ment such as a pair of fine hemostats. the maxillary sinus. The close proximity of maxillary
If the root is not visible, the sinus is then irrigated second pre-molar and first molar to the maxillary air
with normal saline solution while an efficient suction sinus is of great value.
nozzle is placed inside the antrum so that the root Clinically this can be explained as 5 S.
fragment may be recovered on the tip of the nozzle, 1. Sudden loss of resistance during extraction, that
as is often the case. This is preferable to having the means the application of the beak of the forceps,
root flushed out into the oral cavity, where it may be and the tooth may be pushed or intruded within
lost. the socket.
 Diseases of Maxillary Antrum
87
2. Seepage of fluid or water from the nose. cavity and maxillary sinus. This may often occur
3. Sudden alteration of voice or phonation. following the extraction of an isolated molar teeth
4. Sudden leakage of air from the extracting socket when the fistula tends to persist. The features of four
(nose blowing test positive). ‘S’ present in oroantral fistula except the first one.
5. Sudden bleeding from the nose (epistaxis)
Closure of large accidental sinus opening in the Oroantral communication Oroantral fistula
dentulous arch recommended by Phillip Earle Formation, during extraction A tract lined by unhealthy
Williams—cited from Gustav Kruger (Fig. 11.4). of upper posterior teeth granulation tissue
Fractured maxillary tuberosity during extraction following application of between the oral cavity
of posterior teeth may lead to a large accidental beak of the forceps, during and antral cavity is known
opening of oroantral communication. If the bone apical thrust. Tooth may as oroantral fistula.
cannot be dissected from the roots, it should be push or intrude within socket.
carefully dissected from the overlying mucosa and the During removal of the Untreated oroantral
displaced root stumps communication leads
tooth and tuberosity removed together. An extensive
of posterior tooth closer to oroantral fistula.
communication with the antrum results but careful or near to the antral
preservation of the mucosa leaves ample tissue to cavity, leads to oroantral
achieve a watertight closure (Fig. 11.5). communication.
Oroantal fistula can be defined as a creation of a Fracture of thin bony floor More than 72 hours
pathological epithelium lined tract between the oral and subsequent tear of the oroantral communi-
antral lining causes cation consider as
oroantral communication. oroantral fistula.

After obtaining the local anesthesia the steps of

surgical procedures are as follows:
Steps:
A. Excise the fistulous tract, easiest with a No 11 blade.
B. Outline (dashed) of incision for a full thickness
mucoperiosteal buccal flap.
C. Reflect full thickness mucoperiosteal flap and
Fig. 11.4: (A) Relaxing incision is made on the palate, avoiding incise the periosteal layer only. This makes it
the palatine artery. The buccal and lingual alveolar walls are possible to mobilize the flap.
reduced with a rongeur, (B) Mucosal edges on the ridge are D. ‘Stretch’ the flap to assess the degree of elasticity
freshened, and flaps are raised. A periosteal elevator raises once the restraining effect of the periosteum is lost.
the palatal mucoperiosteum so that approximation of mucosal
E. The flap is advanced across the fistula and sutured
edges is made possible, (C) Flaps are sutured. Healing should
take place by primary intention. The palatal wound is left open
to palatal mucosa over palatal bone.
After obtaining the local anesthesia the following
are steps of operative procedure:
A. Excise fistula, outline palatal flap based on greater
palatine artery.
B. Mobilize and rotate palatal flap, suturing its
leading edge to buccal mucosa over bone, donor
site to granulate under surgical dressing or pack.
This procedure does not effect the buccal vestibular
height palatal rotational advancement flap
provides adequate mobility and tissue bulk to the
flap. It requires the mobilization of large amount
Fig. 11.5: (A) Sinus opening immediately after extraction, (B)
of palatal tissue, and may causes kin kin of the
Reduction of buccal and lingual walls to allow coaptation of
buccal and lingual soft tissue flaps. The soft tissue flaps are rotation of the flap, which may predispose to
trimmed conservatively to form a somewhat even line (C) Flaps venous congestion. Phillip Earle Williams
sutured suggested a ‘V’-shaped excision of the lesser
 Synopsis of Oral and Maxillofacial Surgery
88
curvature of the flap to minimize folding—cited technique using the connective tissue under the palatal
from Gustav Kruger. mucosa for the close or repair of oroantral fistula (Figs
All these methods have advantages and disadvan- 11.6 and 11.7).
tages too. To overcome the disadvantages of these
various procedures Teruo Ito and Hironobu Hara of Recommended Surgical
Nagasaki University of Japan recommended a Technique by Ito and Hara
The palatal mucosa is thin in the median region, it
increases its thickness as it approaches the alveolar
process, and is relatively thick even at the alveolar
margin. Moreover, these tissues contain the largest of
the branches of the palatine artery, which runs
anteriorly along the basal part of the alveolar process
through the exterior alveolar groove. Because of these
conditions, the submucosal connective tissue in this
area can be used as a pedicle flap (Figs 11.8 and 11.9).
In this procedure, a full thickness of the palatal
mucosa is incised and separated into a mucosal layer
and an underlying connective tissue layer, and the
submucosal connective tissue flap is used to close the
oroantral fistula.
The initial palatal flap is made leaving a width of
gingiva between the flap and the fistula, as indicated
by the shaded area in Figure 11.10.
This is done to prevent necrosis of the alveolar
margin and gingival recession. The edges about the
periphery of the fistula are then freshened. After
elevating the full-thickness palatal flap to the posterior
area of the fistula, the flap is divided into the mucosal
Fig. 11.6: The repair or closure of oroantral fistula by buccal
advancement flap modified by Rehrmann flap by Nicholas or
Y–V flap procedure—from Harris and Seward

Fig. 11.7: Closure of oroantral fistula by palatal rotation flap

Fig. 11.9: Distribution of arteries in palate
originally described by Ashley and Berger in the year 1939

Fig. 11.8: Coronal view of palatal region Fig. 11.10: Incision of palatal flap (A)
 Diseases of Maxillary Antrum
89
upper layer and the underlying layer of connective 11.14 is illustrating the lateral view of the region of
tissue, without injury to the blood vessels, so as to the closed fistula.
form a connective tissue flap (Fig. 11.11). Because the After suturing is completed, it is followed by the
palatal mucosa near the median line is too thin to be placement of a surgical stent to protect the wound
dissected into two layers (as shown in Fig. 11.8), only surface. The stent is removed after seven days. The
the lateral half to two-thirds of the flap is dissected clinical appearance a month postoperatively. The
into two layers (Fig. 11.11). As this flap is elastic and pedicle flap is epithelialized and the fistula is
flexible, it can be readily adjusted in width and length completely closed.
so as to close even a fistula of considerable size in the Ito and Hara’s (1980) procedures to close an
alveolar ridge and maxillary vestibule. oroantral fistula using a connective tissue flap under
Next, the mucoperiosteum between the palatal flap the palatal mucosa is applicable to a tissue defect in
and the fistula (Fig. 11.11, shaded area) is elevated to the alveolar ridge and the maxillary vestibule.
form a tunnel for passage of the pedicle flap (Fig. Moreover, this connective tissue flap is rich in blood
11.12). The pedicle flap is then rotated under the and is extremely elastic, and it can be easily rotated
mucoperiosteum and across the oroantral fistula (Fig. without producing a “dog ear”, as in the whole-layer
11.13). This ensures a good supply of blood to the palatal pedicle flap procedure. Stable placement in the
surgical area and allows for stable placement of the specified position is also obtainable without excessive
pedicle flap with minimal tension. When the attached tension. The bone surface in the donor site does not
gingiva of the recipient site is thick, it is incised to remain exposed because the epithelial layer of the
allow insertion of the pedicle flap. Otherwise, the palatal mucosa is returned to the original position.
entire mucoperiosteum is elevated and the tip of the Moreover, the attached gingiva in the buccal site can
flap is pushed under the periosteum and sutured. The be maintained at an appropriate height without
primary flap is then returned to its original position obliteration of the vestibule.
and sutured to obtain primary closure. Consequently,
the bone of the donor site is not left exposed. Figure

Fig. 11.13: Closure of oroantral fistula with submucoasl

connective tissue pedicle flap, (A) Tip of submucosal flap, (B)
Primary flap
Fig. 11.11: Formation of submucosal
connective tissue pedicle flap (a)

Figs 11.14: Coronal view of fistula closure, (A) Palatal

Fig. 11.12: Formation of tunnel for passage of palatal flap connective tissue pedicle flap, (B) Gingiva, (C) Buccal mucosa
 Synopsis of Oral and Maxillofacial Surgery
90
This technique gives the patient minimal removal of an impacted canine and third molar. This
discomfort, provides early healing of the wound, and access technique to the maxillary air sinus also helps
leaves no aesthetic disturbance. in performing transantral ligation and Blom maxillary
Analytical observation and the present author in peripherial neurectomy for the treatment of PTN.
the Ito and Hara technique of repair of oroantral Postsurgical prescription, instruction and advice:
fistula, the critical step or phase of surgical procedure 1. Select suitable antibiotics.
is the slicing of the palatal flap into submucosal 2. Suitable analgesic for relief of pain.
connective tissue and the mucosal layer. This can be 3. Nasal decongestant (mentioned earlier).
done by the Von Graefe and Berr Cataract Knife used 4. Instructions (earlier mentioned in this chapter).
is eye surgery. Cyst of the maxillary air sinus is discussed in the
The various methods recommended for repair of chapter of cyst. Regarding the malignant tumor of the
OAC and OAF from time to time starting from the maxillary antrum, the clinical features mentioned in
Proctor operation where a cone-shaped piece of the oral cancer chapter as per collaborating to the
cartilage was inserted into the defect, and other maxillary air sinus in addition to the following
alloplastic materials and metals used with limitation features.
and of little or a questionable value. The combination 1. Extraoral swelling of the infraorbital margin lifting
of the above mentioned techniques as well as a the nasolabial fold with blood stained purulent
slightly-modified reoriented improvised and altered discharge of the affected side of the nose with bad
method used by various surgeons which includes smell and haziness and opacity of the affected
palatal transposition and rotation flap in edentulous antrum. Infra-orbital nerve paresthesia and
maxilla. But one technique that should be mentioned anesthesia may present with heaviness of the antral
is—‘buccal fat pad transferred’ procedure. region.
2. Late features are a nasal obstruction, discharges
Buccal Fat Pad Transfer Surgical Procedure and epistaxis the anterior spread leads to swelling
of the check and face inferior spread causes
This is an excellent reserve reconstruction for OAFs, expansion of the alveolar bone with pain, loosening
which have been subject to difficult or repeated of the teeth, poor fitting of dentures, ulceration of
attempts at closure. The fat pad is easy to find but the palatal mucosa with expansion of the hard
mobilization should be done with care to preserve palate. Superior spread invades the orbit causing
bulk and to avoid the pterygoid venous plexus of proptosis, double vision, ocular pain and epiphora.
veins. It can then be sutured into position. The fat pad Posterior spread causes the involvement of
becomes covered by oral mucosa by seeding of oral pterygomaxillary fossa, pterygoid plates and the
squames and growth from the margins. muscles causing trismus. Growth may also spread
to the nasopharynx (Trotter’s syndrome) and
Intranasal Antrostomy sphenoidal sinus.
1. This procedure facilitates the drainage occasionally 3. Diagnosis:
at the end of operation to close an oroantral fistula. a. Radiograph of sinuses: Opacity of the involved
2. Removed a tooth or a root from sinus (rarely). The sinus with expansion and destruction of the
ENT surgeon mostly uses it. bony wall.
b. CT Scan: If available, this is the best non-
invasive method to find the extent of disease.
Caldwell–Luc Approach
CT scan should be done both in axial and
George Caldwell, an American surgeon and Henri Luc coronal planes. It also helps in the staging of
of France reported this procedure to gaining access disease.
into the maxillary air sinus via the canine fossa. This c. Biopsy: If growth presents in the nose or mouth,
procedure is used for removal of root fragments, teeth a biopsy can be easily taken. In early cases, with
or foreign body, an antral stone or antrolith or polyp suspicion of malignancy, sinus should be
from the maxillary sinus to reduce hematoma from explored by Caldwell-Luc operation. Direct
the maxillary sinus and to control post-traumatic visualization of the site of tumor in the sinus
bleeding in the sinus. This procedure is also used for also helps in staging of the tumor.
 Diseases of Maxillary Antrum
91
d. Sinus endoscopy of the nose and maxillary depending on the prospective of anatomical extents
sinus will provide detailed examination. in case of malignant tumor.
Classification of Malignant Tumor of Maxillary 1. MT confined to maxilla without involvement of
Sinus (Maxillary CA). orbital floor. Surgical modalities subtotal
a. Ohngren’s classification: An imaginary plane is maxillectomy.
drawn, extending between medial canthus of eye 2. MT involving the orbital floor without involving
and angle of the mandible. Growths situated above the peri orbital area, surgical modalities total
the plane (supra structural) have a poorer maxillectomy.
prognosis than those below it that means intra- 3. MT involving the orbital contents surgical
structural. modalities total maxillectomy with orbital
b. AJCC (American Joint Committee of Cancer Classi- exenteration.
fication 1977) classified malignant tumor of 4. MT involving skull base—neurosurgical domain.
squamous cell carcinoma by staging of cancer Commonly used incision in maxillary surgery is
involving the maxillary sinus. the classic Weber – Fergusson incision. It may be
T1 : Tumor limited to the antral mucosa with no modified by a lip—split for better cosmetic results in
erosion or destruction of bone. addition to the intraoral incision is which is necessary
T2 : Tumor causing bone erosion and destruction for the exposure of the tumor.
except posterior antral wall including The reconstruction and prosthesis for rehabilitation
extension into the hard palate and or medial is mandatory for function and some extent, aesthetic.
meatus of nose.
T3 : Tumor involving any of the following bones BIBLIOGRAPHY
of the posterior wall of the maxillary sinus of 1. Clark HB. Practical Oral Surgery, 3rd (edn) 1965;240.
cheek or medial wall of the infratemporal fossa, 2. Cook HE, et al. Bacteriology of the maxillary sinus. JOMFS
pterygoid plates and ethmoid sinuses. 1987;45:1011.
T4 : Tumor invades orbital contents beyond the 3. Drettner B. Pathophysiology of paranasal sinuses with
floor or medial wall including any of the clinical implications. Clin. Oto Laryn 1980;5:277.
following, orbital apex, cribriform plate, bone 4. Harrison DFN. Oroantral fistula. BJ Clin Pract 1961;15:169.
and skin, sphenoidal and frontal air sinuses. 5. Henderson D. The palatal island flap in the closure of
oroantrul fistula. BJOS 1974;12:141-46.
c. Lederman’s classification uses two horizontal lines 6. Killey HC, K LW. Possible scquelae when a tooth or root is
of Sebileau one passing via floor of orbits and other dislodged into the maxillary sinus. BDJ 1964;116:73.
the through the floor of the antrum, thus dividing 7. Kruger G. Textbook of Oral Maxillofacial Surgery.
the area into three: 8. Lee FMS. Management of the displaced root in the maxillary
i. Suprastructure: Ethmoid, sphenoid and frontal sinus. Int JOS 1978;7:374-79.
sinuses and the olfactory area of nose. 9. Martensson G. Dental injuries following radical surgery on
ii. Medial structure: Maxillary sinus and the respi- maxillary sinus with special reference to changes in
sensitivity after Caldwell – Luc operations. Acta Oto Laryn
ratory part of nose.
84: suppl. 1950.
iii. Infrastructure: Containing alveolar process. 10. Perez CA, et al. Diagnostic radiology of maxillary sinus
This classification further uses vertical lines, defects. Triple O, 1988;66:507.
extending down the medial wall of orbit to 11. Reading P, et al. The causation, pathology and treatment
separate ethmoid sinuses and nasal fossa from of oroantral fistula resulting from dental extraction. J
the maxillary sinuses. Laryngol 1955;69:729.
12. Thoma KH. Oral Surgery, 4th (edn) 1963;P-310.
13. Tereo Ito, Horonobu Hara. Department of Oral Surgery,
Treatment Faculty of Dentistry, Nagasaki University, Japan, Personal
Communication. Journal of Oral Surgery, July 1980;38:509-
Includes surgery, radiotherapy and combination of 12
both. 14. Textbook of Human Anatomy R J Last.
Jackson and Callon Fort 1996 recommended a 15. WH Archer. Textbook of Oral Maxillofacial Surgery, 5th
guideline for surgical intervention of the maxilla (edn). 1975;1625.
TWELVE
Surgical Endodontics
• Apicoectomy • Indications • Assessment • Techniques • Types of Incisions
• Tit-Bits about Root Hemisection • Endodontic (Diodontic) Implants Removal
of Extruded Endodontic Paste

INTRODUCTION canals are sampled for sterility. It has been argued that
it is impossible to be certain of the complete
Disease of the pulp, periapical tissues, and their
eradication of bacteria from all the tubules. Therefore,
treatment are called endodontics. Infection of the pulp
it is not necessary to culture each root canal. However,
is known as pulpitis. The pulp can be infected through
the majority of dental institutions suggest routine
dentinal tubules (caries), a trauma, through lateral
culturing of root canals for undergraduates as an
canals (deep periodontal pockets), or through blood
indication of the success of their as aseptic techniques.
stream (anachoresis). Dental caries is the commonest
The surgical endodontics means the various
cause of pulpitis. Acidogenic bacteria demineralize the
methods of surgeries of the soft tissue within the tooth
tubule walls followed by proteolysis of the matrix by
(pulp) and tooth apex and it surroundings. Inflam-
proteolytic bacteria. If caries is not treated pulp is
mation and the septic necrosis and subsequent
eventually infected Pulpitis may acute or chronic,
gangrene of the dental pulp as a result of carious lesion
depending on the duration and severity of the
and trauma. This infected necrotic pulp subsequently
symptoms. Because the pulp tissues are enclosed in
reaches the tooth apex and form the periapical patho-
calcified tissue, inflammation and tissue pressure
logy. The treatment of above-mentioned pathology the
may cause greater problems than those occurring in
following surgical modalities are recommended.
tissues where expansion is possible. The type of
Apicoectomy is the surgical removal of the
bacteria found in infected pulp and root canals, mainly
periapical pathology and removal of one-third of the
depend on the route by which the bacteria gain
root apex and subsequent root canal treatment and
access to pulp. In open lesions, many species of
sealing by orthograde or retrograde method.
bacteria can be found. As the pulp becomes necrotic,
more anaerobes are found. When bacteria reach the
Indications
root canal, inflammation of the periapical tissues
(apical periodontitis) develops. Commonest bacteria 1. Failure of conventional endodontic therapy to
found in these infections are anaerobes, such as eliminate apical infection.
Prevotella, Parphyromonas, Peptostreptococci and 2. Pathological change at the apex of a previously root
Streptococcus anginosus (previously called S. milleri), filled tooth, e.g. granuloma or cyst.
Fusobacterium and viridans streptococci. The micro- 3. Failure during root canal treatment, e.g. overfilling,
organisms are in a low state of metabolic activity instrument fracture, lateral perforation.
making them less sensitive to antimicrobial agents. 4. Root unapproachable by conventional orthograde
Apical periodontitis is usually chronic because the host route, e.g. post-crowned tooth, calcified root canal.
defense mechanism cannot reach the site. As a result, 5. Anatomical variations preclude normal endodontic
there can be several complications such as abscess therapy.
formation, osteomyelitis, metastatic infection.
The treatment of infected root canals involves the Contraindications
removal of infected and dead tissues both mechani- 1. Presence of systemic diseases.
cally and by irrigation, sometimes accompanied by 2. Tooth with deep periodontal pockets with degree
the use of antibiotics and other antimicrobial agents. 3 mobility and existing alveolar bone loss.
Usually, before the root canals are filled and restored, 3. Tooth having short root length.
 Surgical Endodontics
93
4. Tooth damage beyond restoration.
5. Tooth root close to the nerve.

Recommended Procedures
1. Root canal treatment with immediate apicectomy
and curettage.
2. Root canal treatment is done before followed by
apicoectomy and curettage.
3. The periapical lesion initially treated by root canal
treatment and draining via the canal. This may
need the surgical intervention with root
amputation and curettage in future.
The various incisions and flap design are recom-
mended from time to time by various authorities,
which are as follows:
1. Full mucoperiosteal flap may be as follows: Fig. 12.1: Apicoectomy of max. lat incisor
a. Triangular flap.
b. Rectangular flap.
c. Trapezoidal flap.
d. Horizontal flap.
2. The limited mucoperiosteal flap:
a. Semilunar flap.
b. Submarginal rectangular flap (Luebke-Ochsen-
bein).
Assessment by intraoral X-ray: Clinical exami-
nation with detailed study of X-ray reading is
mandatory prior to surgical procedures. Tooth colour,
mobility, extension of the fracture or injuries and
periapical pathology and supporting conditions of the Fig. 12.2:
PDL, lamina dura and alveolar bone should be (A) An approach to apicoectomy
considered prior to treatment planning. a. Outline of incision for 3-sided flap, good access best
flap for the novice.
Steps of Surgical Procedures b. Outline of semilunar flap incision.
(Figs 12.1 to 12.5) (B) An approach to apicoectomy, a window is created in the
buccal cortex to expose the apex, which is resected, leaving
Obtained Local Anesthesia a smooth raw bony cavity (Cited from Prof JR Moore, 1976)
1. Incision and access flap: A mucoperiosteal flap is
raised. A triangular flap is preferred, and careful
repositioning and suturing minimizes post-
operative recession.
2. Apical curettage: Any apical cystic tissue, granu-
lation tissue or infection resulting from failed root
canal therapy should be curetted and sent for
histological assessment.
3. Apicoectomy: Section of the root apex with a slight
anterior bevel to facilitate visualization of the root
canal. In deciding how much apex to remove, Fig. 12.3: (A) Semilunar incision (submarginal)
several factors should be considered: (B) Submarginal rectangular incision (Luebke-Ochsenbein)
 Synopsis of Oral and Maxillofacial Surgery
94

Fig. 12.4: Trapezoidal incision and flap design Fig. 12.5: Triangular flap incision and flap design

a. As much root as possible should remain to deal 7. Recently Abseal also used (Ethicon Limited) to
with occlusal loads. control bleeding.
b. Apical root (with the most potential for lateral
Root perforations: This can be attempted surgically
canals) should be removed.
or by a combined approach; orthograde root filling
c. Plan the root surgery to take account of the
through perforation then immediately trimming
extent of apical pathology.
surgically.
d. Try not to remove so much apex as to expose
any restorative post within the canal. Root hemisection: This simply involves raising a flap
4. Retrograde root filling: Where the apical seal is around the tooth, identifying and horizontally
deficient, a cavity should be prepared in the root sectioning the root and atraumatically elevating it out.
tip with a microdrill. Great care is needed, and the The wound is closed and a cleanable undersurface
use of magnifying loupes is advised. A suitable sealed with amalgam left.
cement, e.g. EBA (orthoethoxybenzoic acid), is
Periapical curettage: Similar to apicectomy except
used as a filling material.
leaves root apex intact.
Analytical Observation ‘Through and through’ root filling: Combined
orthograde root filling with periapical curettage,
The above-mentioned method parenting to the
useful in lower incisions.
anterior teeth. Now-a-days the apicoectomy of
premolars and molars are also routinely operated. The Reimplantation of teeth: Replacement of tooth in
care should be taken in case of upper posterior teeth socket after trauma. Light splinting is required for one
for close proximity of the maxillary air sinus during week and conventional root treatment required.
the preparation of window at the buccal or palatal Complicated by root resorption.
surface.
Transplantation of teeth: One tooth (immature) trans-
In case of lower tooth the close proximity of the
planted into a socket of another; fairly unsuccessful;
inferior dental nerve and mental nerve must notated
often results in root resorption.
by the operator. The success rate of anterior teeth
Incision and drainage of endodontically-associated
apicoectomy is much more than the posterior teeth
swellings sound treatment for dental abscesses.
because of the limited visual and mechanical access
Immediate relief of patient’s symptoms.
of the operative procedure.
Control of bleeding during surgical procedure the Endodontic (diodontic) implants have not received
following measures is routinely in practice. widespread acceptance. They can be used to secure
1. The pressure packs in the form of cotton and gauge. an anterior tooth, which lacks sufficient supporting
2. Use of vasoconstrictors drugs. Epinephrine 1:1000. bone after endodontics treatment. The implant may
3. Calcium sulfate. be fabricated from Wiptam: nickel chrome wire 1.3
4. Gel foam. mm or 1.5 mm in diameter. It must be of sufficient
5. Oxidize cellulose. length to extend to the original position of the tooth
6. Horsley bone wax (yellow bees wax 7 parts, olive apex and must also penetrate at least 5 mm into the
oil 2 parts, phenol 1 part). sound bone. A sterile alloy implant passes through
 Surgical Endodontics
95
the prepared root canal into periapical bone and is 2. In case of posterior endodontic surgery of the
impacted into the bone transfixing the tooth. Such maxillary teeth careful about sinus approximation.
implants are being superseded by single-tooth The incision in the buccal area as well as palatal
implants. area have been discussed in the previous chapter.
Sometimes the root resection of all the multirooted
Removal of extruded paste: Usually, all that is
tooth not necessary in that case selective root
required is an apicoectomy approach. However,
resection and the RCT of the other roots along may
careless use of ‘paste only’ techniques can result in
be recommended.
paste in the floor of the nose, the antrum, or the ID
3. Clinical application of guided tissue regeneration
canal. The nasal floor can be approached sublabially
is the recent procedure in endodontic micro-
or intranasally, the antrum by standard methods and
surgery. The objective of GTR in endodontic
the ID canal by sagittally splitting the buccal cortex.
microsurgery is to enhance the quality and quantity
of bone regeneration in the periapical region and
Analytical Observation to accelerate bone growth in circumscribed bone
cavities after endodontic surgery.
1. Regarding the posterior teeth apicoectomy and
root canal treatment the surgical modalities almost BIBLIOGRAPHY
same as above with certain deviation. The 1. Carrgb. Surgical endodontics. In Cohen Pathways of the
premolars and molars of the maxillary teeth the Pulp, 6th (edn) 1994;535-38.
triangular and rectangular incision and flap design 2. Gutmann JL, et al. Surgical endodontics.
are the first choice. For the lower premolars and 3. Harty FJ. Endodontics in Clinical Practice. Wright 1981.
molars area the flap incision and design should be 4. Nehammer CF. Endodontics in practice: Surgical
endodontics. BDJ 1985;158:400-409.
the triangular flap as because the location of mental
5. Pecora, et al. The guide tissue degeneration principle in
foramen. Sometimes a release incision may be endodontic surgery. Int J Endod 1995;28:41-46.
necessary distal to the second molar to reduces the 6. Seymour RA, et al. Postoperative pain after apisectomy: A
tension of the flap. clinical investigation. Int J Endod 1986;19:242-47.
THIRTEEN
Odontogenic and Non-odontogenic Tumors
• Excerpts of Odontogenic and Non-odontogenic Tumors • Classification
• Diagnosis and Character • Radiological Appraisal and Treatment Modalities

Tumors or neoplasms are abnormal growth of the Benign odontogenic tumor and non-odontogenic
tissue in the body. They are basically divided into two tumors and tumor-like lesions classified by various
separate entity (a) benign, (b) malignant. The benign authorities from time to time on the perspective of its
jaw tumors is divided into two categories—one is origin and characteristic behaviour.
odontogenic and other is non-odontogenic. The benign
odontogenic tumors are neoplasms that arise from the BENIGN ODONOTOGENIC AND
dental lamina or any of its derivatives. In addition to NON-ODONTOGENIC TUMORS
their origin, they have other features in common:
1. All (some reports notwithstanding) are benigns— Classification of Benign Odontogenic Tumor
some (e.g., ameloblastoma) may be persistent, by Ivor RH Kramer, Jens J Pindborg and
extremely deforming and crippling but do not Mervyn Shear 1992
metastasize. This classification is actually the modified and
2. With rare exception, they occur within the jaws. improvised version of WHO’s classification of in the
3. All are slow-growing. year 1972 by the above authorities.
Oral cavity other than above lesions the following
growth can be noticed. A malformation is not A. Odontogenic Epithelium Without Odontogenic
neoplastic growth but it may causes functional and Ectomesenchyme
esthetic problem because of its abnormal size or 1. Ameloblastoma.
anatomical location. Hamartoma and Choristoma— 2. Calcifying epithelial odontogenic tumor—CEOT.
When an excessive amount of normal tissue is seen in Pindborg tumor.
its usual location, the resulting tumor-like mass is 3. Clear cell odontogenic tumor.
called hamartoma. When it occurs in abnormal 4. Squamous odontogenic tumor.
location it is called choristoma. Hamartoma and
B. Odontogenic Epithelium With Odontogenic Ecto-
choristoma usually located on the dorsum of the
mesenchyme, With or Without Dental Hard Tissue
tongue, or on the lip. The masses are circumscribed,
Formation
slow-growing. Hamartoma arise before or soon after
birth and grows with the patient; the swelling stops 1. Ameloblastic fibroma.
growing with the patient. They are not classified as 2. Ameloblastic fibrodentinoma (dentinoma).
tumors. Common examples include: 3. Odontoameloblastoma.
4. Adenomatoid odontogenic tumor (AOT).
Pigmented naevi (moles): A collection of melanocytes. 5. Complex odontome.
Hemangiomas/lymphangiomas: A collection of blood 6. Compound odontome.
or lymph vessels. C. Odontogenic Ectomesenchyme With or Without
Odontomes: Differentiated as compound Included Odontogenic Epithelium
odontomes—normal relationship of enamel, dentine, 1. Odontogenic fibroma.
cementum; and complex odontomes—diffuse masses 2. Myxoma (odontogenic myxoma, myxofibroma).
of abnormal tooth tissue. 3. Benign cementoblastoma (true cementoma).
 Odontogenic and Non-odontogenic Tumors
97
Classification of Odontogenic Tumor by Classification of Non-odontogenic Tumors and
Charls A. Waldron, 1992 Fibro-osseous Lesions of the Jaw Bones

A. Tumors of Odontogenic Epithelium 1. Non-odontogenic tumors:

a. Central fibroma.
1. Ameloblastoma. b. Myxofibroma .
a. Malignant ameloblastoma. c. Ossifying fibroma.
b. Ameloblastic carcinoma. d. Osteoma.
2. Clear cell odontogenic carcinoma. e. Osteoid osteoma.
3. Adenomatoid odontogenic tumor. f. Benign osteoblastoma.
4. Calcifying epithelial odontogenic tumor. g. Chondroma.
5. Squamous odontogenic tumor. h. Giant cell granuloma.
i. Central hemangioma.
B. Mixed Odontogenic Tumors: j. Benign tumors of nerve tissue (Neuroma or
1. Ameloblastic fibroma. traumatic neuroma, neurofibroma and
2. Ameloblastic fibro-odontoma. schwannoma or neurilemoma).
3. Ameloblastic fibrosarcoma. 2. Fibro-osseous lesions:
4. Odontoameloblastoma . a. Fibrous dysplasia of bone.
5. Compound odontoma. b. Cherubism (Inherited fibro-osseous bone
6. Complex odontoma. disease).
c. Ossifying fibroma.
C. Tumors of Odontogenic Ectomesenchyme: d. Central giant cell granuloma.
1. Odontogenic fibroma. Odontogenic Tumors (Tumors Arising
2. Granular cell odontogenic tumor. from Odontogenic Epithelium Without
3. Odontogenic myxoma. Odontogenic Ectomesenchyme)
4. Cementoblastoma.
Ameloblastoma
Analytical Observation Ameloblastoma was described as “adamantinoma” by
Waldron included AOT as epithelial odontogenic Brocca and Malassez in late eighteenth century. The
tumor but according to WHO’s classification (1992) term ‘ameloblastome’ was coined by Ivy and Churchill
the AOT is included in the mixed odontogenic tumor. in the year 1934. Ameloblastoma is defined as, benign
odontogenic neoplasm, locally-invasive epithelial
Classification of Benign Non-odontogenic tumor with strong tendency to recur. Tumor
Tumor of the Jaws by Ivor RH Kramer, consisting of proliaferative odontogenic epithelium in
Jens J Pindborg and Mervyn Shear 1992 a fibrous connective tissue stroma (Modified by
Kramer and Pindborg, WHO 1992).
1. Osteogenic neoplasms. Cemento-ossifying According to Willis, the ameloblastoma is
fibroma. considered as locally malignant. Rabinson described
2. Non-neoplastic bone lesions: ameloblastoma as “usually unicentric, non-functional,
a. Fibrous dysplasia of the jaws. intermittent in growth, anatomically-benign and
b. Cemento-osseous dysplasias: clinically-persistant”.
i. Periapical cemento-osseous dysplasia. Thoma and Williams in 1993 summarized the
ii. Focal cemento-osseous dysplasia. origin of ameloblastoma as follows:
iii. Florid cemento-osseous dysplasia (Giganti- 1. Late and secondary development sources.
form). 2. Early embryonic origin.
3. Other cemento-osseous dysplasias: 3. Basal cells of the surface epithelium of oral mucosa.
a. Cherubism. 4. The heteropic epithelium from other parts of the
b. Central giant cell granuloma. body, especially from the pituitary gland.
 Synopsis of Oral and Maxillofacial Surgery
98
Clinical Features Histopathological Features (Fig. 13.2)
Slow-growing, long duration initially symptomless, The follicular and plexiform ameloblastoma are the
gradually increased in size. Expansion is much more most common variety. The less common histopatho-
than destruction. Lingual expansion is more than logical varieties includes the acanthomatous, granular
buccal, produced marked enlargement and deformity cells, desmoplastic and basal cell types.
of the cortex of the jaw, seldom destroyed. The teeth
in that area may be vital or may shows resorption. Follicular pattern: The most common and recognized
lesion composed of small to large odontogenic
Site epithelial nests (the folliculs) in various size and shape.
The cyst formation is common.
The lesion may occur in either of the jaws the mandible
is affected more than maxilla, the ratio is 5:1. In Plexiform type: The plexiform ameloblastoma consists
mandible, usually affected areas are posterior tooth of long interlinking cords or larger sheets of
and ramus. In case of maxilla the posterior areas are odontogenic epithelium resembling the dental lamina.
involve. Sub-type varities: Acanthomatous ameloblastoma
showing extensive squamous metaplasia, often
Age and Sex associated with keratin formation in the central
portion of the epithelial nest or island of a follicular
The age usually the second to third decades of life
ameloblastoma. In that case, the term acanthomatous
sometimes reported as late as seven decade. The male
ameloblastoma is applied.
is slightly affected > female.
Granular cell pattern: The variety ameloblastomas
Radiological Findings (Fig. 13.1) may shows the transformation of groups of lesional
epithelial cells to granular cell. These cells have
The unilocular (monocystic) or multilocular (multi-
abundant cytoplasm filled with eosinophilic granules
cystic) radiolucency in different forms and shape,
that resemble lysosome ultrastructurally and
which may be described as soap bubble or
histochemically. This variant has been seen in young
honeycomb-like appearance. The buccal and lingual
patient and in clinically aggressive tumors. The
cortical expansion is frequently present. Resorption
granular cell change is extensive in an ameloblastoma,
of the roots of the teeth adjacent to the tumor is
the designation of granular cell ameloblastoma is
common. In many cases, an unerrupted tooth usually
appropriate—Waldron.
a mandibular third molar, is associated with
radiolucent defect. The margins of the radiolucent Basal cell ameloblastoma is the rare type of lesion
zone often showing the irregular scalloping. composed of nests of uniform basaloid cell, and they

Fig. 13.1: X-ray appearance of multilocular Fig. 13.2: Histological appearance of

ameloblastoma of right mandible follicular type of ameloblastoma
 Odontogenic and Non-odontogenic Tumors
99
are histopathologically very similar to basal cell Macintosh and Marx’s et al 1991/93 observe amelo-
carcinoma of the skin. blastoma extents 2.3 to 8 mm its radiographic margins.
The oral surgeon has recommended resecting margins
Desmoplastic type: A variant of solid ameloblastoma
should 1 to 2 cm into the normal bone. This was the
with abundant fibrous tissue stroma in the area of
original dictum of Ivor RH Kramer regarding the
calcification. Presence of increased stromal desmo-
surgical intervention of ameloblastoma quoted from
plasia with high recurrence rate.
his famous article Ameloblastoma – Its Clinico-
pathological Appraisal. The former observers
Analytical Observation
supported the view of Kramer.
1. Some authorities widely believe that amelo-
blastomas frequently arise in dentigerous cysts Calcifying Epithelial Odontogenic Tumor
called mural ameloblastoma or some have been (Pindborg Tumor): CEOT (Fig. 13.3)
term as pre-ameloblastic lesion.
First reported by Jens J Pindborg, a Scandnevian oral
2. The malignant ameloblastoma and ameloblasatic
pathologist in the year 1955. It is a rare odontogenic
carcinoma: The both lesions are controversial
tumor, slowly growing increasing the expansion of
according to the terminology. The term malignant
the jaws. Small lesions are entirely asymptomatic
ameloblastoma should be used for a tumor that
(Franklein and Pindborg) male and female are equally
shows the picture histopathologically as
affected. Mostly occur in the molar region of the
ameloblastoma both in the primary tumor and in
madible. Next the pre-molar region of the mandible
the metastasis deposits. The term ameloblastic
and then molar region of the maxilla. This tumor is a
carcinoma should be reserved for an amelo-
painless slow-growing mass involves the adjacent
blastoma that has cytologic features of malignancy
structure later. The tumor is locally invasive with high
in the primary tumor, in a recurrence or in any
recurrence rate.
metastatic deposit. This tumor having the
aggressive nature and may not have metastases as
Radiological Appearance
a routine—Waldron.
Very much characteristic:
Outline of Surgical Modalities of Jaw Tumors 1. A pericoronal radiolucency.
Including Ameloblastoma 2. A pericoronal radiolucency with radio-opaque foci.
3. A mixed radiolucent and radio-opaque lesion not
Gold, Upton and Marx in the year 1991 standardized,
associated with a unerrupted tooth.
different surgical methods for the lesion in bone. These
4. A ‘driven snow appearance’.
are followings with slight modification:
5. A dense radio-opacity (occasionally) the most
1. Enucleation with or without curettage.
common are of pericoronal radio-lucency and of
2. Marsupialization or partsh operation.
3. Resection without continuity defect also known as
marginal resection (EN block resection).
4. Resection with continuity defect, (the operation for
extensive lesions include the inferior border of the
mandible).
5. Partial resection or peripheral ostectomy.
6. Hemimandibulectomy with removal of condylar
head (disarticulation).
7. The CO2 laser and cryotherapy has been reported
in the management of ameloblastoma in small
lesion.

Analytical Observation
Regarding the above treatment categorized in (7) Fig. 13.3: Calcifying epithelial odontogenic tumor (Right
needs time tested interpretation of the therapeutic mandible). The first molar is embedded. Calcified masses are
measures and supportive documents. seen close to the crown of the tooth
 Synopsis of Oral and Maxillofacial Surgery
100
diffuse radio-opacities within the radiolucent
areas—Franklein and Pindborg 1976.

Histopathologically (Figs 13.4A and B)

CEOT has discrete islands, strands, or sheets of
polyhedral epithelial cells in fibrastroma. The tumor
island frequently enclose amorphous, eosinophilic
hyalinized (amyloid-like) extracellular materials. The
areas of calcification form concentric rings are termed
as Liesgang rings.

Management
Careful excision of the tumor along with the normal
A B
margins of the bone and the soft tissue.
Figs 13.4A and B: (A) Calcifying epithelial odontogenic tumor
Squamous Odontogenic Tumor calcification in tumor tissue. (B) Calcifying epithelial odontogenic
tumor fluorescence of amyloid-like material stained with
It is a rare benign odontogenic neoplasm, was first thioflavine
reported by Pullon in the year 1975.
Chales A Waldron in the year 1984. Male and female
Pathogenesis or Origin of Development
both are equally affected, commonly seen at the fifth
It is probably arise from neoplastic transformation of decade of life. Mostly seen in the mandible about 75
epithelial cell rests of malassez within the PDL of percent of the mandible anterior region followed by
lateral surface of erupting tooth. Histologically, it the body and the angle. Rarely 25 percent seen in the
assumes as an acanthamatous ameloblastoma or well- maxilla.
differentiated epidermoid carcinoma. It apex male and
females and the age ranges from 2nd to 6th decades Radiological Appearance
of life.
A unilocular and multilocular radiolucency with ill-
Site: Maxilla and mandible both are affected equally. defined irregular borders with evidence of root
Usually asymptomatic lesions but sometimes causes resorption and bony destruction.
mild pain, discomfort and mobility of the teeth.
Histopathology
Radiological Appearance
Odontogenic epithelium by sheets and islands
As a semicircular or triangular radiolucency with uniformly along with vacuolated and clear cells.
sclerotic or well-defined, margins may be seen
associated with cervical part of the tooth. Management
CCOT having highly growth potentiality and local
Histopathology
aggressiveness the radical, resection is recommended.
Histopathology includes various size and shape of
islands of matured squamous epithelium. Adenomatoid Odontogenic Tumor (AOT)
It is an uncommon benign odontogenic non-invasive
Management
tumor. The AOT first reported by Stafne and then
Conservative, local excision or peripheral osteotomy. coined by Phlipsen and Birn in the year 1969.

Clear Cell Odontogenic Tumor (CCOT) Pathogenesis/Origin

It is a rare, benign, odontogenic central tumor locally Arises from residual odontogenic epithelium. Some
invasive, slow-growing lesions first reported by consider as hamartomas of ROE (Residual
 Odontogenic and Non-odontogenic Tumors
101
Odontogenic Epithelium)—Courtney et al 1975. persist without any symptom for decades. And it may
Females are affected more than males. The youngers grows for time being and then remain static for the
are affected more that means second to third decade rest of the patient’s life. On the basis of radio-
of life. Commonly seen in the maxilla involving canine graphically and miscroscopic features two types of
and pre-molar region. AOT is slow-growing soon odontoma are recognized. One is compound
infiltrating bone and inclined to displace the tooth odontoma and other is complex odontoma.
instead of root resorption—Philipsen et al 1991. In the compound odontoma, crudely formed teeth
on varying in size and shape may be recognized as
Radiological Appearance (Figs 13.5A and B) radio-opacity in X-rays.
In the complex odontoma, the X-rays show clearly
Well-circumscribed radiolucency or it may contain
outline very dense radio-opacities. A thin radiolucent
radio-opaque foci.
zone often surrounds these. The radio-opacity does
Histopathology (Fig. 13.6) not represent any specific shape but appears as a
disorganise irregular mass.
The lesion is well-capsulated by the fibrous tissues.
The tumor is composed of duct-like structures lined Histopathology
by columnar or cuboidal epithelium. Sometimes the The compound odontoma shows tooth-like structure
majority of the tumors are associated with impacted consists of a central core of pulp tissue encased in a
tooth or irregular masses of calcified materials. cell of dentil and covered in part by enamel.
The complex odontoma consists of haphazard
Management
conglomeration of dentil, enamel matrix, cementum
As the tumor is encapsulated, the conservative and areas of pulp tissues.
excision or enucleation is sufficient. The recurrence is
rare and prognosis is good. Management
Odontoma Since the tumors are separated from the surrounding
bone by a zone of connective tissue it can be easily
The tumor of odontogenic origin, composed of hard
enucleated and removed, there is no recurrence, and
dental tissues. Tumors occur at any age and in both
prognosis is good.
the sexes, affect the maxilla and mandible equally, and
are usually asymptomatic non-aggressive and non- Odontogenic Fibroma
invasive in character. They are slow-growing and may
Odontogenic fibroma is a central benign odontogenic
neoplasm found as peripheral and central variety.
Though some reported it as an uncommon, poorly-

A B
Figs 13.5A and B: (A) Adenomatoid odontogenic tumor in right
maxilla associated with impacted tooth. (B) Adenomatoid
odontogenic tumor associated with embedded tooth and Fig. 13.6: Histopathologically shows duct-like structures in
calcified masses adenomatoid odontogenic tumor
 Synopsis of Oral and Maxillofacial Surgery
102
understood entity but some authority consider it is as Radiological Appearance
a common odontogenic tumor, but it has not been
Multiloculars small or extensive lesion. May be
well-recognized in spite of the great frequency of the
completely radiolucent or soap bubble, honeycomb,
lesion. Because in X-rays it resembles or is identical to
or tennis racket appearance with scalloped irregular
the dentigerous cyst and consequently is misdiag-
margins.
nosed. This odontogenic tumor occurs with equal
frequency in both the sexes usually in the second
Histopathology
decade of life. The mandible is affected more
frequently than the maxilla, with the third molar and Stellate angular or rounded mesenchymal in a homo-
the canine areas the most common site of involving. genous mucoid stroma with few collagen fibrils.
The central lesion radiologically shows multiloculated
radiolucency with well-defined scelerotic margin Management
associated with the crown of the tooth. The lesion Tumor is infiltrative in nature. Excision by resection
therefore, resembles a dentigerous cyst. At exploration with sound bony margins. The chances of recurrence
of surgery, however, a solid rather than a cystic lesion are high. Long-term follow-up is necessary.
is found. The peripheral odontogenic fibroma found
frequently on the gingiva as pedunculated or sessile NON-ODONTOGENIC LESIONS OF THE JAWS
growth and normal colour of gingiva. Males and
females are both affected. Usually found second to six Ossifying Fibroma
decade of life.
Ossifying fibroma is a true osteogenic benign
neoplasm with a significant growth potential. This
Origin
lesion previously termed as cementifying fibroma,
The odontogenic fibroma raises from the tooth follicle originally derived from undifferentiated cells of the
that is the connective tissues that surround that enamel periodontal ligament.
organ.
Histopathologically shows a circumscribed mass Clinical Features
of dense or loosely-arranged connective tissue in
Commonly affected age is third and fourth decades
which strands and islands of epithelium are dispersed.
of life. It is affected more female rather than male. The
These epithelial cells do not memic ameloblasts. In
ratio is 5:1. It is a rare tumor. Mostly seen in the
some cases, they may undergo calcification, and the
mandible premolar and the molar areas in maxilla
lesion may be called as calcifying odontogenic
posterior areas are affected. The neoplasm is
fibroma.
composed of fibrous tissue that contains a variable
mixture of bony trabeculae, cementum like spherules,
Management
or both. Although the lesions do contain a variety of
As the lesion has slow growth and limited the excision mineralized structures, most authorities agree the
and the curettage is sufficient. same progenitor cell produces different materials.
Though it is derived from the cells of periodontal
Odontogenic Myxoma ligament recently many authorities preferred to
Odontogenic myxoma is an infiltrative benign odonto- designate the cementum-like material present in
genic neoplasm of bone that almost occurs exclusively ossifying fibroma as variation of bone. The designation
in the jawbones. The neoplasm is mesenchymal and cementifying fibroma, cemento-ossifying fibroma and
the myxomatous components are gelatinous in nature. cementying fibroma are all-appropriate under this
Slow-growing, painless enlarging and expansion of tumor – Charels A Waldron cited from Neville, et al.
the jaw with possible spreading, loosening and
migration of teeth and roots resorption is occasionally Radiological Appearance
seen. Age first to fifth decade of life. Females are less Radiologically well-circumscribed tumor with
affected than the male. Site mostly in the tooth-bearing sharply-demarked margins with unilocular radio-
areas. lucency and with varying degree of radio-opacity.
 Odontogenic and Non-odontogenic Tumors
103
Histopathology reported by Von Reckling Hausen in 1891. In the year
1938 Lichtenstein introduced the term fibrous-
Encapsulated fibrous capsule surrounding a tumor or
dysplasia.
its well-demarked neoplasm composed of fibrous
tissue stroma, contains varying amount of calcifying
Clinical and Radiological Features
mass resembling bone, cementum or both.
Fibrous dysplasia may manifest as a localized process
Management or Treatment involving only bone called as mono-ostotic fibrous
dysplasia of the jaws. When the FD involving multiple
Enucleation and local resection or peripheral
bones it is called multiostotic fibrous dysplasia. The
ostectomy. Recurrence is not reported.
mono-ostotic lesion is more common than the
polyostotic or multiostotic. The mono-ostotic fibrous
Fibro-osseous Lesions of the Jaws
dysplasia occurs during the first or second decade of
FOL are diverse group of processes that are charac- life. It is asymptomatic painless, slow-growing
terized by replacement of normal bone by fibrous insidious growth. Both males and females are affected
tissues containing a newly-formed mineralized equally. Maxilla is more affected than the mandible.
product. The designation FOL is not a specific Maxillary lesion extends to zygoma sphenoidal floor
diagnosis and describes only a process. FOL of the of the orbit and maxillary air sinus and are not strictly
jaws includes developmental (hamartomatous) lesions mono-ostotic. Hence, they are called cranio-facial
reactive or dysplastic process, and neoplasms. The fibrous dysplasia. In the mandible, body is most
histopathological features of these lesions may be frequently involved.
similar. The final diagnosis depends on clinico- FD is unilateral, slow progressive enlargement and
pathological and surgical appraisal. develops facial asymmetry, which may be the patient’s
chief complaint. Teeth in the involved area usually
Classification of Fibro-osseous Lesion firm but may be displaced by bony mass or occlusal
Modified from Charles A Waldron, 1993 level can be changed. Aggressive clinical features
1. Fibrous dysplasia. include rapid growth pain, nasal obstruction or
2. Cemento-osseous dysplasia (Reactive or dysplastic exophthalmos. The radiological features include
lesions arising in the tooth-bearing areas). These ground glass appearance in mature stage due to
are presumably of periodontal ligament origin. It homogenious radio-opacity with numerous trabeculae
is convenient to divide them into types based on or woven bone or orange peel appearance. In early
their radiologic features, although they seem to stage, some lesions may be seen as unilocular or
represent the same pathologic process – multilocular radiolucencies and intermediate stage the
a. Focal COD, radiolucent lesion intermediate with patchy, irregular
b. Periapical COD,
c. Florid COD.
3. Fibro-osseous neoplasms: These are widely
designated as ossifying fibroma (discussed before),
cemento- ossifying fibroma.

Fibrous Dysplasia
Fibrous dysplasia is a developmental tumor-like
conditions characterized by replacement of normal
bone by an excessive proliferation of cellular fibrous
connective tissue intermixed with irregular bony
trabuculae (Fig. 13.7).
It is a sporadic condition that results from a
postzygotic mutation in the GNAS-1 (Guanine
Nucleotide – binding protein, ulfa-stimulating activity Fig. 13.7: Radiographic picture shows the ground glass
polypeptide gene. The fibrous dysplasia was first appearance in fibrous dysplasia of right maxilla
 Synopsis of Oral and Maxillofacial Surgery
104
opacities similar to Paget’s disease. A finger print bone Cemento-osseous Dysplasia
pattern and superior displacement of inferior dental
COD occurs in the tooth-bearing areas in the jaws
canal may be noted.
and is probably the most common FOL in clinical
In maxilla, increase bone density with obliteration
practice. The COD arises in close approximation to
of the maxillary sinus. In polyostotic fibrous dysplasia
the PDL and exhibit hystopathologic similarities
or Mc Cune–Albright syndrome the involvement of
with the structure, some investigators have suggested
skull and jawbones leads to facial asymmetry.
these lesions are PDL origin. Others believe, COD
Simultaneous of involvement of both the jaws
represents defect in extra-ligamentary bone
along with involvement with other bone.
remodeling that may be triggered by local factors
Café-au-lait pigmentation of the skin and oral
and possibly correlated to underlying hormonal
mucosa with sexual precocity may be present in
imbalance.
females is due to endocrine disturbances.
On the basis of clinical and radiological features
they can be classified as the periapical COD, focal COD
Etiology: Idiopathic (Unknown)
and florid COD. All these forms represent only
Several hypotheses have been postulated from time variants of the same pathological process.
to time: (1) As a non-neoplastic hamartomatous
growth resulting from altered mesenchymal cell Periapical COD or Cemental Dysplasia
activity or a defect in the control of bone cell activity. or Cementomas
(2) Inherited basis. (3) Focal bone expression of a
complicated endocrine disturbance (finding of PCOD involves the periapical region of the anterior
estrogen receptors in an osteogenic cells of a patient). part of the mandible.
Solitary lesions may or may not with multiple foci.
Investigation The females are affected more than the male ranging
from 10:1 to 14:1 and approximate affected age from
Ca, phosphorus and alkaline phosphatase are within
third to fifth decade of life.
normal range.
PCOD is an asymptomatic condition. X-ray shows
in early lesion osteolitic and fibroblastic stage with
Histopathologically
radiolucency in later stage matured lesion almost
Proliferating fibroblast in a compact stroma of calcified solid homogenous radio-opacity surrounded
interlacing collagen fibrous with irregular bony by a thin radiolucent border.
trabuculae may be scattered haphazardly given the
picture of Chinese alphabets. Focal COD
Management/Treatment The name suggests that exhibits single sight of involve-
Osseous recontouring or reshaping via transoral ment but may occur in any areas of the jaw. The
approach to achieve esthetic and functional require- posterior mandible is the pre-dominate area the
ments. disease is typically asymptomatic and detected only
on radiography examination. Most lesions are smaller
Analytical Observation than 1.5 cm in diameter. Radiographically or X-ray
appearance varies from completely radiolucent to
Cherubism is rare developmental jaw condition that densely radio-opaque with a thin periapical
is generally inherited as a autosomal dominant trait radiolucent rim.
with high penetrance but variable expressivity. The
name cherubism was applied to this condition were
Florid COD
the facial appearance is similar to that of the plump –
cheeked little angles (cherubs) depicted in renaissance Appears with multifocal involvement, not limited to
painting. The cherubism previously called as familial the anterior mandible. The lesion show a marked
fibrous dysplasia. This term should be avoided tendency for bilateral often quite cemetric
because cherubism has no relationship to fibrous involvement with asymptomatic but patient may
dysplasia—Waldron C. A. 1992. complaint of dull pain and an alveolar sinus tract may
 Odontogenic and Non-odontogenic Tumors
105
be present, exposing yellowish, avascular bone to the 2. Gardner DG. Some current concepts on the pathology of
oral cavity may present some degree of expansion. ameloblastomas. Triple O and Oral radio Endod 1996;82:
Radiologically, initially radiolucent, later become 660-69.
3. Gardner DG, et al. The treatment of ameloblastoma based
mixed that means the radio-opaque and radiolucent
on pathology and anatomic principles. Cancer, 1980;46:
zone with a thin peripheral radiolucent rim. The florid 2514-519.
COD also known as familial gigantiform cementoma 4. Kramer IRH. Ameloblastoma: A clinicopathological
or FGC. Both the dentulous and the edentulous areas appraisal. BJOS 1963;1:13-28.
are affected. The mandible is more affected than the 5. Lucas RB. Pathology of Tumors of Oral Tissues. Churchill,
maxilla. Many times all the four posterior quadrants London, 1964.
may be involved. 6. Pinborg JJ. A calcifying epithelial odontogenic tumor.
Cancer 1958;11:838-43.
7. Philipsen HP, et al. Adenamatoid odondogenic tumor: Facts
Treatment and figures. Oral oncol 1998;35:125-31.
8. Poulson TC, et al. Adenamatoid odontogenic tumor : A
Most of the lesions not required any treatment clinicopathologic and ultrastructural concepts. JOMFS
following the biopsy as because the lesions are same 1983;41:818-24.
limitative process. In case of focal COD can not be 9. Slootweg PJ. Maxillofacial fibro-osseous lesions: Classi-
separated bone easily and is removed by curettage. fication and differential diagnosis. Semindiagn pathol
The florid COD or FGC shows relatively rapid growth 1995;13:104-12.
10. Shatkin S, et al. Ameloblastoma: A rational approach to
resulting in facial deformity. Recontouring or resaving
therapy. Triple O 1965;20:421-35.
the procedure may not help as because the rapid 11. Waldron CA. Ameloblastoma: In Perspective Oral Surgery
growth of the tissue. 1966;24:331-33.
12. Waldron CA, et al. Adenamatoid odontogenic tumor. Triple
BIBLIOGRAPHY O 1970;36:69-86.
13. Waldron CA. Fibro-osseous lesions of the Jaws. JOMFS
1. Franklin CD, Pinborg JJ. A calcifying epithelial odontogenic 1993;51: 828-35.
tumor: A review and analysis of 113 cases. Triple O 14. Waldron CA. Benign fibro-osseous lesions of the Jaws—
1976;42:753-65. Part-I. Tripple O 1973;35:90-121.
FOURTEEN
Some Soft Tissue Tumors and Central Oral
Lesions or Tumors-like Growth
• Special Emphasis on Hemangioma • Histocytosis X of Interest to the Oral
Surgeons

Central Giant Cell Granuloma (Giant Cell Histopathology is composed of a proliferation of

Reparative Granuloma, Osteoclast Granuloma) spindled-fibroblasts in variable collagenous stroma.
Multi-nucleated giant cells are present thoughout the
A central lesion consisting of a more or less cellular
connective tissues trauma.
fibrous tissue containing multiple foci of haemorrhage,
focal aggregations of multinuclear giant cells, and
Treatment
sometimes trabeculae of woven bone forming within
the septa of more mature fibrous tissue that may 1. Corticosteroids.
traverse the lesion. Waldron and Shafer used the term 2. Human calcitonin 0.5 mg (100 IU) deep subcu-
central giant cell granuloma in 1966. The central giant taneous injection for 1 year recommended by Prof.
cell granuloma and its cystic counter part the Malcolm Harris 1993.
aneurysmal bone cyst tend to occur in young patients 3. Interferon alpha–2a.
in the second decade with a slightly increased
incidence in female. The most common sight in the Surgery
mandible followed by the maxilla (Salzman and Jun This includes curettage and enucleation.
1981). Jaffe’s 1953 considered the lesion is dysplastic
rather than neoplastic and also considered not as Prognosis
tumor but as reactive granuloma.
The lesion is relatively uncommon. It is good and low recurrence.
Based on the clinicoradiological perspective, they
have been divided into two groups: non-aggressive Brown Node or Giant Cell Lesion
and aggressive. (Hyperparathyroidism)
Clinical picture shows slow-growing asympto- It is a very rare lesion of the jaw. It affects both the
matic swellings of the affected jaws, which fail to mandible and the maxilla. Females are more affected
demonstrate the cortical perforation or root resorption, than the male usually third to forth decade of life. The
to rapidly expanding aggressive growth associated enlargement of the jawbones with clear-cut areas of
with pain, paraesthesia, occasionally resulting the radio lucency; teeth in the area are vital. It occurs
ulceration of the mucosal surface. secondary to hyper-parathyroidism, although this
Radiologically, there is an area of bone destruction diagnosis is usually suggested after enucleation on
which has a smooth or lobulated outline and which finding giant cells in a fibrous stroma histologically.
may be traversed by slender bony septa. The In the jawbones, the brown tumor of the hyperactive
radiographic appearance may thus bear some parathyroidism may be Histologically indistinguish-
similarity to that of an ameloblastoma. able from ‘giant cell (reparative) granuloma’—L.V.
Ackerman.
Diagnosis and Histopathology The general systemic manifestations consist of
Estimation of serum Ca and serum phosphate, alkaline weakness, fatigue, constipation, polydipsia, polyuria,
phophatase, and PTH are normal to confirm a spontaneous fractures, marked resorption of bone
diagnosis. increased blood calcium >11 mg per 100 ml low blood
 Some Soft Tissue Tumors and Central Oral Lesions or Tumors-like Growth
107
<2.5 mg per 100 ml, and increased urine calcium and Hand-Schuller Christian Disease
phosphorus.
Usual location, both jaws are involved, children are
affected more, males are affected than female.
Treatment
Clinical and X-ray features same as in previous
Removal of disease parathyroid gland. lesion.
Histological features shows histiocytes, some of
Central Hemangioma which contained cholesterol and appear large and
Extreme rare lesion of the jaw and extremely foamy.
dangerous. The mandible is affected twice as Treatment : Symptomatic, radiation.
frequently as the maxilla. Slow growing and Prognosis: Poor.
asymptomatic lesion or they may grow rapidly, Letterer-Siwe Disease
expand the cortical plate, and lead to loosening of the
teeth. Teeth that become loose can be “pumped” in Usual location, mandible and maxilla both are
and out of their sockets. On palpation, a pulsating thrill affected. Usual age, under three years. Males and
may be felt. The cervical area of the teeth may show females both are affected equally.
oozing of the blood. This is very important to note, Clinical and X-ray features: Multiple jaw radio-
that the teeth on the affected area act as valve. The lucencies; enlargement of spleen, liver, and lymph
extraction is absolutely contraindicated, and chances nodes; rapid deterioration of general health.
of profuse intractable bleeding problems. The X-ray Histological picture shows proliferation of
shows radiolucent area of honeycombed appearance. histiocytes.
Aspiration of the lesion is a great value. Frank blood Treatment: Symptomatic; corticosteroids.
will come out.
1. Includes ECA ligation. Multiple Myeloma
2. Sufficient arrangement of blood transfusion. Multiple myeloma is a malignant tumor of bone
3. Arrangements for packing. marrow. Patient affected about third to fourth decade
4. Rapid jaw resection. of life. Males are affected twice as female. Most usually
5. Radiotherapy. involved are the skull, jaws, vertebrae, pelvis and
femur.
Treatment Clinical pictures show pain and pathological
Histocytosis X which includes eosinophilic fractures, numbness, and jaw swelling, and mobility
granuloma, Hand-Schuller Christian disease and of tooth; solitary lesions may occur in jaws.
Letterer Siwe disease. Diagnosis: Includes leukopenia means decrease
WBC count. Anemia, decrease RBC count. Elevated
Eosinophilic Granuloma gamma globulin, presence of Bence Jones protein in
the urine (a protein in urine which coagulates between
Usual location, both jaws are involved; usual age, third 40 to 60oC, and disappears on boiling), deposition of
and second decade of life. Females and males both amyloid-like (paramyloid) material in tissues,
are affected equally. including the gingiva, tongue and hypercalcaemia.
Clinical and X-ray features: Sharp clear cut areas The mandible is involved more frequently than the
of complete radiolucency, if around teeth, later appear maxilla, the lesions are multiple, the sites usually
to be ‘hanging in air’; associated soft tissue of oral affected are the premolar and the molar region and
mucosa shows ulceration and necrosis; pain malaise, the coronoid process.
and other systemic symptoms; teeth in area vital. X-ray shows multiple, clear cut, punched out areas
Histological features: Histiocytes and eosinophils; of radiolucency and do not show any peripheral
and destruction of bone. osteosclerotic bone reaction. Root resorption and loss
Treatment: Surgical excision and low dosage of of laminadura may also be seen.
radiation. Histological pictures show a solid tumor mass
Prognosis: Fair to good, depending on other composed exclusively of normal and abnormal plasma
systemic and skeletal involvement. cells.
 Synopsis of Oral and Maxillofacial Surgery
108
Treatment: Symptomatic; surgical, radiation and maxilla. The vast majority of lesions occur after the
massive doses of fluorides. age of 20 years, with average age of occurrence about
Prognosis is grave. 43 years. Males are affected slightly more often than
females. Duration of the lesion is usually a few weeks
Osteosarcoma (Osteogenic Sarcoma) to a few months. Often there is a history of trauma,
such as tooth extraction.
A malignant tumor of the bone rarely affects the jaws, Roentgenograms are negative, but on rare
usually seen in the childhood or young adults. Males occasions, the underlying bone may show radio-
are affected more than the females. Many of the tumors lucency. Microscopic sections are diagnostic and are
developing after middle age are associated with identical to those of a central giant cell granuloma.
Paget’s disease. It is a highly malignant potential The tumor is made up of fibroblasts, young blood
tumor characterized by the direct formation of bone vessels, and multinucleated giant cell, and all lesions
or osteoid tissue by the tumor cells. The mandible is show mild to marked amounts of emosiderin.
affected more than the maxilla. Rapidly growing The tumor is completely covered by stratified
tumor with the enlargement of the jaws and vague squamous epithelium or may be partly-ulcerated.
pain, and paresthsia. Often there is a history of tooth Peripheral giant cell granuloma does not recur
extraction or trauma. Teeth in the area may be loose following local removal.
and show migration and root resorption. The oral
mucosa and overlying skin of the face may appear Pyogenic Granuloma
erythematous. Spontaneous pathologic fractures may
occur. A tumor-like growth, which occurs in all ages, females
X-ray shows radio-opacity in which bone are affected slightly more frequently than males. The
trabeculae radiate from the periphery of the lesion, gingival area are affected more in maxilla rather than
giving it a sun ray effect, may consist of irregular mandible, the buccal aspect more often than the
radio-opaque and radiolucent areas, or may show and lingual aspect.
almost entirely radio-lucent area. In some instances, Clinically the pyogenic granuloma usually presents
widening of the periodontal space may be the earliest as an elevated, soft, pedunculated or broad-based
radiological sign. growth, has a smooth red surface mostly ulcerated,
Treatment includes radical resection followed by bleeds easily, and may have a raspberry–like
radiation therapy 5000 r is recommended or radiation appearance. It has duration of weeks to month. The
prior to surgery. major mass of the growth is composed of numerous
Prognosis is grave. small capillaries, which are often arranged in islands
and lobules and are interspersed by edematous
connective tissue. The lesion shows mild to dense
Chondrosarcoma
infiltration by polymorph nuclear, leukocytes, plasma
It is also rare tumor of the jaws. It involves more the cells, lymphocytes. The cause of pyogenic granuloma
mandible than the maxilla and usually between 25 to is unknown it is believed that this lesion represents
50 years of age. The clinical features of the tumor and overzealous response of tissues to some local
almost same as osteosarcoma but only the effect of trauma.
sun ray in X-ray is usually absent. The tumor does Treatment consists of excision, by blade. Electro
not metastasize show readily as osteogenic sarcoma. or cryosurgery.
Treatment includes radical surgery.
Prognosis is poor. Irritation Fibroma
Most common tumor-like growth of the oral cavity.
Peripheral Giant Cell Granuloma
Its origin is due to some local irritation. It is an
These are pedunculated or broad-based growth, elevated, pedunculated or sessile lesion which is
usually have a smooth surface, are reddish-blue, and usually firm paler in varying size and usual sites are
sometimes lobulated, and bleed easily. They are tongue, lips, cheek and gingival tissue.
limited to the gingival tissue of edentulous ridges, and Treatment of irritation fibroma is excision, by
the mandible is involved more frequently than the blade—Electro or cryosurgery.
 Some Soft Tissue Tumors and Central Oral Lesions or Tumors-like Growth
109
Squamous Papilloma Bataille et al, (1970) have observed in children that
after a stationary or regression period, oral
It is a benign soft tissue epithelial tumor of the oral
hemangiomas may develop as further growth
cavity. It appears like white, cauliflower-like
continues. In adults their evolution is connected with
pedunculated painless growth of oral cavity. Usual
masticatory trauma.
sites cheek, lip, tongue commonly seen in adult both
Angiography, as an investigation method for
males and females are affected equally. Presumably,
clinical study, for establishing the therapeutic
this lesion is induced by the human papilloma virus
indications and for the evaluation of treatment of
(HPV).
hemangiomas (Lasjaunias and Doyon, 1982).
Histopathological features: The papilloma is
Treatment of hemangiomas a very large number
characterized by a proliferation of keratinized
of methods are known, modified according to the
stratified squamous epithelium with finger-like
clinical condition and the site, size and structure
projections in fibrovascular connective tissue.
involved. In clinical practice radiotherapy, sclerosing
Treatment is excision.
injections, antimetabolities, corticosteriods,
Prognosis is excellent.
cryotherapy, vascular ligation, surgical excision, laser
surgery, embolisation etc. are used.
Lipoma
In cavernous hemangiomas sclerosing injections
It is a rare soft adipose tissue tumor of the oral cavity. with Sodium Morrhuate or PEOS (Polyethyl Enoxi
If it is seen in the mouth. The usual site is cheek. The Sclerol) and surgery (Popescu and Stavos 1981). The
oral lipoma is very slow-growing tumor, usually soft, intratumoral ligation the method described by Prof.
smooth-surfaced nodular mass, and sessile Valerian Popescu in the management of orofacial
asymptomatic in nature. cavernous hemangioma in different sites prove
Treatment is excision and recurrence is rare. excellent result and follow up period of 1 to 8 years.
This method by which interception of the blood
Hemangiomas supply to the hemangioma is achieved and also break
Classically considered benign tumors of the vascular down of the angiomatous mass into segments by
system, are now classified as hamartomas, thus occlusion of vascular channels, thus completely inter-
denying their neoplastic nature (Andersen, 1951, rupting the intra-tumoral blood flow. Obstructions of
Lucas, 1976). Histologically there is a proliferation of vascular lumina, endothelial atrophy, blood clot
branching vascular channels wandering through a organisation in the small diverticula between them
poor connective tissue stroma. Hemangiomas may be and also subsequent fibrous hyperplasia which take
divided into several types according to the size of the place of the vascular hyperplasia ensue.
vascular channels, their arrangement and the amount
of the surrounding connective tissue. General Technique for Performing Intratumoral
Capillary type: Small blood-filled spaces, lined Ligation in Hemangioma Recommended
with a thin endothelium. by Popescu (Figs 14.1 to 14.3)
Tuberous type: Vascular dilatations having a
nodular appearance. Management and Treatment Appraisal
Cavernous type: Large lacunar vascular spaces. of Hemangioma at a Glance
Over 50 percent of hemangiomas are encountered 1. Injection scelorising sol. start with boiling water,
in the head and mouth area (Popescu, 1942). Very quinine, sodium morrhuate and sodium psyllate,
often of congenital origin (Wolfe, 1962) 85 percent sodium tetradecyl sulphate.
of hemangiomas can be seen in new born and first 2. Injection antimetabolite: 5 fluorcil, nitrogen
year infants (Kauffman and Stout, 1963). Some mustered etc (Added risk of hemorrhage and some
hemangiomans may regress spontaneously (Tressera general site effects).
et al., 1977). 3. Corticosteroids—may cause growth disturbances
The tendency is explained by Longacre and and risk of malformation in children.
Corning 1972 blood clot formation. The blood clots 4. Superficial cryotherapy with CO 2 snow, can
undergo further fibrous transformation thus improve the facial appearance in the case of flat
producing obstruction of the vascular lumina. hemangioma.
 Synopsis of Oral and Maxillofacial Surgery
110
5. Vascular ligation of E.C.A. and facial artery. This
method has got limitation as because the tumor is
supplied by multiple vascular sources.
6. Blade—surgical removal of small lesion. Careful
about hazardous bleeding.
7. Laser surgery.
8. Embolization—various materials are used to
produce both afferent vessels and vascular
channels. Silicone spheres, silicone pallets, gelfoam
soaked in thrombing, muscle fragments and lastly
intratumoronal ligation is a new therapeutic
possibility in the treatment of carvenous
hemangioma.

Central Hemangioma

Extreme precaution is mandatory with microvascular

surgeons and good anesthetic support with following
measures:
1. Treatment includes ECA ligation.
2. Arrangement of plenty of blood transfusion.
Figs 14.1A to G: (A) The Hagedorn needle (number 7 or 8) is introduced 3. Packing arrangements.
percutaneously (or through the mucosa) by a progressive forward and
rotation movement (position no. 123), a segment of the whole 4. Rapid jaw resection.
angiomatous mass is surrounded. (B) The needle tip is then pulled out
through the skin at a point situated at 1, 5-2 cm distant from the point of
penetration. (C) The thread is introduced again on a Hagedorn needle
Lymphangiomas
with a smaller curvature. This needle is introduced through the same
point and then inserted under the skin as far as the point of entry. (D) Lymphangiomas are benign, hamartomatous growth
The thread ends are tightened progressively so that the loop strangulates of lymphatic vessels. It is debatable that whether
the surrounded segment of the angiomatous mass. (E) The threads they are true neoplasm or not. They are usually
are tightened so that the knot remains under the skin. (F) The placement
of peripheral strangulating loops in a buccal hemangioma. (G) The representing developmental malformations that arise
appearance after tightening the knots, the ends remain over the skin; from sequestrations of lymphatic tissues.
the blood and serum from the wound seeps out along the loops thus
avoiding hemantoma formation

Fig. 14.2: Preoperative appearance at the age of Fig. 14.3: Postoperative appearance after 7 years
8 months prior to Popescu technique of age following Popescu technique
 Some Soft Tissue Tumors and Central Oral Lesions or Tumors-like Growth
111
There are three types of lymphangiomas: 3. Bhaskar SN, et al. Inflammatory papillary hyperplasia of
1. Capillary lymphangioma (lymphangioma the oral mucosa. Report of 341 cases. JADA 1970;81:949-52.
4. Burker DS, Lucas RB. Localized fibrous overgrowth of the
simplex), which consist of small, capillary-sized
oral mucosa. BJOS 1967;5:86-92.
vessels. 5. Bunnel K, et al. Central haemangioma of the mandible.
2. Cavernous lymphangioma, which is composed of Triple O 1993;75:565-70.
larger dilated lymphatic vessels. 6. Delange, et al. Treatment of central giant cell granuloma of
3. Cystic lymphangioma (Cystic hygroma), which the Jaws with calcitonin. Int. JOMFS 1999;28:372-76.
exhibits large, macroscopic cystic spaces. 7. Green LA, et al. Capillary haemangioma of the maxilla.
Triple O 1990;70:268-73.
8. Harris M. Central giant cell granuloma the jaws regress with
Clinical Features
calcitonin therapy. BJOMFS 1993;31:89-94.
Oral lymphangiomas may occur at various sites but 9. Hayduk JW. Hand-Schüller–Christian disease. Triple O
most frequently seen cheek and anterior 2/3rd of the 1967; 23:29.
tongue, which may sometimes leads to macroglossia 10. Jarzab G. Clinical experience in the cryosurgery of
haemangioma JMFS 1975;3:146.
or large tongue and may cause difficulty in phonation
11. Kobus K, et al. The surgical treatment of the vascular tumors
and deglutition. The growth is superficial soft a plebby of the face. JMFS 1982;2:99.
surface looks like a cluster of translucent vesicles. 12. Kaban LB, et al. Anti-angiogenic therapy of a recurrent giant
Usual age child to adulthood. Male equally affected tumor of the mandible with interferon alpha 2a. Pediatre
with the female. Lymphangioma may occur in 199;103:1145-49.
conjunction with hemangioma. 13. Katsikerisn et al. Peripheal giant cell granuloma: Clinico-
pathology study. Int. JOMFS 1988;17:94-98.
Histopathologically, numerous large thin-walled
14. Lucus RB. Pathology of Tumors of Oral Tissues. Churchill
spaces that contain clear homogenous lymph. Livingstone.
Treatment: Surgical excision. 15. Longacre JB. Treatment of facial haemangioma by
Unfortunately, lymphangiomas do not respond to intravascular embolisation with cilicone spheres Plst Recons
sclerosing agents as do hemangiomas. However, some Surgery 1972;50:618.
success with sclerosant therapy for unresectable 16. Ogita S, et al. O K-432 therapy for unresectable
lymphangioma in children. J Ped Surgery 1991;26:263-70.
lymphangiomas has been reported using OK – 432, a
17. Rapidis AD. Lipoma of the oral cavity. Int JOS 1996;11:30-
lyophilized incubation mixture of a low-virulent strain 35.
of Streptococcus pyogenes with penicillin G. 18. Saplan I. The CO2 laser in maxillofacial surgery. World
Potassium, which has lost its streptolysin S-producing Congress Maxillofacial Surgery 1982.
ability. 19. Shklar G, et al. Oral lesions of eosinophilic granuloma.
Prognosis is good for most patients. Triple O 1966;22:592.
20. Sleeper, et al. Eosinophilic granuloma of bone: Its
relationship to Hand-Schüller-Christian disease and L.S.
BIBLIOGRAPHY
disease. Triple O 1951;4:896.
1. Adornato MC, et al. Intralesional corticosteroid injection 21. V Popescu. Intratumoral ligations in the management of
for treatment of central giant granuloma. JAMA 2001;132: orofacial haemangioma. JMFS Maxillofacial Surgery 1985;
186-90. 13:99-107.
2. Bataineh AB, et al. Oral infiltrating lipomas. BJOMFS 22. Woods WR, et al. Management of oral haemangioma. Oral
1996;34: 520-23. Surgery 1977;44:39.
FIFTEEN
Inflammation of Bone
• Periostitis • Osteitis • Osteomyelitis • Osteoradionecrosis • Paget’s Disease of
the Jaw Bones

Definition of Periostitis Predisposing Factors

Inflammation of periosteum (outer covering of bone). 1. When the general condition of the patient is lower
It is referred to reactive response of the periosteum, or the local resistance of the bone is decreased,
which is characterized by the deposition of new bone which may be chronic debilitating systemic disease
formation subperiosteally. This may induce such as diabetes, agranulocytosis, severe anemia,
osteoblastic activity of the adjacent periosteum by syphilis, tuberculosis, leukemia, extensive
some unknown stimulus or by exudates, directly malnutrition and typhoid fever.
spreading to involve the periosteum and raising it 2. When the vascularity of the jaw is impaired,
form the cortical surface. X-ray appearance the therefore, its ability to withstand infection include
subperiosteal new bone formation. Initially, there is a marble bone disease, long standing Paget’s/
linear opacity parallel to the cortex and later a fuzzy obliteration of the vascular supply of the jaw bone
mass, usually with a smooth lateral contour or the following radiation.
onion skin lamination.
Osteomyelitis
Treatment It is divided into two varieties according to its clinical
This includes identification of underlying conditions: perspective:
1. Removal of the source of infection as infected tooth A. Acute osteomyelitis, and
or roots. B. Chronic osteomyelitis.
2. Drainage of pus, and Vibhagool et al. 1993 classified osteomyelitis based
3. Suitable antibiotics. on the pathogenesis of alter vascular perfusion consi-
dering major contributing factors to the present and
Localized Osteitis persistence of osteomyelitis as a clinical disease entity.
A – Hematogenous osteomyelitis
The localized osteitis is referred to a condition of a B – Osteomyelitis secondary to a contiguous focus
localized low-degree infection of bone. Example, acute of infection.
alveolar osteitis sicca dolorosa (ASD) discussed in C – Osteomyelitis with or without peripheral
detail in other chapter. vascular disease.
Hudson’s classified osteomyelities of the jaws as
Definition of Osteomyelitis follows:
Osteomyelitis of the jaws is an inflammatory condition
of bone which involves the medullary cavity and Acute Forms of OML (Suppurative or
Haversian system of adjacent cortex. Osteogenic Non-suppurative) Include
connective tissue dies due to deprive of its blood a. Contiguous focus:
supply resulting pus in the cancellous spaces and/or i. Trauma,
beneath the periosteum and resulting extensive ii. Surgery, and
destruction of affected part of the jaw bone. iii. Odontogenic infection.
 Inflammation of Bone
113
b. Progressive: Arachnia also causes osteomyelitis of the jaws—Marx
i. Burns, et al 1992.
ii. Sinusitis, and
iii. Vascular insufficiency. Clinical and Radiological Features
c. Hematogenous (Metastatic): Developing skeleton Acute osteomyelitis: Fever associated with
(children). leukocytosis, lymphadenopathy less that one month
in duration. Associated with soft tissue swelling of the
Chronic Forms of OML affected region. Deep-seated throbbing continuous
a. Recurrent multifocal OML: intense pain with intermittent paresthesia of the lower
i. Developing skeleton (children), lip, which may differentiate the clinical features of
ii. Escalated osteogenic activity (age < 25 years). acute alveolar abscess. The affected teeth are tender
b. Garre’s OML: on percussion and showing mobility. Inability to open
i. Unique proliferative sub-periosteal reaction, the mouth partially or totally (trismus).
ii. Developing skeleton (children to young adults). Investigation shows elevated ESR, moderate leuco-
c. Suppurative or non-suppurative OML: cytosis, anemia and albuminuria. The radiographi-
i. Inadequately treated forms, cally, initially unremarkable or may demonstrate and
ii. Systemically compromised forms and ill-defined radiolucency. A fragment of necrotic bone
iii. Refractory forms (CROM: Chronic refractory that has separated from the adjacent vital bone is
OML). termed sequestrum. A sequestra often exhibits
d. Diffuse sclerosing OML: spontaneous exfoliation. Sometimes the fragments of
i. Fastidious organisms, and necrotic bone surrounded by vital bone and this mass
ii. Compromised host/pathogen interface. of non-vital bone within the vital bone is called
involucrum.
Etiology Chronic osteomyelitis: When the persisting
1. Odontogenic infection derived from pulpal or osteomyelitis is not resolved expeditiously the
peridontium, pericoronal infection, infected tooth transformation of the acute phase to chronic variety
socket, secondarily infected cyst and tumor. or the process may arise primarily without a previous
2. Traumatogenic: Specially untreated and acute episode. Clinical features include swelling, pain,
compound fracture, surgical trauma. formation of discharging sinus, tooth loss or patho-
3. Infection from orofacial regions originating from logical fracture and ultimately the formation of
mucosal ulceration leads to periostitis subse- sequestrum. Radiographic pictures show a patchy,
quently causes osteomyelitis. Infection from ragged, ill-defined radiolucency that may contain
lymphatic spread lacerations of the orofacial central radio-opaque sequestra, explain as ‘moth eaten
regions and quensy. appearance’.
4. Blood borne infection, septicemia (later two groups
very rarely affect). Modified Treatment Modalities on the
Basis of Guidelines Recommended by
Microbiological Perspective of Osteomyelitis Marx and Hudson
Majority of cases are caused by aerobic streptococci 1. Antibiotics: The choice of antibiotics should be
usually hemolytic streptococci, Strep viridans and also based on the culture and sensitivity. Hudson 1993
anaerobic streptococci and other anaerobes like personally preferred various methods to augment
peptostreptococci, fusobacteria and Bacteroides. systemic host immune response to reach the site
Occasionally, anaerobic or microaerophilic cocci, of infection, which includes intravenous antibiotic
gram-negative such as Klebsiella, Pseudomonas therapy, local implantation of antibiotics—
aeruginosa and Proteus are also found. saturated beads by Nakajima et al, 1977 and
Mycobacterium tuberculosis, Treponema pallidum Goodell et al, 1986 and hyperberic oxygen therapy.
which causes syphilis and Actinomyces also produce The HBO therapy used in osteomyelitis on view
osteomyelitis of the jaw. Actinomycoses, Eikenella and of stimulation and enhances the oxygenation of
 Synopsis of Oral and Maxillofacial Surgery
114
hypovascular, hypocellular and hypoxic bone Actinomycotic Osteomyelitis of the Jaws
tissue.
It is a chronic infection represent both suppuration
2. Disruption of infecous foci.
and granulomatous features. There are varieties of
3. Removal of any foreign bodies, necrotic tissue with
actinomycotic infection of which cervicofacial variety
flashing with hydrogen peroxide or povidone
affect mostly soft tissue overlying lower third molar
iodine solution or metronidazole infusion may be
of the facial structure includes tongue, parotid gland
used for irrigation of the area of infection.
and maxillary air sinus. The actinomycotic infection
4. Culture and identify specific pathogens for
of the jaws mostly caused by Actinomyces israelii. It
definitive antibiotic selection.
is considered not as a fungi but as a gram-positive
5. Start the empiric antibiotic based on Gram’s stain.
microaerophilic, nonspore bearing nonacid-fast
6. Stabilize calcified tissue regionally.
bacteria.
7. Consider adjunctive therapy to enhance
a. Microvascular reperfusion. Clinical Features
b. Trephination (This may be performed during
debridement, that is the stage 3 mentioned Soft and firm tissue mass, which have dark-red and
above). purple with minute zone of fluctuation in oily area.
c. Decortication (This may be performed during Spontaneous discharge of serous yellow granules
the debridement process). The technique known as sulpher granules associated with fever
known as Mowlem’s decorticotomy— difficulty in opening the mouth (trismus) and regional
described by Moor. lymphadnopathy.
d. Use of vascular flap muscles. Radiology: Radiological appearance the area of
e. Hyperberic oxygen therapy. radiolucency with varying sizes with marked sclerosis
8. Reconstruction if necessary after resolution of of bone. Sequestrum may or may not seen.
infection. Diagnosis: Culture, sensitivity, and biopsy.
Culture includes aerobic/anaerobic antibody.
Direct fluorescent test positive.
Analytical Observation Closely pack branching filament 1 inch diameter
1. Regarding the choice of antibiotic recommended (Sulphur granules)
Amoxycillin 500 mg 8 hourly and Flucloxacillin 200 Increased ESR and slight increase of W.B.C.
mg 6 hourly may be preferred. In case allergic to Treatment: Incision, drainage. High doses of
above antibiotics sodium fusidate 500 mg 8 hourly suitable antibiotics for long duration, mentioned
may be used or Clindamycin 300-600 mg may be above.
given because of ability to defuse widely in bone.
Garre’s Osteomyelitis
2. Present author personally experienced the use of
lincomycin is one of the effective antibiotic for the In some patients with osteomyelitis there is a marked
treatment of osteomyelitis injection lincomycin 600 growth of newborn tissue underneath the periosteom.
mg IM daily for one week followed by 500 mg This type of proliferative or sclerosing reaction on the
capsule 3 to 4 times daily for another 1 week may periosteal site of the inflammatory lesions in bone has
give better result. The use of drug, care should be been called Garre’s osteomyelitis. The mandible is
taken in case of renal impairment. more frequently involved than the maxilla, and the
3. Prof William Irby incase of osteomyelitis due to lesion occur in children or young adult. There is
Pseudomonas aeruginosa personally preferred usually an inflammatory lesion within the jaw
injection Carbenicillin 1 to 2 gm/day in divided (example periapical abscess, radicular cyst etc.) The
doses through IV route along with injection periosteal surface of the bone opposing the area shows
Gentamicin 80 to 120 mg per day in divided doses marked thicking. Radio-opaque buldge of cortical
by IM route. surface of mandible; associated with carious tooth,
4. Chronic external sinuses may irrigate daily with usually first molar.
Eusol (Calcium hypochlorite 1.25% and Boric acid Microscopic show elevation of the periosteum, new
1.25%) or Milton’s solution (stabilized 1% sodium bone formation as parallel traveculae of bone, fibrous
hypochlorite solution) or Metronidazole infusion marrow, and the presence of the plasma cells and
also used. lymphocytes in the marrow space.
 Inflammation of Bone
115
Treatment: Extraction of offending tooth. Antibiotics, Treatment
following which deformity may disappear.
Prophylaxis: Prior to radiation to avoid ORN,
Prognosis excellent. metronidazole 400 mg 2 times a day for 7 to 10 days.
Maintenance of oral hygiene. Chlorhexidine
Condensing Osteitis
mouthwash after each meal.
Localized low-grade chronic inflammation of the bone
marrow is sometimes associated with bone formation Therapeutic
rather than with bone destruction. This productive
osteitis is called sclerosing or condensing osteitis. It Includes long duration of antibiotics with or without
occurs in middle age, and the mandibular molar area minor surgical procedure to induce healing or mucosal
is the most commonly affected site. Usually there are cover by local intraoral flap, metronidazole 400 mg 2
no symptoms. Condensing osteitis is associated with times a day for 7 to 10 days.
a tooth having pulp or periapical pathology or is seen Hyperberic oxygen therapy to promotes
in an old extraction site. angiogenesis. Sometimes resection may be required.
Roentgenograms show localized areas of A conservative measure may be achieved 48
radiopacity. Microscopic sections show dense bone percent healing in ORN by ultrasound therapy. The
trabeculae, narrow marrow spaces, and the presence ultrasound programme of 1 watt/cm2, 3 MHz, Pulsed
of mild plasma cell and lymphocytic infiltration. The 1:4, 15 minutes per day for 60 days recommended by
lesion does not require any treatment. M. Harris 1992.

Osteoradionecrosis Paget’s Disease of Bone (Osteitis Deformans)

ORN is the consequence of postradiation complication First described in UK by Sir James Paget in the year
also known as radiation osteomyelitis. The radiation 1876. The cause of Paget’s disease is unknown but
leads to hypovascular, hypocellular and hypoxic tissue inflammatory, genetic and endocrine factors may be
with diminish capacity of normal repair. The soft contributing agents.
tissue and its overlying mucosa may break down,
leading to superficial infection of the denuded bone.
Clinical and Radiographic Features
ORN may develops twelve months after completion
of radiation therapy, with a variation from 2 weeks to Asymptomatic disease initially often is discovered
34 months—Widemark et al, 1989. during radiographic examination. PD may be mono-
Marx (1983) not accepting the proposed concept ostotic limited to one bone; most of the cases are
of ischaemic necrosis with superficial infection of the polyostotic in nature that means more than one bone
exposed bone or in other words the healing problem is affected. Bone pain may be severe, headache,
is essentially due to hypovascularity, hypoxia and deafness, blindness and facial paralysis associated
hypocellularity. Thus, ORN of the mandible can be with dizziness, weakness and mental disturbances.
defined simply as exposed irradiated bone that has The frequency increases with the age, men are affected
fail to heal over a period of three months in the absence more than female. The disease principally affects fifth
of localized malignancy. to sixth decades of life. The X-ray appearance shows
the mixed radiolucence and radio-opaque throughout
Clinical Features the jaw bone appears as cotton wool. The elevitated
• Asymptomatic in early stages if overlying mucosa serum alkaline phosphatase about 250 BU. Incidence
remain intact. of osteogenic sarcoma and giant cell tumor is increased
• Late stage tenderness, pain and ulceration of the in-patient with Paget’s disease.
surface mucosa.
• Radiographic appearance shows a mixed Treatment
radiolucence and radio-opaque lesion. Anti-inflammatory analgesic helps to relieve pain
Investigation: Radionuclide bone scans is helpful to frequent adjustment of new denture as because of
determining the extent of ORN. constant bony growth of the jaws.
 Synopsis of Oral and Maxillofacial Surgery
116
Early stages drug-therapy with bisphosphonates 7. Harris M. The conservative management of osteoradio-
(includes etidronate, pamidronate, alendronate) in necrosis of the mandible with ultrasound therapy. BJOMFS
mild cases, a single infusion of a biphosphonate may 1992;30:313-18.
8. Heslop IH. Cyphilitic osteomylitis of the mandible. BJOS
present year long remissions. Plicamycin, a cytotoxic
1968;6: 59-63.
antibiotic, is known as inhibit osteclastic activity used 9. Kclekye EO. Osteomyelitis of the jaws: A review of the 141
with precaution or calcitonin to arrest osteoclastic cases. BJOMFS 1985;23:24-35.
activity. 10. Marx RM. Chronic osteomyelitis of the jaws. Oral MF Clin
North Am 1991;3:367-81.
BIBLIOGRAPHY 11. Miller M, et al. Cervicofacial actinomycosis. Triple O and
Oral Rad and Endod 1998;85:496-508.
1. Alling CC. Postextraction osteomyelitic syndrome dent. 12. Marx RE. Osteoradionecrosis. A new concept of its patho-
Clin. North Am 1959;621-36. physiology. JMFS 1983;41:283-88.
2. Ankoran, et al. Paget’s disease of bone (Osteitis deformans). 13. Marx RE. A new concept in the treatment of ORN. JMFS
J Am GER SOC 1990;406:1025-033. 1983;41:351-57.
3. Barak S, et al. Treatment of ORN with pathological fracture 14. Pell GJ. Garrei’s osteomyelitis of the mandible. JOS
and osteomyelitis of the mandible with electromagnetic 1955;13:248.
stimulation. Int JOMFS 1988;17:283. 15. Rowe NL, et al. Periosteitis and osteomylitis of the mandible
4. Boyane PJ. Incidence of osteosclerotic areas in the mandible in childhood. BDJ 1957;103:67-68.
and maxilla. JOS 1960;18:486. 16. Smith J, et al. Paget’s disease of bone with particular
5. Cronje FJ. A review of Marx protocols prevention and mana- reference to dentistry. JOP 1981;10:233-47.
gement of ORN by combining surgery and HBO. SAOJ 17. Tilman HH. Paget’s disease of bone. Triple O 1962;15:1225.
1998;53: 469-71. 18. Young SR, et al. Effect of theraputic ultrasound on
6. Fels GJ, et al. Sclerosing osteomyelitis of Garrie (Periosteitis angiogenesis. Ultrasound in Medicine and Biology
ossificans). Tripple O 1990;70:117-20. 1990;16:261.
 SIXTEEN
Various Common Sutures
and Suture Technique

• Sutures • Classification of Sutures • Principle of Suturing • Knot Tying

• Interrupted Suture • Continuous Suture Locking Technique • Mattress Suture
• Suture Removal

The sutures are the essential part of the all-surgical The suture needles are composed of three parts –
modalities either primarily to repair injured wound the eye, body and the point.
and vessels or repair of inductive incised surgical The eye can be closed or swaged, and it holds the
wound. suture.
The sutures are to hold the flap and tissue in The body is the shaft section of the needle. The
apposition to facilitate the wound healing. longitudinal shape of the body may be circle, half-
The modern sutures are prepared commercially circle and straight. The half-circle needles are mostly
and sterilized by gamma radiation. used in oral surgery.
Surgical silk braided black multifilament 000/00 Point is the tip of the needle, it can be cutting round
is mostly used in oral surgical procedure. It should be or blunt. The cutting needles have at least two opposite
remained 5 to 7 days in normal surgery but in case of edges. The curve cutting half-circle, Lane half inch,
oroantral fistula, it should be 14 days. The higher the 5/8th circle of Dennis Brown of 22 and 25 mm. length
number the smaller the suture size. The larger the is normally used in oral and maxillofacial surgery.
number stronger the suture.
Requirements of suture materials it should have Principle of Suturing
adequate strength with least tissue irritation and
reaction, easy to handle and knotting properties with 1. The needle should pass through the tissue along
low capillarity and easy to be sterilized without its curve.
deterioration. 2. The needle should pass the tissue perpendicular
Sutures are classified broadly into — Absorbable to the tissue circle.
and non-absorbable. Absorbable means the sutures 3. The needle should pass at an equal depth and
are digested by the body fluids and non-absorbable distance from incision of both sides.
means it cannot be digested by the tissue fluids. 4. The needle should always passes through the
Absorbable sutures are: thinner tissue to the thicker tissues.
• Plain gut, 5. The sutures never be closed under tension. It
• Chromic gut and should not blanch.
• Synthetic, example — Vicryl and Dexon. 6. The knot should be tied only approximate of the
Non-absorbable sutures are tissue and placed at a greater depth and distance
• Silk, from the incision.
• Synthetic, example — Nylon, Mercilene and
Proline. Knot Tying
Other varieties of wound closure mechanical A knot can be tied using the needle holder or with the
devices include Ligating clips, surgical staples and hand. The various knot includes — Square knot,
Tissue adhesives like n-butyl cyanoacrylate. Surgeon’s knot and Granny’s knot.
 Synopsis of Oral and Maxillofacial Surgery
118
The various suturing technique available and below and obliquely above. Passing a knot over the
commonly used are : untightened end of the suture finishes the suture. It
a. Interrupted suture. provides a rapid technique for closure. This technique
b. Continuous suture. is explained as above in addition to providing by
c. Mattress suture of which may be horizontal and withdrawing the suture via its own loop to achieve
vertical. locking to prevent excessive tightening of the suture
as the progresses of the wound closure (Fig. 16.2).
Interrupted Suture
Mattress Sutures maybe
The suture is passed via the both edges at an equal
Horizontal or Vertical
depth and distance from the incision and placement
of knot at one side. It is mostly used in oral and Horizontal mattress suture: This has the property of
maxillofacial surgery. These are almost universal everting the mucosal or skin margins, thereby
application. The wound is free of interference between bringing greater areas of raw tissue into contact. For
each suture and it is easy to keep clean (Fig. 16.1). this reason it is useful for closing wounds over bony
deficiencies such as oro-antral fistulae or cyst cavities
Continuous Suture Locking Technique (Fig. 16.3).
Initially, a simple interrupted suture is placed; needle Vertical Mattress Suture: Specially designed for use
is then reintroduced in a continuous manner such that in the skin, they pass through it at two levels, one deep
the suture passes perpendicular to the incision line to provide support and adduction of the wound
surface at a depth and one superficial to drawn the
edges together and evert them (Fig. 16.4).

Fig. 16.3: Horizontal mattress suture

Fig. 16.1: Interrupted suture technique

Fig. 16.2: The continuous suture locking suture Fig. 16.4: Vertical mattress suture
 Various Common Sutures and Suture Technique
119
Suture Removal
Normally, intraoral suture in uncomplicated cases
may be removed with 5 to 7 days after placement. The
suture is grasped tissue holding forceps and lifted
above the surface and then suture cutting scissors
passed via the pull loop and cut the thread close to
the surface. Then the suture is pulled-out, and thereby
prevent contamination from outer surface to the inner
tissue.

Analytic Observation
1. Suture is used to repair of injured wound and
vessels, and repair of incised area after surgery.
2. Suture is also used to keep the pack (White head
varnish pack) inside the oral wound as called stay
suture.
3. Suture is also used to keep the drainage tube in
position (extraoral corrugated rubber sheth in case
of draining abscess). Fig. 16.5: A diagrammatic representation of the insertion of a
4. Suture is also used to hold the button in Kazanjian’s Hammock suture. Modern absorbable suture materials mean
that these no longer have to be removed. Sutures made of
operation and Clerk’s technique as retraction polyglycolic acid resorb slowly and are very strong
suture. In vestibuloplasty in pre-prosthetic surgery,
Hammock suture is also used (Fig. 16.5).
5. Retraction suture is used to pull the tissue for visual avoid any distal pocket of second molar and
and mechanical access. horizontal mattress suture is mandatory following
6. Other use includes external carotid artery ligation*, repair of oroantral fistula.
maxillary artery ligation via transantral approach,
stick tie technique. FURTHER READING
7. Distal to second molar after removal of third molar 1. Kirk RM. Basic Surgical Techniques, 3rd edn. Churchill
impaction an interrupted suture is mandatory to Livingstone, Edinburgh 1989.

*Harry Sicher, Oral Anatomy.

SEVENTEEN
Clinical History and Examination
in Oral Surgery and
Some Dictum and Discipline

• Objectives of Clinical History Taking • Medical History • Surgical Dictum

• Clinical Examination • Blood Examination • Urine Examination • Pus and
Purulent Discharge Examination • Skin Test

The objective of clinical history taking is to achieve a b. To consider the ability of the patient to with stand
correct evaluation of the patient’s problems and surgical trauma. Necessary assessment for use of
analysis of his/her symptoms, general conditions, proper pre-medication.
habits and social economic status. The enquiry into c. The choice of local anaesthesia/local anaesthesia
the history of the problems provides valuable clues; under sedation or general anaesthesia.
it is mandatory to establish the nature of the problem. Again the stages of clinical history taking denotes:
Example as follows: 1. General information regarding the name, age, and
• Pain, discomfort or altered or abnormal feeling his/her marital status, address, race, habits and
• An esthetic problem occupation.
• Altered function 2. Chief complains:
• Bleeding or exudates a. All the symptoms chronologically arrange in
• Lump or swelling the patient own version.
• Halitosis. b. The onset duration and propagation or progress
The above mention problems may combinely or of each of the symptoms.
isolatedly present. The determination based on the c. Any treatment prior for the condition and the
following: patient feedback if there any past history of
• When the problem was first noticed? similar episode and treatment along with the
• Is it continuous or intermittent and the frequency outcome.
of attack? Medical History
• Is there any initiating or relieving factors, example
Medical history of the patient is important for oral
hot/cold, worse on biting, worse on bending
surgical protocol. History of the following disease or
forwards? conditions are important for further treatment
• Exact location of the problems, example specific modalities as follows:
tooth or generalized a. Hypertension.
• The character of pain dull, sharp, throbbing, b. Bleeding disorder.
shooting, lancinating, disturbing sleep, relieved by c. Rheumatic heart disease (sub-acute bacterial
analgesics, spread or radiated to adjacent endocarditis) precaution is important for prior to
structures or referred. oral surgical procedure.
The clinical perspective helps the pre-operative d. Diabetes mellitus.
assessment as follows: e. Liver disease manifested by jaundice.
a. Treatment planning that will beneficial to the f. Thyroid problems.
patient as per age/general health condition, socio- g. Pregnancy (Physiological condition).
economic status. h. Asthma.
 Clinical History and Examination in Oral Surgery and Some Surgical Dictum and Discipline
121
The above mention conditions require thorough The basic extraoral incision for drainage from
investigation, precaution and medical consultations different spaces commonly as follows:
before surgery. 1. Submandibular incision
2. Temporal incision
The diagnostic panorama includes:
3. Submental sublingual incision.
a. History and clinical examination including
The following incisions are mostly used in
radiological interpretation example–I/O,
maxillofacial regions in different maxillofacial
Periapical, occlusal, parrllax, extraoral X-ray
includes different angulation (lat. oblique), O.P.G., surgical procedures:
P.N.S View, Town’s view etc. 2. The exposure area should be repairable with
placement of sutures with or without pack and
b. Laboratory aids, example, CBC, HB percentage,
without any discomfort and tension.
ESR, BT and CT, PTT etc.
3. Maintenance of wound must be taken care of
c. Biopsy includes Pap smear F.N.A.C.
following surgery.
d. Study model.
4. Preoperative check-up and choice of anaesthesia
e. Special investigation includes CT scan, Ultrasound,
should be assessed within the basis of history and
MRI etc.
anesthetic consultation with chest X-ray and others
f. Examination under anesthesia (EUA).
relevant X-ray and laboratory findings.
g. Test block for diagnostic aid for neuralgia. 5. Always reassured the patient with confidant.
Apprehensive nervous patient should deal with
Surgical Dictum (Figs 17.1 and 17.2) care and sympathy but in a gentle strong manner.
1. The incision and exposure of the operative field Otherwise, your low tone sympathetic attitude
should provide the maximum visual and may leads to patient more nervous.
6. Do not do anything (surgical modalities) beyond
mechanical access to the surgeon’s and assistant.
your limit, if it is not feasible for your part. No
It should be optimum neither minimum nor
harm to send the patient to the competent
maximum. Mouth prop various retractors, Gag
consultant. This is very important to avoid
and various pull suture also provide operative
unnecessary problem in future.
access.
7. If anything unto ward has happened to any
patient, explained gently to the patient and if
necessary accompanying person. Help as much as
you can to send the patient to the proper place or
give a next appointment according to the patient
convenience.
8. During surgery bleeding vessels should be
cauterize or ligated.
9. Prior to closing the wound care should be taken
that field of operative zone almost blood free.

Fig. 17.1: Some of the most common incision for approaches

to fracture of the middle-third of the face Fig. 17.2: Surgical approaches to orbit
 Synopsis of Oral and Maxillofacial Surgery
122
10. Ask anesthetist frequently during the surgery Clinical Examination
about the condition of the patient or looked to the
Some important features of the lesions characterized
monitor (lovely).
as follows:
11. Throat pack must be removed at the end of the
• Site or location. Shape sharpness of boundary.
surgery and also removed the clot and saliva by
• Color consistency or contour.
sucker. Examine the patient’s mouth carefully
• Texture, mobility or fixation.
prior to IMF in case of fracture.
• Ulcer or erosion.
12. Incision for drainage should be on the dependent
part of the abscess to free flow of pus. • Localized inflammation or indurations.
13. Incision as much as possible along the Langer’s • Regional lymphadenopathy.
lines of tension preferably on skin crease to avoid • Pulsation and fluctuation.
scar. This is very important for esthetic viewpoint. • Radiological changes.
14. Surgeon must be careful during removal of broken Important pain character already discussed early
needle and foreign bodies like tooth or root stump. of this chapter. The examination of lump or swelling
Good light is essential particularly in this case and must be considered for diagnosis. The character of
careful about accidental seepage of foreign bodies. swelling may be tender on palpation denoting
15. Incision should be made by sharp blade with a inflammatory, traumatogenic or malignancy. The non-
gentle continuous stroke. tender swelling may be cystic, pulsatile thrill (carotid
16. Surgeon should be careful about vital structure aneurysm) soft tissue growth (lipoma, papilloma)
and vessels during incision and should have central or peripheral bony lesion.
through the epithelial surface. The characteristic of lump or examination of the
17. In oral cavity the incision should be placed on facial lymph nodes in the form of cervical
healthy bone and attached mucosa. lymphadenopathy may be characterized by:
18. The skin edges must not be suture too tightly, and
a. Infection—nodes are tender on palpation and
suture should be removed on third or fourth day
fixed. Features of septicemia increased E.S.R.
to avoid sutures scar.
increased P.T.R. in case of tuberculosis, CHXR,
Important Aspects of Anatomy mantoux test positive, increased E.S.R. positive
Necessary for Operative Technique acid fast stain of sputum;
Fundamentally, the major facial vessels concerned in b. In case of malignancy—nodes are tender palpable,
oral surgical exposures run a course that is (1) deep to matted and fixed, the oral ulcer is typical rolled
the superficial muscles of expression (including the out everted margin with indurations, X-ray FNAC
platysma but excluding the caninus and buccinator and biopsy confirm the diagnosis;
muscles) and (2) superficial to the muscles of c. Hodgkin’s disease—nodes are palpable and
mastication and, of course, the deeper facial bones. In rubbery.
a similarly general sense, the facial vein drains areas The above-mentioned features of nodes denoting
supplied by the facial artery, and the posterior facial the probable path of diagnosis.
vein drains those deeper facial areas supplied by the
terminal branches of the external carotid artery. The Common Investigation for Routine Practice
major sensory nerve to the face is the fifth cranial
Examination of blood, urine, pus and culture and
nerve. The major motor nerve to the face (other than
different skin test mostly helps in diagnosis.
to the muscles of mastication, which are supplied by
Learning of normal blood physiology and
the fifth cranial nerve) is the seventh cranial nerve.
chemistry is essential for practice (Tables 17.1 and
Surgical injury to the fifth cranial nerve may be
17.2).
considered of minor significance, since sequel to such
injury most likely would be sensory paraesthesia, with
Blood Examination
good chance for regeneration. However, surgical
injury to the seventh cranial nerve and subsequent loss Blood examination is done to find out quantitative and
of function of the muscles of expression presents qualitative abnormality of its formed elements, viz.,
extreme cosmetic problems, without much hope for erythrocytes, leukocytes and thrombocytes, and
spontaneous and functional regeneration. chemical components of blood plasma, viz., non-
 Clinical History and Examination in Oral Surgery and Some Surgical Dictum and Discipline
123
Table 17.1: Physiologic norms of blood
Volume 7 to 9% body wt. (4,000 – 6,000 cc)
pH 7.35 to 7.45
Erythrocytes 4,500,000 – 5,000,000/cu mm
Leukocytes 5,000 – 9,000 cu mm
Polymorphonuclear neutrophils 60 – 70%
Lymphocytes 25 – 33%
Monocytes 2 – 6%
Eosinophils 1 – 4%
Basophils 0.25 – 0.5%
Reticulocytes 0.5 – 1.5%
Platelets 200,000 – 600,000/cu mm
Hemoglobin (average for both sexes) 14 – 15 gm/100 cc
Hematocrit (men) 38 – 48%
Hematocrit (women) 36 – 47%
Color index 0.9 – 1.1
Volume index 0.9 – 1.1
Mean corpuscular volume 80 – 94 cu U
Mean corpuscular hemoglobin 27 – 32 micro-micrograms
Mean corp.hemo.concentration 32 – 38%
Bleeding time 1 – 3 min
Coagulation time 2 – 8 min
Clot reaction time Begins in 1 hr, complete in 24
Sedimentation rate, in 1st hr. 0 – 10 mm (men), 0 – 20 mm (women)
Prothrombin time (Quick) 10 – 15 sec

Table 17.2: Blood chemistry finding–normal and abnormal

Minimal quantity Normal range Conditions in Decrease
necessary for values/100 cc which variations from
determination normal may occur increase
Glucose 5 cc. Serum, oxalated 80–120 mg Diabetes mellitus; hyperthy- Hyperinsulinism Addison’s
whole blood or roidism, acromegaly; disease, adenoma or
plasma 0.1 cc hemochromatosis; adrenal carcinoma of islands
(micro method) tumours, cortical or medullary of Langerhans
Total serum 5 cc serum 6.0–7. 5 Gm Dehydration Cachectic illnesses, renal
protein disease, severe burns,
malnutrition, liver disease
Albumin 5 cc serum 3.5–5.5 Gm Dehydration Renal disease, malnutrition,
liver disease
Globulin 5 cc serum 2.5–3.0 Gm Chronic infectious disease such as tuberculosis, syphilis, malaria,
rheumatoid arthritis lupus erythematosus, periarteritis nodosa,
kala azar, lymphogranuloma venereum, sarcoidosis, cirrhosis,
myeloma, carcinomatosis
Albumin
Globulin 1.3:1to 3:1 See albumin and globulin above
(A/G) Ratio
Fibrinogen 5 cc oxalated serum 0.25–0.5 Gm Most infectious disease, Liver disease, cachexias
conditions producing inflam-
mation or destruction, traumatic
injuries
Contd...
 Synopsis of Oral and Maxillofacial Surgery
124
Contd...
Nonprotein 5 cc serum oxalated 25-38 mg Renal disease, urinary obstruction; cardio failure; intestinal
nitrogen whole blood or plasma obstruction, gastro intestinal haemorrhage; metallic poisoning,
dehydration and shock
Urea nitrogen 5 cc serum, oxalated 8-20 mg Same as non-protein nitrogen Severe liver damage
whole blood or plasma
Creatinine 5 cc serum, oxalated 1-2 mg Renal disease, urinary obstruction, metallic poisoning
whole blood or plasma
Uric acid 5 cc serum, oxalated 1.5-4.0 mg Gout, nephritis, eclampsia
whole blood or plasma
Calcium 5 cc serum 9.5-11.5 mg Hyperparathyroidism, para- Hypoparathyroidism,
thyroid administration, severe nephritis, uremia,
vitamin D over dosage rickets
Phosphorus 5 cc serum 2.5-3.5 mg Tetany, nephritis, uremia, Hyperparathyroidism
(Inorganic) (adult) rickets
3-5 mg (children)
Sodium 0.315-0.340 Gm Addison’s disease, severe
5 cc serum diarrhoea, high fevers,
diabetic acidosis
Potassium 5 cc serum 16-22 mg Addison’s disease
Chlorides as 5 cc serum 0.57-0.62 gm Nephritis, eclampsia, Gastrointestinal
NaCl cardiac failure disturbances, febrile
conditions, acidosis,
vomiting, shock
Cholesterol 5 cc serum 150-250 mg Lipoid nephrosis amyloidosis, biliary cirrhosis, myxedema,
obstructive jaundice, diabetes
Cholesterol 5 cc serum 50.75% of Obstructive jaundice Severe liver disease
esters total cholesterol
Total lipids 5 cc serum 0.57-0.82 gm Nephrosis, diabetes, arthritis, hypothyroidism
Serum acid 5 cc serum 1-3 King
Armstrong u
Phosphate 0-1 Bodansky u
Serum alkaline 5 cc serum 1-13 King Increased osteoblastic activity (Paget’s disease, osteogenic
Phosphate Armstrong u sarcoma, osteoplastic bone metastases, rickets, hyperpara
1-4 Bodansky u thyroidism), obstructive jaundice
CO2 5 cc serum 50-70 Emphysema, chronic, Acidosis, ketosis, intestinal
Combining taken under volumes/100 cc vomiting, alkalosis obstruction, diarrhea,
Power liquid petrolium traumatic shock

protein (nitrogen components), proteins, electrolytes, Bence-Jones protein, Benedict’s qualitative test for
inorganic components, lipids, enzymes, hormones, glucose, Lange’s test for acetone, bilirubin,
and vitamins. urobilinogen, benzidine test for blood, Sulkowitch test
for calcium. The pathologist can do microscopic
Urine Examination examination of urine for presence of RBCs, WBCs,
Urine examination for oral surgery, specific gravity, epithelial cells, casts, mucous threads, and micro-
reaction (acidity test), Purdy’s heat test for albumin, organisms.
 Clinical History and Examination in Oral Surgery and Some Surgical Dictum and Discipline
125
Table 17.3: Physiologic norms of urine Pus and Purulent Exudates Examination
Average amount in 24 hours 1,200 to 1,500 cc Pus may be collected by means of a sterile syringe
Reaction of litmus Fairy acid and should be sent to the laboratory in a suitable
Specific gravity 1,005 to 1,022 plugged tube. Only in exceptional circumstances
Color Amber
should a swab be used to collect the material. In
Constituents (in 24-hours specimen):
Urea 20.0 – 30.0 gm general, the examination of pus should be by films
Uric acid 0.6 – 0.75 gm and culture.
Total nitrogen 10.0 – 16.0 gm
Ammonia 0.5 – 15.0 gm Skin Test
Chlorides 10.0 – 15.0 gm
Phosphate 2.0 – 4.0 gm This susceptibility is indicated by an inflammatory
Total sulfur 1.0 – 3.5 gm reaction at the point of application of infection of
Creatinine 0.3 – 0.45 gm the test substance; it may indicate normal suscepti-
Total solids 50.0 – 70.0 gm bility to toxic material, or it may indicate a state of
Total acidity Equiv. to 400 – 600 cc delayed hypersensitivity or allergy to protein
of N/10 NaOH substance.
EIGHTEEN
Orofacial Infection and Its Spread

• Key Words • Periapical (Dental Abscess) • Periodontal Abscess • Pericoronitis

• Routes of Spread of Orofacial Infection • Fascial Spaces • Facial Cellulites
• Necrotizing Fasciitis • Cavernous Sinus Thrombosis • Infection of Nonodonto-
genic Origin

KEY WORDS Pathophysiology of odontogenic infection can be

explained as: invasion of the dental pulp by bacterial
Abscess infection following dental caries of a tooth →
A collection of pus in a cavity formed by disintegration inflammation, edema and lack of collateral blood
of tissue as result of infection. supply → venous congestion or a vascular necrosis
consequently death of the pulp → reservoir for
Infection bacterial growth → the bacteria penetrate and
The communication of disease by the invasion of body spreading into the surrounding bone.
tissue by specific pathogenic microorganisms.
Treatment
Inflammation 1. Suitable antibiotics to control infection.
The inflammation is the series of changes which 2. Analgesic, anti-inflammatory to relieve pain and
occurred in the living tissue to response to the irritant, inflammation.
provided the irritant is not such of to kill the tissue Table 18.1: The differentiation of abscesses which are
out right. periapical and periodontal in origin

Discharging Sinus Periapical (dental) abscess Periodontal abscess

An unhealthy granulation tissue tract opening in one Pain History of toothache Acute onset
side of the single compartment (example extraoral swelling Over tooth apex, likely to Usually localized.
Extraoral swelling
discharging sinus).
may or may not be
present
Fistulae
Pocket May or may not be present Always present, more
An unhealthy granulation tissue tract opening in both likely in presence of
side of two different compartment (example oroantral periodontal disease
Sinus Tracks to periapically Frequently on
fistulae).
attached gingiva
Infections of odontogenic in origin have a mixed Percus- Tooth/teeth tender on Tooth/teeth tender
bacteriological etiology, which includes streptococci, sion percussion (TTP) specially on percussion (TTP),
which may be aerobic and anaerobic, and Bacteroides, on axial direction worse laterally
which are anaerobic. The majority of localized dental Restora- More likely in heavily More likely tooth is
infections are as follows: tion restored fractured crown caries-free or
status unrestored
Vitality Tooth nonvital Tooth usually vital
Periapical (Dental) Abscess X-ray Loss of lamina dura in Little evidence in early
Commonest type of abscess arises from an infected periapical region after 10 stages there may be
to 14 days bone loss
pulp chamber.
 Orofacial Infection and its Spread
127
3. Periapical curettage apisectomy, R.C.T. and crown c. Via the blood stream very rare example local
preparation if possible. thrombothlebitis may propagate along the veins,
4. Otherwise remove the offending tooth and entering the cranial cavity via emissary veins to
curettage of the socket and sutures. produce cavournous thrombothlebitis.

Periodontal Abscess The Factors Influencing Spread

An acute infection and collection of pus within a The general factors includes:
gingival or periodontal pocket. a. Host resistance.
b. Virulence activity of microbes.
Treatment c. Compromise proposed defenses.
d. Combination of both.
1. Suitable antibiotics preferably combination with
metronidazole to control infection;
Local Factors
2. Analgesic to relieve pain;
3. Maintenance of oral hygiene by chlorhexidine a. Via alveolar bone.
mouth wash; b. Via periosteum.
4. Followed by supra and subgingival curettage to c. Adjacent fascia and muscles.
remove the calculus as foreign bodies.
Spread of Infection
Pericoronitis
The majority of infection remains localized and
Define as infection under the operculum or infla- infection may spread in the form of pus from an
mmation of a surrounding soft tissue of a partially infected tooth with spread along the path of least
erupted tooth. resistance. This may produce an extra-oral and intra-
oral discharging sinus. This may spread along the
Clinical Features tissues and fascial planes to produce severe life
threatening systemic infection. The pattern of spread
Pain, swelling, difficulty in opening the mouth
associated with specific teeth having a distinct
(trismus), difficulty in swallowing (dysphagia),
correlation can be shown as in Table 18.2.
regional lymph adenopathy.
Fascial Spaces
Treatment
The fascial spaces are potential areas between layers
1. Primary treatment of irrigation under the
of fascia. These areas are normally filled with loose
operculum with hydrogen per oxide or povidone
connective tissue, which readily breaks down when
iodine solution.
invaded by infection, as per Shapiro.
2. Antibiotic, analgesic and anti-inflammatory to
control spread of infection, trismus and lymph
adenopathy.
3. The secondary treatment includes chemocau-
tarization by 30 to 40 percent trichlor acetic acid to
cautarize the opercurculum or operculectomy by
electrocautary loop.
4. In case of repeated episodic attack, surgical
removal of the offending tooth is a choice of
treatment.

Routes of Spread of Orofacial Infection

a. By direct continuity via the tissue.
b. Via the lymphatics into the regional lymph nodes
and subsequently into the blood stream. Fig. 18.1: Lymphatic drainage of tongue
 Synopsis of Oral and Maxillofacial Surgery
128
Buccal Skin of anterior face, mucous
Table 18.2: Pattern of spread of odontogenic abscesses
according to position of the tooth and the potential path membrane of lips and cheeks
of spread Mandibular Skin over mandible, mucous
membrane of lips and cheeks
Tooth Potential path of spread Preauricular Skin inferior to temple, external
auditory meatus, lateral part of
Maxillary teeth
forehead, lateral part of eyelids,
Molars and premolars Swelling or sinus in buccal sulcus posterior part of cheeks, portion of
may spread to buccal space (lateral outer ear, parotid gland
to buccinator) Postauricular External ear, scalp above and
Canine Canine fossa - facial nasolabial fold behind the ear
area Infra-auricular Pre and postauricular nodes
Lateral incisor May track to palate due to distal Occipital Scalp posterior to ear, occipital
inclination of root, - but usually region
labial Superficial cervical Pinna and adjoining skin, pre and
post auricular nodes
Cental incisor Labially - can give a swollen lip
Deep cervical Submandibular, submental,
Mandibulor teeth inferior auricular, tonsillar and
Pericoronitis may tack Both have the potential to tongue nodes.
buccally along the inner spread in various direction,
aspect of buccinator to submandibular space via lingual
present in second plate, pterygo mandibnular space, Facial Cellulites
pre-molar and first lateral pharyngeal space and on
It is a diffuse inflammation involving subcutaneous
molar region. Migratory down the neck
abscess of buccal sulcus
and deeper tissues on examination overlying skin is
firm without fluctuation. The condition having the
Second molar Spread laterally infection from the
third molar may gives severe rapid onset without any formation of pus.
trismus with an extension into the
submasseteric space Treatment
First molar Buccally, if lingual may be sub-
1. Surgical eradication of infected focus.
mental or submandibular depen-
ding on level of drainage and
2. Suitable systemic antibiotics.
mylohyoid attachment 3. In case of abscess formation, incision and surgical
Premolar and canine Buccally
drainage by Hilton’s method is necessary.
Incisors Labially
Hilton Method
The location of the lymphatic nodes and the In this technique, a pair of fine sinus forceps are
lymphatic drainage areas of the face and neck: inserted closed into the wound and opened slowly but
firmly to separate the soft tissue planes. The forceps
Lymphatic nodes The areas of drainage
are then withdrawn open to avoid damaging nerves
Submental The tip of tongue, part of the floor or vessels by closing them blind. This procedure is
of the mouth in the midline, repeated till the abscess is reached and pus discharges.
mandibular incisors, related In dental infections, an area of rough cortical bone can
gingiva, middle alveolar process
and basal bone of the mandible,
be felt on the mandible or maxilla where the
midportion of lower lip and chin periosteum has been raised — cited from Prof JR
Submandibular All maxillary teeth, mandibular Moore.
teeth except incisors, inferior nasal Solnitzky discuss an excellent article describe the
cavity, palate, body of tongue, relations of dental infection and facial spaces of the
upper lip, lateral portion of lower head and neck region. The most common dental
lip, angle of mouth, medial angle sources of infection are infections of the lower molar
of eye, and submittal lymph nodes
teeth. Such infections tend to spread particularly to
Accessory facial Skin of the medial angle of eye, skin
infraorbital of anterior face, superficial part of one of the following compartments or space: the
nose masticator space, the submandibular space, the
 Orofacial Infection and its Spread
129
sublingual space and temporal space. Infections of the
maxillary teeth are less frequent and tend to spread
to the pterygopaltine and infratemporal fossae. In
either case, the spreading suppurative process may
involve secondarily the parotid space the lateral
pharyngeal space. In fulminating cases, the infection
may spread through the visceral space into the
mediastinum.
Submasseteric space infection is characterized by
mandibular sub periosteal abscess cellulites of the
mandibular area involving medial pterygoid and
obviously masseter. Clinically, the feature of trismus,
pain and swelling. Fig. 18.2: Cross-section of premolar area in mandibular region:
Submandibular and sublingual space infection The 1. Sublingual space
most serious infection involving the sublingual and 2. Submandibular space
3. Submandibular salivary gland
submandibular space is Ludwig’s angina. This acute
4. Hyoid bone
overwhelming, generalized condition involving the 5. Mandible
above spaces. This is a cellulites involving floor of the 6. Mylohyoid muscle
mouth and quickly extend into the neck. Tongue and 7. Platysma muscle
floor of the mouth are elevated. As it tracks down to 8. Deep cervical fascia
the pharynx, “a hot potato speech” is a very important
significance feature. The danger signs are dysphasia
and phonation problems includes asphyxia known as
edema glottis and need immediate airways establish-
ment by tracheostomy. Recent advancement of
antibiotics the cases of Ludwig’s angina not commonly
seen.

Treatment
1. Reverse ‘U’ shape incision along the deep part of
the chin recommended by Love and Baily for
drainage.
2. High doses of suitable systemic antibiotics along
with the intravenous or oral fluids and therapeutic
oxygen.
3. If necessary tracheostomy for airway establish-
ment.

Necrotizing Fasciitis
This is a rare infection in the head and neck
characterized by a rapidly progressive necrosis of Fig. 18.3: Cross-section of mandibular ramus region:
fascia and subcutaneous fat, which undermines and 1. Superficial temporal space
eventually causes necrosis of overlying subcutaneous 2. Infratemporal space
tissue and skin. 3. Masseteric space
4. Pterygomandibular space
Cavernous Sinus Thrombosis 5. Lateral pharyngeal space
6. Lateral pterygoid muscle
The facial veins do not have any valve. The veins in 7. Medial pterygoid muscle
the facial regions directly communicate with the 8. Temporalis muscle
 Synopsis of Oral and Maxillofacial Surgery
130
cranial cavity, and very rarely infection may backtrack Treatment
from the face up into the skull to the cavernous sinus. 1. Removal of infective focus;
According to Eagleton, the six important features 2. Incision and drainage by Hilton methods;
of cavernous sinus thrombosis: 3. Suitable appropriate antibiotics, for control of
1. A known site of infection. infection;
2. Evidence of blood stream infection (septicemia). 4. If necessary fluid transfusion;
3. Early sign of venous obstruction of the retina, 5. Relief of pain by suitable analgesics.
conjunctiva, or eye lid.
4. Paresis of the third, forth and sixth cranial nerves Some Analytical Observations
resulting from inflammatory edema. 1. Submasseteric space infection is more common in
5. Abscess formation of neighboring soft tissues; Disto Angular impaction as because the insertion
6. Evidence of meningeal irritation. of the masserter of the intermediate part is floating
The condition is very dangerous and fatal to the or loosely attached below (Bransby and Zachary)
patient. The recent advancement of antibiotics and the Cited from Shafer. The infection and pus may tract
supportive surgical protocol the condition can be the least resistance path under the masseter which
controlled before the development of the cavernous is attached to the lateral surface of the ramus of
sinus thrombosis. the mandible.
2. Migratory abscess of buccal sulcus is a compli-
Treatment cation of subacute pericoronitis. Pus may track
1. High doses of selective systemic antibiotics. buccally along inner aspect of the buccinators and
2. Fluid transfusion, therapeutic oxygen. discharging extra oral sinus in relation to the first
3. Treatment of toxemia. molar and second premolar cited from Howe.
4. Constant monitor of the patient. 3. Impacted lower third molar have the potential to
5. In case of edema glottis emergency tracheotomy. spread in many directions; some mandibular space
via lingual plate, pterygo mandibular space, lateral
Infection of Nonodontogenic Origin pharyngeal space and on down the neck. Spreading
laterally infection from the third molar may give
Any of the spreading infection above may derived severe trismus with an extension into the sub-
from non-odontogenic sources as follows: masseteric space.
1. Salivary Gland: Suppurative parotatis. 4. The choice of antibiotics depends on certain aspects
2. Skin: Furncle (Suppurative follicutitis), infected in orofacial infections. The oral surgeon should
sebaceous cyst. provide drainage of any collection of pus whether
3. Bone: Acute osteomyelitis and chronic osteo- by incision, extirpation of pulp, or extraction.
myelitis (See the Vol. I). Ideally antibiotics, supplement of drainage, where
4. Nasal passages, paranasal sinuses infection (See the drainage is possible. But certain clinical features
Vol. I). like:
• Toxemia (↑ temperature and malaise)
Assessment of Infection • Associated regional lymphadenitis
• Trismus
History of the patient includes speed of onset, features
• Dysphagia
of toxemia and difficulty in breathing and swallowing.
• Inadequate drainage
Medical factors may be due to drugs, diabetes.
• Supportive medical background
Examination includes TPR, heart rate, lymphade- • Rapid spread towards soft tissue.
nopathy, spread towards floor of the mouth, tongue
elevation, neck involvement and special examination Demands Intensive Immediate Antibiotic Therapy
of airway and voice. Delineate extend of swallowing The empirical choice of antibiotics commonly and
as base line. Bacteriological culture includes aspiration recent trend of using as follows:
of pus and culture. Other test includes radiography, Penicillin derivatives Amoxycillin 500 mg 8 hourly
vitality test and urinalysis (routine urine analysis, alone and Cloxacillin 500 mg 8 hourly used combine,
random blood sugar and PP Blood sugar). in case of normal infection.
 Orofacial Infection and its Spread
131
In case of allergic to penicillin derivatives, Sometimes due to haphazard irregular use of
Erythromycin 600 mg 6 to 8 hourly may be given. antibiotics surgeon may face difficulty to control
Gentamicin (Genticin actively against some resistance infection. In particular case, stoppage of antibiotics for
staphylococci and Seudomonas auriginosa. 80 mg at least 3 days and collection of infected pus or
twice daily by I/M route along with ampicillin 500 mg materials for culture and sensitivity may helps proper
twice daily by I/M route. Clindamycin a improvised selection of antibiotics.
form of Lyncomycin very effective against anaerobic Ciprofloxacin 500 mg with Tinidazole 300 mg this
infection and achieve high concentration of bone. It is combination drugs twice daily commonly routine
used in septicemia, severe dental infection and used in case of average normal orofacial infection for
osteomyelitis. The doses are 300 to 600 mg 8 hourly 5 to 7 days.
by oral, IM and IV. Typical incision and drainage the various facial
Moderate of severe infection author’s clinical spaces recommended by Cunnings et al as A,
experience Cefotexime (Omnatax, Taxim) 1 to 2 gm superficial and deep temporal space, B, submandi-
twice daily IM, IV as Ceftrioxone (Monocef 1 to 2 gm bular masseteric space and pterygomandibular space,
IM or IV twice daily is effective. C, submental space, D, lateral pharyngeal and
In addition to that Metronidazole 400 mg 3 times retropharyngeal space.
daily in oral route also effective in anaerobic infection
in orofacial origin.
NINETEEN
Excerpts of Orthognathic Surgery

• Introduction • Role of Orthodontics • Operative Techniques for Correction of

Anterior Maxillary Segment • Methods Used to Treat Relative Mandibular
Retrognathism and Maxillary Protrusion

INTRODUCTION the teeth and the investing bone with its blood
supply maintained in a collateral fashion through
To appear attractive to others is a biological instinct
the soft tissue. Another definition postulated by
of human beings, though, the definition of beauty is
Barton and Rayne states that alveolar osteotomy
only relative to time, place and person. Still facial
appearance (symmetry or harmony) has always of surgical movement of the teeth together with
played the pivotal role in determining the beauty the alveolar bone.
criteria. B. Alveolar ostectomy: As per Hinds and Kents’s
Acceptability in society or to be precise, to look definition alveolar ostectomy is merely an osteo-
normal like others or better than others if not best, tomy with excision of a predetermined segment
of alveolar bone. Segmental/alveolar ostectomy
face has been considered as a index.
is explained by Barton and Rayne as an extension
The intense primitive desire to look attractive or
of alveolar ostectomy wherein adjacent segment
at least acceptable particularly for those with
or segments of bone are excised to reduce horizon-
congenital malformation, to society, is a driving force
tal or vertical dimensions. The point of importance
from ages in the development of use of beauty aids
in that the vitality of the teeth is maintained,
from the herbs to the present day cosmetics mostly
though the innervation of pulp is impaired.
to improve facial appearance. Cosmetic surgery,
C. Corticotomy: On the other hand, is a method of
orthodontics and where orthodontic fails or is not
ensuring rapid movements of teeth with their
feasible in the treatment of dentofacial disharmony,
investing bone by utilizing an orthodontic
orthognathic surgery is recommended. The word
appliance. In corticotomy, complete separation of
ortho means straight, nathic means face. The concept
alveolar processes is not needed. Bonycuts are
of orthognathic surgery actually derived from the
made in the cortical plate of bone and only the outer
fracture mandible and middle-third of the facial
cortex is removed. The medullary bone is left
skeleton. Thematically the ioatragenic creation of
undisturbed. Now, it is possible to producing
fracture and reduction, and fixation according to the
rapid orthodontic movement of the segment.
necessity of the correction of jaw deformity. Hence,
the orthognathic surgery define as surgery of facial Role of Orthodontics
skeleton can radically alter function and appearance;
often undertaken in collaboration with specialists in Prior to surgery in any case of malocclusion, a
orthodontics, restorative dentistry and prostho- complete preliminary study of the case is essential.
dontics. The various orthodontic diagnostic aids like
To initiate the planning of orthognathic surgery cephalometry, computerized cephalometry, study of
certain criteria must be fulfill to achieve the success model, soft tissue analysis is necessary for accurate
of the surgery. For our convenience the following diagnostic and treatment plan.
nomenclature for terminology which simplify the Harowitz and Hixson defined cephalogram is an
understanding of various operative procedure. oriented roentgenogram, i.e. the position of head and
A. Alveolar osteotomy: According to Hinds and Kent film and the angulation of the central ray are all
alveolar osteotomy is the surgical movement of predetermined and fixed for each and every case.
 Excerpts of Orthognathic Surgery
133
Though it is only a ‘two-dimensional shadow of the lip is located at a distance of 4 mm +/- 3 mm behind
three dimensions of the face’, its use is invaluable. The the E-plane. The lower lip lies slightly closer to the
various linear and angular measurements of cephalo- E-plane than the upper lip. In children, the lower lip
metry help in our study especially to determine : lies on the or slightly behind the line because of the
a. Case analysis and diagnosis, delayed development of chin and nose. In Blacks and
b. Prognosis during treatment. Chinese adults, the lower lips lines 1 to 3 mm ahead
of E-plane and the upper lip is located approximately
Cephalometry was first used by Broadbent of
at the midicine (Fig. 19.1).
America (1931). His pioneering work was followed A very simple and practical method of deter-
by other orthodontists. Brodie Bjork, Downs, Highly, mining chin position with facial balance is that
Steiner, Tweed, Ricketts and many others contributed advocated by Gonzales-Ulloa. He considers a face
to complete the mosaic of cephalometric diagnosis. beautiful if the chin sis tangent to a vertical line or a
Cephalometric analysis has four Cs namely, (1) To ture meridian 0 degrees of the face. One simply draws
clarify (2) to characterize, (3) to communicate, and the Frankfort plane either from the cephalogram or
(4) to compare (Ricketts 1961). from properly oriented lateral pliotographs, and then
Though various methods of studying the places the vertical line perpendicular to the Frankfort
cephalogram (various analysis) are available, the plane and through nasion. The normal chin promi-
simplest and most widely used is Steiner’s analysis nence (soft tissue) is tangent or closely aligned to the
(1958). Steiner uses the Sella-nasion plane (SN vertical line. Gonzalez-Ulloa classifies the chin
Plane) as the guideline landmark ‘A’ is the deepest retrusion as first, second, or third degree retraction.
This classification is based on increments of milli-
midline point on the premaxilla and ‘B’ is the
meters (0 to 10 mm, 10 to 20 mm, greater than
corresponding point in mandible. Angle SNA is the
20 mm). Treatment of the chin is based upon this
anteroposterior relationship of maxillary basal arch
classification (Fig. 19.2).
to the anterior cranial base. Angle SNB is the
Mock surgery using a paper cutout should be done
anteroposterior relationship of mandibular basal arch
preoperatively to determine the postoperative profile,
to the anterior cranial base. The difference between regardless of surgical techniques. The paper cutout
angle SNA and angle SNB is angle ANB. Angle SNA may also be helpful in determining the osteotomy
is measure of maxillary prognathism angle SNB is plane when utilizing the sliding horizontal osteotomy
thus the relationship of maxillary basal arch to the technique.
mandibular basal arch. In class I arch to the mandi-
bular basal arch. In class I, it is 2° to 4°. In class II
malocclusion, it is greater than 4° and in class III
malocclusion it is less than 2°.
Apart from studying the relationship of various
hard tissues, soft tissue analysis is also an inseparable
part of preliminary investigations. The increased use
of maxillary surgical procedure necessitates a judicial
assessment of the accompanying soft tissue profile
changes. Since the maxillary surgical procedures alter
the facial profile, the ability to predict the extent of
these changes is essential for treatment planning
(Engel et al. 1979).
A number of eminent orthodontists like Stenier,
Ganzalez-Ulloa, Merrifield, Wits and Ricketts have
proposed various techniques for profile measure-
ments. Out of these on indigenous but a very simple
method is that proposed by Ricketts. He describes
an E-plane, which is a line tangent to the chin and
tip of the nose. In European races, in adults, the lower Fig. 19.1: E-plane (esthetic plane) of ricketts
 Synopsis of Oral and Maxillofacial Surgery
134
1. For the correction of open bite when lowering of
the anterior portion of the maxilla is indicated for
a more normal occlusal relationship and bite
closure.
2. For correction of closed bite when the raising the
anterior maxillary fragment is indicated.
3. Correction of the under developed maxilla when
advancement of a portion of the maxilla or of the
entire maxilla is indicated.
4. For correction of protruding maxilla when it is
necessary to move the anterior portion of the
maxilla posteriorly.
5. In combined procedures in which sectioning of
the anterior maxillary segments of bone palatally,
superiorly and buccaly to rotate, lower, raise, or
set back fragments concurrently with the
mandibular correction of class II, class III or open/
Fig. 19.2: Profile line advocated by bite malocclusion.
Gonzalez–Ulloa is simple and practical Surgical treatment of angle class II divisions
malocclusion, the advocates of surgical orthodontics
point out, reduces the duration of time (Salzman).
The decision to use a combined surgical ortho- Surgical correction of maxillary protrution has
dontics approach reserved for patients under three been labelled as ‘Instant Orthodontia’. Treatment of
categories: this malocclusion is sometimes, unpredictable unless
1. Patient having severe dentofacial deformities and concerted efforts of the surgeons and orthodontist are
orthodontic treatment alone would not produce combined (Hinds and Kent 1979).
acceptable esthetics or functional result. The surgical principles for correction of maxillary
2. Moderate dentofacial deformities for whom to protrusion were established in 1921 in Berlin by
reduce significantly the duration of treatment time Cohnstock. The first attempt was made to retreat the
(mainly adult patient). anterior maxilla surgically. A wedge segment of bone
3. Moderate dentofacial deformities and in whom was excised from the maxilla through a transverse
orthodontic treatment alone would adversely affect incision in the palatal mucosa. Because the segment
the facial appearance (mandibular deficiency might was green stick fractured the maxilla relapsed, to the
be accentuated to the set back maxillary teeth preoperative position within 4 weeks.
(Stoelinga and Leena). Analysis of Chonstocks initial attempt by Bell’s to
The choice between orthodontic and surgical retroposition the anterior maxilla surgically indicates
treatment is based on the severity of the deformity
that he feared the consequences of such procedures
and the age of the patient. Generally, surgery is
and attempted to avoid them by green stick fracturing
preferred when the malformations are very pro-
the anterior maxilla through a transverse palatal
nounced and when bone growth has ceased. Such
incision. The consequent relapse after the fixation
operations are justified also when the entire permanent
dentition has been completely formed and only appliances were removed is ample testimony to the
partially satisfactory results may be achieved by fact that adequate mobility was not attained by the
conservative orthodontic therapy. operation.
The operation to correct maxillary protrution is In Europe the awakening to the possibilities for
best performed on patients between the ages of 16- surgical correction of facial deformities begun at the
30 years. At this age, it is either too late for ortho- then West German maxillofacial clinic in Duesldrof
dontic treatment or a relapse is probate (Kole 1959). in the year 1927 by Bruhn.
Mohnac in 1966 summarized excellently the Although maxillary surgery was described in the
indications of anterior maxillary osteotomy as follows: European Literature over 75 years ago, it was not
 Excerpts of Orthognathic Surgery
135
performed routinely in the United States until the
work of Prof. Heinz Kole of Graz University of Austria
was published in the English Literature in 1959. The
surgical principle for correction of maxillary
protrusion were first made by Wassmund (1935)
Spanier (1932), Axhausen (1947), Immenkump (1961)
modified and expanded the technique above, who
were unaware of the biologic basis of surgically
created wound. Fear of loss of blood to the fragment
and devitalization of teeth was tempered by
development of two stages technique of Schuchardt
(1954).
William Bell’s micro-angiographic study 1969 to
1973, the original work established the biological
basis for surgical treatment following surgical insult
to the tissues. Bell original animal study established
and explained the theory confirm the long-standing
clinical observation, the preservation of a single
mucoperiosteal flap is mandatory (Fig. 19.3). Fig. 19.3: Blood supply to anterior maxillary region showing
The above study facilitates and confidential freely anastomosing gingival plexus, palatal plexus, periodontal
support to the operator by William Bell dictums the plexus, labial artery, intra-alveolar vessels, apical vessels, and
preservation of single muccoperiostal flap is essential. pulp vessels. This vascular architecture permits anterior
maxillary octotomies to be performed without compromising
Operative modalities of anterior maxillary osteotomy
circulation to the anterior maxillary segment and teeth
of Wassamund subsequently modified by Cuper via
labial approach then by Wunderer via palatal
approach. Epkar again remodified the Cuper Wunderer (1962) developed his procedure to
operative technique means via the labial approach provide palatally oriented approach to the sectioning
the palatal bone cut is made on direct vision. and repositioning of the anterior maxillary segment.
Though the two basic operative approaches for Because the segment is pedicled on the labial
anterior maxillary osteotomy have been used by most periosteum, it is possible to rotate it anteriorly for
surgeons the Wasmund (1935), and Wunderer (1962), better visualization of the recipient sites. Hence, the
both have been clinically and experimentally tested bony trimming takes place under direct vision. A brief
and found to be sound procedure. Bell (1969), Jensen outline of above mentioned techniques are summa-
et al (1976), Sokaloski (1976), Epkar (1977) developed rized.
and modified the operative techniques basically
recommended by Cuper labial approach (1954) has Outline of Different Operative Techniques for
some techniqual advantages as per author: Correction of Anterior Maxillary Segment
1. It is technically simple. See Table 19.1.
2. Provides direct access to the nasal septal structure
and thereby allow one to deal with these Line Diagram of Some Methods used to
structures directly and prevent buckling of the Treat Relative Mandibular Retrognathism
cartilaginous nasal septum. and Maxillary Protrusion
3. Permits excellent access to the anterior-superior
maxilla so that when it is moved superiority it See Figs 19.4 to 19.8.
can be readily osteotomized without compromise
of the nasal airway. ANALYTICAL OBSERVATION
4. Permits removal of palatal bone under direct 1. Presurgical orthodontic measures and post-
visualization. surgery orthodontic protocol, causes the less time
5. Provides an excellent vascular pedicle. of total treatment modalities. In addition, the
 Synopsis of Oral and Maxillofacial Surgery
136
Table 19.1: Operative techniques for correction of anterior maxillary segment
Surgical approach Blood supply Chief indication Advantage Disadvantage
Cuper method Via labial incision From palatal Intruding Access to Difficult to
1954 pedicle segment nasal floor retrusion
Wunderer Via palatal incision From labial Retruding Access to Difficult to
intrusion method 1965 pedicle segment palate
Wassmund Via tunneling of From labial and Retruding advanc- Maintenance of Limited bony
method 1935 palatal and labial palatal pedicle ing or lowering blood supply access
mucosa segment
Epkar modification 1977 Same as Cuper method approach via nasal floor, palatal bone cut made under direct vision

Figs 19.4A to G: A. The Chin onlay. B, The sliding genioplasty.

C, Body osteotomy and block graft. D, Advancement of the
lower incisor segment with the placement of a graft and bridge.
E, The Wassmund procedure on the premaxilla combined with
the Kole procedure on the mandible. F, Advancement of the
mandible using a sagittal spitting procedure combined with
lowering of the lower incisor region. G, Seward’s modification
of the Caldwell procedure whereby a vertical osteotomy is
combined with a block graft to advance the mandible

Figs 19.5A to G: Diagram illustrating some ramus procedures used in the treatment of mandibular prognathism. A, Section of
the condyle neck. B, Section of the condyle neck with removal of bone from below the sigmoid notch (Smith and Johnson). C,
Blind section of the ramus (Kostecka). D, Horizontal ramus section. E, The vertical subsigmoid (Caldwell and Lettermann). F,
The inverted L (Trauner). G, Oblique osteotomy (Thoma)
 Excerpts of Orthognathic Surgery
137

Figs 19.6A to G: Diagram illustrating some angle, body, and maxillary procedures used in the treatment of mandibular
prognathism. A, The angle ostectomy. B, The body ostectomy. C, Regression of the lower incisor segments. D, Maxillary
osteotomy (Wassmund). E, The Y body ostectomy (Sowray and Haskell). F, The Y body ostectomy combined with the Kole
procedure whereby the anterior alveolar segment is raised to close on anterior open bite, the height of the chin is reduced, and
the point of the chin raised into the chin pad by wedging the chin fragment into the gap (Obwegeser). G, The Obwegeser-Dal
Pont peration (left) and the Dal Pont-Hunsuck variant of the sagittal split (right)

Fig. 19.7: The ideal means of internal fixation is the use of Fig. 19.8: In the above figure, maxilla may be lowered placing
Champy mini plates. These plates are malleable and can be blocks of iliac crest cancellous bone or split rib between the
fitted across the posterior and anterior bony buttresses and cut margins of lateral maxillary wall. Always over-corrected by
screwed into plate. An L-shaped plate will avoid the apices of 25 percent. This procedure will produce a downward and
the canine anteriorly, and a horizontal plate across the vertical posterior rotation of the mandible. The mini bone plates gives
cut of the posterior step osteotomy to similarly preserve the greater stability. Cited from Haris
molar roots

chances of relapses are minimum. Presurgical arch the ostotomized segment will maintained
wires alignment. adequately, if at least one soft tissue pedicle is
2. Model or mock surgery help surgical plan and its preserved intact.
require modification. 4. Reckett’s E-plane (estheticplane) also help for
3. William Bell’s microvascular study on rhesus esthetic evaluation.
monkeys (1969-75) give support and extra- 5. Concept of orthognathic surgery especially maxilla
confidence to the orthognathic surgeons. Prof. derived from fracture middle third of facial
Bell’s experimentally show the blood supply to skeleton. Leforte I and II osteotomy.
 Synopsis of Oral and Maxillofacial Surgery
138
6. French surgeon Maxim Champy introduced mini
plates used for stabilization and fixation of bone
after osteotomy.
7. Hind and Kent consider surgical orthodontic as
instant orthodontics.
8. Obwegeser and Marentette (1986) concept of three
esthetic profile norms is an important reminder
to avoid the temptation of fitting all patient into
the same mould. The normal patient should be
considered to be anterognathic (a) mesognathic
(b) retronathic (c) (cited from Harris) (Fig. 19.9).
9. Present author very temptated to quote the Fig. 19.9
Molina F et al. (Plastic Reconstruction Surgery 96:
825-842 in the year 1995) research article in which
the author is fare welling to major ostotomies after
improvement osteo distraction technique. The FURTHER READING
comment of Molina is very much questionable and
time will establish or reject the above concept. 1. Derreck Anderson. Orthognatic Surgery.
2. Hind, Kent. Text book of Surgical Orthodontics.
3. Malcom Haris, et al. Fundamental of Orthognathic
ACKNOWLEDGMENTS
Surgery.
1. Author is personally indebted a lot in early 1980s to Prof. 4. Obwegeser, et al. Profile planning based on alternation in
Heinz Kole of Graz University, Austria. the position of the bases of the facial thirds. JOMFS 1986;44:
2. Author is personally indebted a lot in early 1980s to Bruce 302-11.
N Epker of United States. 5. William Bell, Profit. Surgical Orthodontics.
 TWENTY
Tidbits of Cryo and Laser Surgery
Used in Oral Maxillofacial Surgery

• Cryosurgery • Mechanism of Tissue Destruction • Indications and Contra-

indications of Cryosurgery • Analytical Observations • Laser Surgery
• Development of Laser Technology • Laser Types • Analytical Observations

CRYOSURGERY surgery: When the freezing process stops and tissues

are allowed to rewarm (Thawing). Soon after thawing,
Intense cold kills living tissue. Cryosurgery involves
the affected tissues swell and exhibit hyperemia. There
controlled destruction of tissue by freezing. Liquid
may be some postoperative pain at this time but this
nitrogen, Nitrous oxide and carbon dioxide taking
is readily controlled by mild analgesics. Pain, bleeding
energy from their surroundings when they vaporize
and infection are exceedingly rare sequelae of
or expand. The clinical application of a freezing probe
cryosurgery. In skin and mucous membranes, vesicles
to living tissues is termed Cryosurgery by Poswillo.
may form some hours after cryosurgery by the
accumulation of extracellular fluid. Occasionally, large
Mechanism of Tissue Destruction superficial blebs may form. Unless evacuated they
Explained by Prof Poswillo coagulate and remain on the lesion for several days.
The mode of cell death following cryosurgery is More commonly, a slough or eschar forms on the
complex. Freezing induces ice crystal formation within surface of the lesion within 48 hours. There are few, if
cells and extracellular spaces. The intracellular ice any, signs of an inflammatory response around the
crystal may rupture cell membranes where cooling cryolesion and healing occurs by secondary intention.
rates are rapid. Slower cooling produces large ice Within 7 days, re-epithelization takes place from the
crystal in the space between cells. As the crystal grow, wound margins and healing is usually completed
water is removed from neighboring cells leading to within 2 to 3 weeks. Scarring is noticeably reduced
following repair in cryosurgical wounds, particularly
an increase in the concentration of electrolytes. These
in mucous membranes. On the skin, the epithelial
soon reach toxic level, initiating cell death by osmotic
cover may remain thin and depigmented for a
shock when thawing commences and water returned
considerable period after healing.
to the cells.
When bone and cartilage are frozen, they retain
This can be summarized as:
their structural integrity, although devitalized, and
1. Ice crystal formation extracellular and within continue to provide mechanical support for the
the cells; adjacent soft tissues until repopulated by vital cells.
2. The changes is the osmolarity; The walls of arteries and the sheaths of nerves are not
3. Changes in the vascular bed, leads to ischemic disrupted by cryosurgery, but retain their morpho-
necrosis and resulting microthrombi formation logical features, thus provide facilitating the
within the capillary and arterioles due to restoration of function in these structures. Because of
vascular stasis; these unique biological responses, the over-extension
4. Changes in cellular metabolism, which causes of a cryolesion into adjacent normal structures is often
inhibition of enzymes and denaturation of of less concern than would be a similar incident with
lipoprotein complexes. the diathermy or scalpel.
Effects of cryosurgery on the tissues is discussed According to Poswillo, the nitrous oxide system
in detail by Prof. Poswillo on general principle of cryo- achieves a pro-tissue temperature of around minus
 Synopsis of Oral and Maxillofacial Surgery
140
70° centigrade. It uses Joule–Thomson Principle of e. Rotatory spray technique. This spray is directed
rapid expansion of a gas-producing freezing. The in multiple, concentric circles of increasing
equipments is simple to use and more suitable for diameter, till the whole lesion is frozen.
smaller or more superficial lesion. The cryo pro Prof Paul F Bradly described a variety of methods
produces the lowest temperature at the tissue probe of freezing bone in the maxillofacial region with object
interface, about –190° centigrade, its use is essential of eradicating neoplastic or other abnormal cellular
when large or vascular lesions are to be frozen. Liquid elements, without the need for radical excision. This
nitrogen is a powerful refrigerant and great care must was the experimental work by Gag and his team
be excised when charging and handling the appara- freezing segments bone in dog.
tus. This form of equipments is for the experienced
operator. There are various procedures in case of Tissue Response (Fig. 20.2)
cryosurgical method, dipstick method and spray
method. The initial necrotic phase lasting several days with a
provisional osteogenic phase for some weeks in which
Dipstick Method new subperiosteal woven bone is laid down over the
necrotic bone. Marrow spaces repopulated with
The lesion about 0.5 to 1 centimeter, dipstick method fibrous tissue and there is a leaser deposition of
is suitable. Topical anaesthetic may apply to minimize endosteal bone. The data in the experimental work is
discomfort. The technique consist of dipping a cotton not significant.
swab into the liquid nitrogen for 1 to 2 second and The various methods of freezing bone described
applying it on the lesion with pressure till the by various authors:
formation of ice crystals that is within 30 to 60 seconds. a. Probe alone shows freezing a mucosal lesion
Following thawing procedure for 60 to 120 seconds. extending into the bone.
Two consecutive freeze and thaw cycles were used. b. Pro plus water soluble K Y Jelly freezing a bone
In this method temperature may be –20oC and depth cavity after curettage of an intra-bony lesion;
upto 2 to 3 mm may be needed. This technique is c. Liquid nitrogen spray shows use in a large bone
limited for superficial lesions. cavity;
d. Liquid nitrogen coil. Liquid nitrogen circulates
Spray Technique (Fig. 20.1)
through a coil around the bone;
Based on the shape and size of the lesions: There are e. Explant technique: the segment of bone is removed,
various spray technique: frozen in a bathe of liquid nitrogen and then return.
a. Spot spray free technique for small round lesion Note the central thermocouple ( oC) and holes
< 2 cm in diameter. drilled in cortex (needs further time tested
b. Overlapping technique for lesion > 2 cm diameter outcome).
and the field is divided into over lapping circles of
2 cm diameter.
c. Paint brush technique for larger lesions, much
longer time is needed for concrete spray. This
technique is employed for adequate freezing for
irregularly shaped lesions.
d. Spiral spray technique. The spray started in the
centre of the lesions and carried in an ever-
widening spiral. This is also useful for treating
larger lesions.

Fig. 20.1: Spray technique Fig. 20.2: Methods of freezing bone

 Tidbits of Cryo and Laser Surgery Used in Oral Maxillofacial Surgery
141
Indications and Contraindications e. Edema.
of Cryosurgery f. Syncope.
g. Vesicular-bullous formation.
Prof Setrag A. Zacarian summarized the indications II. Delayed:
of cryosurgery as follows: a. Postoperative infection.
I. Tumors with definable margins: b. Febrile systemic reaction.
a. Nodular or ulcerated lesions. c. Hemorrhage from the wound site.
b. Instrument delineation by means of a curette; d. Pyogenic granuloma.
c. Chemical delineation by means of 5-fluo- e. Pseudoepitheliomatous hyperplasia.
rouracil.
III. Prolonged:
d. Tumors overlying cartilage and bone.
a. Hyperpigmentation.
e. Lentigo maligna (State I level of invasion).
b. Development of milia.
II. Nature of the neoplasms:
c. Hypertrophic scars.
a. Infected tumors.
d. Neuropathy.
b. Recurrent tumors from previous radio-
IV. Permanent:
therapy.
a. Hypopigmentation.
III. Patient with idiosoimcrasies:
b. Ectropion and notching of eyelids.
a. Patient with pacemakers (electro cautery in
c. Notching and atrophy of tumors overlying
contraindicated).
cartilage.
b. Patient old enough to be poor surgical risk.
d. Tenting or notching of the vermilion border
c. Patient with anaesthesia idiosymcrasies.
of the upper lip.
IV. Inoperable patient:
e. Atrophy.
a. Palliation.
f. Alopecia of hair-bearing sites.
b. Removal of bulk vegetative lesions.
ANALYTICAL OBSERVATIONS
Contraindications
1. Oral white lesions* treated with cryotherapy by
The absolute contraindication of cryosurgery are clear Marvin E. Chapin et al. 1973 showed decreased
cut and definitive: pain bleeding, minimum scar formation. When
1. Intolerance to cold. bone was frozen, there was no formation of
2. Cryoglobulinemia. sequestrum (*see the photograph in Vol. I)
3. Raynaud’s disease. 2. Prof D Proswillo et al. in 1974 stressed on the
4. Cold urticaria. importance of cryosurgery in the management of
5. Collagen and autoimmune disease. premalignant oral lesions and suggested the
6. Concurrent treatment with rental dialysis. cryotherapy as a palliative mode in the primary
7. Concurrent treatment with immunosuppressive treatment of malignancies.
drugs. 3. Radden BG et al. observed that oral lesions treated
8. Platelet deficiency disease. with cryotherapy were followed by formation of
9. Blood dyscrasias disease. extensive granulation tissue with subsequent
10. Blood dyscrasias of unknown origin. repair without scar tissues.
11. Multiple myelomas. 4. Prof Paul F Bradly et al. 1975 an experimental and
12. Agammaglobulinemia. clinical study shows the affects of liquid nitrogen
cryosurgery on bone histologically showed three
Complications maybe: overlapping phases of necrosis, osteogenesis and
I. Immediate: remodeling.
a. Pain during the freezing and thawing period. 5. Joanna M Zaakrzewska et al 1988. Eastman
b. Headache affecting forehead, temples, and Hospital, London showing their six years studies
scalp. for the management of trigeminal neuralgia with
c. Insufflations of subcutaneous tissue. cryotherapy revealed and average period of pain
d. Intradermal hemorrhage. relief 16 to 17 months.
 Synopsis of Oral and Maxillofacial Surgery
142
6. Pro Raghabendra Pradhan et al in 1992 an excellent more powerful. The depth of destruction can be
comparative study between scalpel surgery, controlled precisely, and small blood lymphatic
cryosurgery using nitrated oxide and electro vessels are sealed (with possible prevention of tumor
surgery in the treatment of pre-malignant oral spread). Wound produced by a carbon dioxide laser
lesions. They concluded electro surgery; excision is said to heal with less scarring than other wounds.
and closer best followed that cryosurgery. Fewer myofibrils are generated in healing. This,
7. Yeh CJ 1965 explained a phenomenon as follows: together with retention of connective tissue skeleton,
The tissue mostly freezes at –2.2oC and cell death reduces scar contraction. Carbon dioxide laser surgery
occurs at a temperature of –20 o C after the may also be associated with less postoperative pain.
biochemical changes takes place within the cell The commonly known the advantages and the
least to destruction and sloughing. disadvantages of carbon dioxide laser chronologically
It is convenient to the patient especially older and arranged by Timothy J. Atkinson as follows:
the children. Minimal complication rate with this
technique and therefore suitable extensive superficial Advantages
lesions it can be repeated any number of times. It may a. Production of a sterile surgical field, bactericidal,
be used as an adjunct to surgery and for palliative vircidal.
measures only the postoperative swelling was much b. Minimal cicatrix formation/wound contraction.
more in this technique. c. Access to difficult to reach anatomic sites by
reflection or through waveguides.
LASER SURGERY (Figs 20.3 to 20.5)
d. Ability to coagulate, vaporize, or incise tissue.
Laser the word L for (Light), A for (Amplification by), e. Good hemostasis.
S for (Stimulated), E for (Emission of) R for (Radiation). f. Reduced local tissue trauma and edema.
A device that emits and intense coherent directional g. Precise delivery of energy to diseased tissue via
beam of radiant energy by stimulated electronic for microscopes for reduced damage to surrounding
molecular transitions to a lower energy level. structure.
h. Reduced pain by induced neural anaesthesia as a
Development of Laser Technology function of neuron sealing and decreased pain
mediator release.
During early 20th century Neilsbohr of Germany in
i. Minimized tumor cell dispersion by lymphatic
1913 and Albert Einstein in 1917 a quantum theory
sealing.
and theory of stimulated emission are initial concept
of carbon dioxide. Shafir in 1977 was first documented
Disadvantages
case in the field of oral and maxillofacial surgery.
a. Specialized didactic and clinically oriented
Laser types include instruction required for laser use by the surgeon
and ancillary assistants.
• Carbon dioxide.
b. Hazards to patient, operating and assistant team,
• Neodymium YAG (yttrium aluminium garnet).
and anesthesia personnel from misdirected and
• Argon laser.
inadvertent laser radiation.
• Tunable dye laser.
c. Expense of laser equipment.
Carbon dioxide laser offers several advantages
d. Specialized wiring and plumbing connection.
over the blade surgical procedure and over chemical
e. Maintenance requirements.
in skin rejuvenation. Ablation gross removal of tissue
f. Fire hazard as related to anaesthesia risk.
as in tumor removal, debulcking, or vaporization is
g. Electrical hazards of laser equipment.
perform without char and bleeding, operating is
minimized and the laser seals blood vessels during Neodymium YAG (yttrium aluminium garnet)
surgery with minimal thermal damage to the laser: The laser is composed of a medium consisting
surrounding tissue. The major intra oral application of a YAG crystal “doped” with a rare earth element,
is an excision of pre-malignant lesions. Excision of soft neodymium. This laser is capable of stimulated
tissue neoplasms is also possible with models that are emission when excited by external energy (e.g., xenon
 Tidbits of Cryo and Laser Surgery Used in Oral Maxillofacial Surgery
143

Fig. 20.4: Excisional and incisional biopsies can be promoted.

A, First, an outline is made with adequate margins around the
altered tissue to be excised, with the laser beam perpendicular
to the surface. B, A forceps is used elevate a margin and the
specimen is raised ahead of the laser beam thus excising the
lesion. Larger vessels (upto 2.0 mm) that continue to
hemorrhage can be coagulated by defocusing a continuous-
wave laser beam (A laser that emits a continuous laser beam
without pulses). C, The resultant wound can be left to granulate
secondarily or closed primarily in a routine fashion (Adapted
from Pick R, Pecaro)
Fig. 20.3: Defocusing the laser beam decreases the power
density and increases thermal conduction and coagulation
capability

flash lamp) and can emit radiant energy at 1.06

microns, which is absorbed within 30 mm of tissue
with moderate lateral scattering. Nd: YAG is known
as a dopedinsulator laser, the YAG acting as the
Fig. 20.5: Laser vaporization/ablation is accomplished by first
insulator and the Nd as the dope.
achieving the critical power density, which is 50 watt/cm2. Using
Argon laser: A visible light laser producing radiant a pulsed mode in a crosshatch pattern, the lesion is removed
energy of a 488- or 514 nm wavelength in which argon with minimal thermal damage adjacent tissue
gas is the active medium after ionization either by an
electric charge (electron beam) or by energy from a by focusing the laser beam onto the tissue surfaces
diode laser. with a smallest spot size possible, which posses the
highest power density.
Tunable dye laser: A laser in which an organic dye is
dissolved in a solvent and is the active medium. These
The Laser Surgical Environment
lasers are tunable by adjusting the dye medium and
the excitation radiation. 1. The surgeon should have thorough knowledge in
laser tissue reactions.
Photocoagulation: During the laser surgery it is
2. The assistant should be trained and prepared to
observed irreversible, denaturation of tissue proteins
make any adjustment in the laser’s timing or power
heated between 50 to 200oC the zone of coagulation
during the procedure.
necrosis is produced. During the incision of tissue the
3. Care must be given for the comfort of the patient
carbon dioxide laser can concurrently blood vessels
and surgical team, the ease of surgeon access and
upto 0.5 mm diameter. Larger vessels, upto 2 mm
correct equipment setup. Personal safety pre-
diameter requires interruption of the incising process
caution must be taken for the patient and all the
and defocusing of the laser beam to cause coagulation.
members of the surgical team.
Incision: Laser can be used easily to create surgical Argon laser was one of the first lasers to be used in
incisions without tissue contact. This is accomplished the treatment of vascular lesions.
 Synopsis of Oral and Maxillofacial Surgery
144
CW laser or pulsed dye laser has become an • “Ranula” (mucous escape phenomenon)
excellent modality for the treatment of superficial • Salivary gland tumors
vascular lesions such as telangiectasias, hemangiomas, • Sialolithiasis
port winestaim. • Hemangioma
• Lymphangioma
Q-switched Nd • Dysplasia/leukoplakia
• Ankyloglossia
YAG Laser, which produced very high energies. It has
found great useful for the treatment of oral pigmented
lesions. Some Analytical Observations
Defused intraoral surface lesions includes focal 1. The laser surgery is highly cost oriented surgical
hyperkeratosis, nicotinic stomatitis, erythroplakia, modalities.
verrucous carcinoma, oral papillomatosis, leukoplakia 2. The separate surgical environment is mandatory
can be treated by laser surgery according to Catone. for this surgery.
Benign lesions of the tongue amenable to laser 3. The special knowledge and training is needed the
treatment include: operative surgeons as well as the assistance.
• Fibroma 4. Though the laser surgery is an avascular surgery
• Papilloma in spite of that it has limitations for the surgical
• Granular cell tumor (granular cell myoblastoma) viewpoint.
• Lingual thyroid nodule 5. The surgical removal of growth by laser achieve
• Hemangioma only in ablative surgery or due to vaporization.
• Lymphangioma 6. Guy A. Catone also reported open laser TMJ.
• Lingual tonsil Arthroplasty via preauricular approach or question
• Pyogenic granuloma mark incision of Adil Alkyte and Paul Bramly.
• Lipoma 7. Jeffrey Moses reported the use of laser in cosmetic
• Aphthous ulcer. maxillofacial surgery.
Some lesions of the lips amenable to laser surgery
include:
• Mucocele FURTHER READING
• Pyogenic granuloma 1. Anthony Pogrel M. The use of liquid nitrogen
• Fibroma cryotherapy in the management of locally aggressive
• Actinic cheilitis bone lesions. Journal of Oral and Maxillofacial Surgery
• Hemangioma 1993;51:269-73.
• Aphthous ulcers. 2. Bradley PF. The cryosurgery of bone—an experimental
and clinical assessment. British Journal of Oral Surgery
Lesions of the buccal/cheek mucosal with the laser
1975;13:111-27.
include:
3. Catone GA. Page 1-37.
• Hyperkeratosis/dysplasia 4. Catone GA. Laser technology in oralmaxillofacial
• Fibroma surgery. In selected readings in OMFS Vol III (3)
• Pyogenic granuloma University of Texous, South Western Medical Centre
• Hemangioma/lymphangioma 1993.
• Salivary gland tumors 5. Catone GA. Laser in dentoaleveolar surgery. OMOS
• Hyperplastic tissue, scar tissue Clinic North AM 1993;5:45-61.
• Lichen planus. 6. Catone GA. Open laser. TM Jt Arthoplasty part-II 201.
Some lesions involving floor of the mouth may 7. Fischer AC, et al. Effects of the carbon dioxide surgical
have difficult access, prominent vascularity leading laser on oral tissues. BJOMFS 22:414-25.
8. Joanna M Zakrewska, et al. Cryotherapy in the manage-
to vision-obstructing bleeding, an extreme tissue
ment of paroxysmal trigeminal neuralgia. Journal of Oral
distensibility often makes scal surgery of the floor of and Maxillofacial Surgery 1986;14:5-7.
the mouth a tedious and difficult task. The hemostasis 9. Joanna M Zakrzewska, Nally F. The Role of cryotherapy
and non-tactile surgical nature of the laser. It is in the management of paroxysmal trigeminal neuralgia
favourable to use in this anatomic region by carbon a six year experience. British Journal of Oral and
dioxide laser. The following lesions treatable by lasers: Maxillofacial Surgery 1988;26:18-25.
 Tidbits of Cryo and Laser Surgery Used in Oral Maxillofacial Surgery
145
10. Leopard PJ, Poswillo DE. Practical cryosurgery of oral 16. Poswillo DE. A comparative study of the effects of
lesions. British Dental Journal 1974;136:185-96. electrosurgery and cryosurgery in the management of
11. Leopard PJ. Cryotherapy and its application to oral benign oral esions. British Journal of Oral Surgery
surgery. British Journal of Oral Surgery 1975;13:128-52. 1971;9:1-7.
12. Marvin E Chapin, et al. Cryosurgery of oral white lesions. 17. Radden et al. The effects of cryosurgery on oral mucosa.
Journal of Oral Surgery 1973;31:584-91. Journal of Dental Research 1975;54:49-55.
13. Moses J. Laser for use in cosmetic maxillofacial surgery,
18. Roodenburg. JLN Laser in oral leukoplakia, thesis with
page 219 cited from Catone and Alling.
English Summery 1985.
14. Poswillo DE. A comparative study of the effects of electro-
19. Shafir R, et al. Excession of buccal haemangioma by
surgery and cryosurgery in the management of benign
oral lesions. British Journal of Oral Surgery 1971;9:1-7. carbon dioxide laser. Triple 1977; 0 44 (3):347-50.
15. Pradhan R, et al. Special surgery, electrosurgery and cryo- 20. Tuffin JR. Carbon dioxide laser. BDJ 1980;149:255-58.
surgery in the treatment of premalignant lesions of the 21. Yeh CJ. Simple cryosurgical treatment for oral lesions.
oral mucosa. Indian Journal of Oral and Maxillofacial International Journal of Oral and Maxillofacial Surgery
Surgery 1995;7:27-35. 1995;53:784-90.
TWENTY-ONE
Hemorrhage and Shock

• Definition of Hemorrhage, Shock, and Types • Various Coagulation Factors and

Hemostasis • Prof. Macferlane Cascade Theory • Detection of Bleeding Disorder,
Determine on History, Examination finding and the Screening Laboratory Test
• Types of Hemorrhage from Different Vessels and Bone. Treatment Modalities
of Hemorrhage • Medicinal Management of Bleeding Disorder • Pathophysiology
of Shock • Different Types of Shock and the Clinical Features and Supportive
Treatment Measures

HEMORRHAGE Venous bleeding is characterized by non-pulsating

dark red colour of the blood with a steady flow.
Hemorrhage or bleeding is escape of blood from the
vessels due to damage or injury in vasculature. Capillary bleeding oozing bright red blood from the
Hemorrhage can be: capillary bed.
a. Primary: Hemorrhage during surgery or persisting
Bony bleeding from the nutrient vessels of the bone.
bleeding from surgical wound.
This short of bleeding mostly found during removal
b. Intermediate or reactionary: It is due to within rise
of lower third molar from the bony bed.
of blood pressure following immediate after 24
The hemostasis meaning the control or arrest of
hours of surgery.
the bleeding. There are four important steps of
c. Secondary: Hemorrhage after 48 to 72 hours due
hemostasis.
to infection. The digestion of the clot due to
1. The injured blood vessels attempt to reduce blood
liberation of bacterial toxin from infection.
flow undergoes constriction due to curling of the
Other hemorrhage includes petechial hemorrhage
intima causes spasm in the vessel wall.
seen in subcutaneous or submucosal area in the form
of minutes pinpoint spots. Ecchymosis, the large area
of bluish or purple coloration of the skin or mucous
membrane due to extravasations of the blood into the
subcutaneous tissues.

Hematoma
Collection of blood in the facial planes due to injury
or surgical trauma.
Other types of hemorrhage includes:
a. Arterial.
b. Venous.
c. Capillary.
d. Bony.
Arterial bleeding characterized by bright red in color Fig. 21.1: Cited from D. M. Harmening-Clinical Hematology
with pulsating flow. and Fundamental of Hemostasis, 1992
 Hemorrhage and Shock
147
Table 21.1: Classification of various Detection of bleeding disorder, determine on
coagulation factors (Fig. 21.1) history, examination finding and the screening
laboratory test:
1. Substrates
Factor I Fibrinogen • No clinical or historical clues to bleeding problem;
2. Cofactors – accelerate enzymatic reactions excessive bleeding occurs after surgery;
Factor III Tissue factor (thromboplastin) • History or clinical findings or both suggest possible
Factor V Labile factor bleeding problem but no clues to cause the
Factor VIII Antihemophilic factor following:
Fitzgerald factor High-molecullar-weight kininogen — PT
(HMWK) — apt
3. Enzymes
— TT
a. Serine proteases
Factor II Prothrombin
— PFA-100 or BT
Factor VII Proconvertin — Platelet count.
Factor IX Plasma thromboplastin component • Aspirin therapy: PFA-100 or BT
Factor X Stuart –Prower factor • Coumarin therapy: PT
Factor XI Plasma thromboplastin antecedent Low-molecular weight heparin: apt
Factor XII Hageman factor • Possible liver disease: Platelet count, PT
b. Transamidase
• Chronic leukemia: Platelet count;
Factor XIII Fibrin-stabilization factor
4. Contact proteins
• Malabsorption syndrome or long-term antibiotic
Factor XI Plasma thromboplastin antecedent therapy: PT
Factor XII Hageman factor • Renal dialysis (heparin): apt
Fletcher factor Prekallikrein • Vascular wall alteration: BT (results often
Fitzgerald factor HMWK inconsistent);
5. Prothrombin proteins (vitamin K-dependent factors II, • Primary fibrinogenolysis (active plasmin in
VII, IX, X
circulation), cancers (lung, prostate): TT.
6. Fibrinogen group (high-molecular-weight) factors I, V, VIII,
XIII Screening laboratory test:
• PT—activated by tissue thromboplastin
2. Activation of platelets and formation of platelet
a. Tests extrinsic and common pathways;
plug.
b. Control should be run;
3. Coagulation: Activation of clotting mechanism and
c. Normal (11 to 15 seconds, depending on
formation of clot leads to secondary hemostasis (by
laboratory);
physiological process). Coagulation is an auto-
d. Control must be in normal range.
catalytic reaction a short of chain reaction which
ones started end in completion keeping the only • aTT—Initiated by phospholipid platelet substitute
one motto, clot formation. There are several and activated by addition of contact activator
theories have been postulated from time to time (kaolin)
starting from Morawitz via Howel, end in Prof. a. Tests intrinsic and common pathway;
Macferlane Cascade Theory. b. Control should be run;
4. Fibrous organization of the clot or retraction of clot. c. Normal (25 to 35 seconds, depending on
Hence, the primary hemostasis is a process of laboratory);
platelet plug formation at the site of injury. Secondary d. Control must be in normal range;
hemostasis is activation of clotting process of plasma • TT—activated by thrombin;
resulting the formation fibrin. This can be summarized a. Tests ability to form initial clot from fibrinogen;
a. Platelets + Ca++ + Thromboplastin Precursor = b. Controls should be run;
Thromboplastin. Which is present in plasma. c. Normal (9 to 13 seconds);
AHG VIII PTC IX X PTA XI XII + Accessory factor • PFA-100*
VI VII and AHG a. Tests platelet function;
b. Prothrombin (Source from vitamin K + Thrombo- b. Normal if adequate number of platelets of good
plastin + AF = Thrombin quality present;
c. Fibrinogen + Thrombin = Clot + FSF = Fibrin. c. Normal (60 to 120 seconds);
 Synopsis of Oral and Maxillofacial Surgery
148
• Platelet count Ethampsylate (local and systemic)
a. Tests platelet phase for adequate number of Oxidized cellulose, (oxycel, local)
platelets; Human thrombin powder (local)
b. Normal (140,000 to 400,000/mm3);
Surgicel: It is glucose polymer-based, sterile knitted
c. Clinical bleeding problem can occur if less than
fabric by the control oxidation of regenerated cellulose
50,000/mm3.
(local hemostatic).
Treatment modalities of hemorrhage or bleeding:
Bleeding (par-operative, reactive and postope- Fibrin Glue (local hemostatic). It is a biological
rative): adhesive, composed of thrombin, fibrinogen and
factor XIII and aprotinin.
During extraction
Thrombin converts fibrinogen to unstable fibrin
Bleeding Reactive bleeding after 24 hrs clot, factor XIII stabilize the clot and aprotinin prevents
Post-extraction after 48–72 hrs its degradation.
During extraction or paroperative bleeding:
Careful about tender handling of the soft tissue and Hemolock (Feracrylum HCl)
alveolar bone. It will definitely help to control par
Pressure and pack with soaked and dried with white
operative extraction bleeding. Undue trauma causes
head varnish gauge. Suture if necessary.
damaging the nutrient vessels of the bone.
The reactive bleeding: It is mostly due to the rise Bleeding from the arterial wall and the vein mostly
of blood pressure in some patients because of due to trauma or injury. The spurting of blood, frank
apprehension and fear of post extraction bleeding. The red in colour in case of injury to the artery. In case of
semi supine position preferably sitting posture helps vein non-pulsating, steady flow of blood dark red in
to reduce the bleeding and maximum visual and colour
mechanical access can be achieved to control the above
problem. Management
Treatment includes reassurance. Diazepam 5 mg. Catch hold the artery, vein, and ligate.
at bedtime or if necessary antihypertensive treatment Surgical diathermy.
with consultation of physician or cardiologist. Or
Postextraction bleeding after 48 to 72 hours: Electrocoagulation/Argon beam coagulator
The postextraction bleeding is mostly due to (a superior form of electrocoagulation method using
infection. The toxin liberated by the local bacteria Argon gas)
which digest the clot. Bleeding from the bony bed.
Management of bleeding maybe summarized as: Crush the nutrient vessels supply the bone by blunt
instruments or artery forceps.
3P and 3S Application of Horsley’s bone wax (Bees wax 7 parts,
Pressure Saline olive oil 2 parts, phenol 1 part).
3P Pack 3S Styptic After control suture with pressure pack.
Posture Suture Post-extraction bleeding usually the disturbances of
clot and due to intervention of infection. After obtain
Treatment modalities maybe a combination of both
L. A. removal of infected clot. Irrigation with normal
or according to the case.
saline or povidone iodine or hydrogen peroxide.
Bleeding from the capillary bed presented by oozing Control of bleeding by pressure pack and sutures.
of blood. Then suitable antibiotics are the main treatment
Controlled method application of local haemostatic modalities as because the cause is due to infection.
(styptic) like adenochorome monosemi carbazone Analgesics to relieve pain and above selected
(locally and systematic methods) measures may be used.
E.A.C.A (Epsilon aminocaproic acid) (local and The treatment modalities of hemorrhage or
systemic) bleeding based on three basic perspectives:
 Hemorrhage and Shock
149
1. Sought the cause. The above measures according to case and need
2. Remove the cause. base. The management of different bleeding disorder
3. The consequence of hemorrhage, which may lead summarized as follows:
to hypovolumic shock. In case of surgical protocol requires certain need
In addition to the above, surgical protocol the base essential amenities and the preparation prior to
following supporting measures is mandatory for operative session:
management, which includes: 1. Selection of anaesthesia;
1. Transfusion of fluids; a. Malamed intraligamentary local anesthesia is
2. Plasma expander; preferable.
3. Transfusion of blood; b. Above anesthetic procedure under deep
Criteria sedation (injection diazepam fortwin I/V).
a. To maintain blood volume on the basis of degree c. Short-acting enfluren or halothane usually not
of loss of blood and replace accordingly to prevent used now a days may be used as inhalation
shock. anesthesia.
b. To improve oxygen carrying capacity. 2. Preparation of pre-formed hemorrhagic splint
4. Cryoprecipitate AHG; made of stent compound or clear acrylic.
a. To promote or maintain coagulation; 3. White head varnish pack or zinc oxide euginol pack
5. Platelet transfusion. is necessary prior to surgical procedure.

Table 21.2: Medical treatment of bleeding disorders

Condition Defect Medical Treatment
Hemophilia B Primary thrombo- Deficiency or defect in F-IX F-IX
cytopenia (idiopathic thrombocyto- Platelets destroyed by autoimmune Prednisone
penia) process IV gamma globulin
Platelet transfusion
Hemophilia A Deficiency or defect in F-VIII Porcine F-VIII, PCC, APCC, F-VIIa, and/
Some patients develop antibodies or steroids for patients with inhibitors
(inhibitors) to F-VIII
von Willebrand’s disease Deficiency or defect in vWF causing DDAVP
poor platelet adhesion and in some EACA
cases deficiency of F-VIII F-VIII replacement that retains Vwf
DDAVP
Secondary thrombocytopenia Deficiency of platelet because of Platelet transfusion
accelerated destruction or consumption,
deficient production, or abnormal pooling
Bernard-Soulier disease Genetic defect in platelet membrane, Platelet transfusion
absence of glycoprotein Ib causes
disorder in platelet adhesion
Liver disease Multiple coagulation factor defects Vitamin K
Patients with portal hypertension Replacement therapy only for serious
may be thrombocytopenic bleeding or before surgical procedures.
DDAVP provides some benefit.
DIC Multiple coagulation factor defects Treatment of primary disorder.
due to triggered consumption. For- Heparin
mation of fibrin and fibrinogen Cryoprecipitate for replacement of
degradation products due to fibrinogen. Platelet transfusion.
fibrinolysis. Thrombocytopenia Other blood product replacement leads to
mixed results.
 Synopsis of Oral and Maxillofacial Surgery
150
4. Surgery must be done carefully atraumatically and alpha, interleukins and prostaglandins. The patho-
tissue should be handle with tender care. In physiology of septic shock is an extremely complex
addition to that, the medicinal management mechanism interaction between tissue hypoxia and
mentioned below: the host’s immune response and the cause of death
sepsis-induced multiorgan failure.
Shock
Shock is defined as inadequate blood flow to vital Neurogenic Shock
organs or failure of the cells of vital organs to utilize Neurogenic shock occurs due to sympathetic nervous
oxygen (MacLean). MacLean recommended eight system blockage, therefore the dilatation of capillaries,
measures for monitoring all types of shock. veins and arterioles → pulling of blood → leads to
1. Arterial blood pressure (normal range of adult, hypovolumia → hypotension → shock.
120/80 mm of Hg plus/minus 10 mm);
2. Pulse rate (80/min); The clinical features of shock:
3. Central venous pressure (5 cm H2O); a. Mild < 20 percent blood loss showing the features
4. Urine flow (50 ml per hour); of cold calmy mois skin, fall of blood pressure,
5. Cardiac index (3.2 L/min/m2) rapid pulse, collapsed neck veins, concentrated
6. Arterial blood – PO2 (100 mm Hg); pCO2 (40 mm urine;
Hg) and pH (7.4); b. Moderate > 20 to 40 percent blood loss feeling of
7. Arterial blood lactate (12 mg/100 ml); thirsty, supine hypotension with rapid pulse,
8. Hematocrit (35 to 45%). oliguria or anuria;
Shock can be classified mainly into four types on c. Severe > 40 percent blood loss patient is agitated,
the perspective of patho physiology and rapid confused, supine hypotension, rapid and thready
haemodynamic changes. pulse, positive findings, rapid respiration.
As per classification, they are follows: Management of hypovolaemic shock based on three
1. Hypovolemic shock. basic principles:
2. Cardiogenic shock. a. Controlled bleeding that means ensure hemostasis;
3. Septic shock. b. Maintain homeostasis (maintenance of internal
4. Neurogenic shock. environment) by appropriate fluid therapy;
c. Assure oxygen exchange (Therapeutic oxygen
Hypovolemic Shock under pressure).
In oral maxillofacial surgery the hypovolaemic shock The above-recommended measures are already
as result of maxillofacial trauma or injury leads discussed at the early part of this chapter.
profuse bleeding or due to surgical problems. The Management of cardiogenic shock includes with
hemorrhage causes decrease venous return → the consultation of cardiologist. Dopamine is a
decrease cardiac output decrease blood volume vasopressor may be recommended with normal saline
→decrease tissue perfusion → leads to tissue hypoxia or 5 percent dextrose I/V drip given at 5 to 10
→ hypotension → shock. microgram kg./minute. Management of septic shock
based on:
Cardiogenic Shock a. Replacement of the fluid therapy;
b. Therapeutic oxygen;
As a result of inadequate cardiac output → reduce
c. High doses of selective antibiotic therapy;
oxygen supply → reduce tissue perfusion which leads
d. Removal of source of infection;
to effective contractile function of the myocardium. e. IV use of betamethasone/dexamethasone
(betnesol/decadron)
Septic Shock
Management of neurogenic shock includes
Septic shock is due to severe septicemia and resulting vasovagal syncope activated by sympathetic
toxemia. Development of sepsis is related to complex stimulation → dilatation of vessels of muscles →
interplay between endotoxin, release of pro-anti- pulling of blood in the lymps → transient ischemia of
inflammatory mediators, like tumor necrosis factor, brain leads to loss of consciousness (syncope).
 Hemorrhage and Shock
151
The clinical features include: c. Anxiolytic medicine prior to surgery. Diazepam
1. Pail or ashen skin. (5 mg) day before surgery night and one tablet half
2. Sweating with nausea. an hour before surgery.
3. Rapid pulse. d. Patient should not come with empty stomach.
4. Pallor tongue and lip in early stages.
In late stages: Treatment
1. Cold calmy skin.
1. Change the patient position. Sitting to supine. Head
2. Fall of blood pressure.
should be lower than feet (15 o Trendlenberg
3. Pupil dilated.
position).
4. Slow pulse.
2. Flashing the face with cold water.
5. Dizziness.
3. Therapeutic oxygen inhalation.
6. Visual disturbances, and
4. Sp. Ammon Aromaticus (stimulant haustus).
7. Loss of consciousness.
5. Glucose drinks.
Management of Vasovagal Shock 6. Injection dexamethasone if necessary.
7. Injection mephetemine sulphate is given in case of
Prevention fall of B.P.
a. Reassurance. 8. If the pulse is extremely weak, injection atropine
b. To achieve confidence of the patient with soft sulphate is given slow IV 0.6 mg diluted in 5 ml
conversation. distilled water till the pulse become palpable.
TWENTY-TWO
Cleft Lip and Palate

• Introduction • Classification • Embryology • Etiology • Anatomy • Clinical

Presentation • Management • Neonatal Care • Surgical Timing • Preoperative
Preparation • Anesthesia • Surgery • Secondary Surgery • Palatal Revision

Introduction Bilateral—Complete
Cleft lip and palate are the most commonly found —Incomplete
facial congenital anomaly, it constitute 80 percent of Midline—Complete
orofacial cleft. Cleft of the lip and palate may occur in —Incomplete
isolation or involve both lip and palate together. The 2. Cleft of Secondary Palate
incidence of cleft lip among Caucasians is higher than —Complete
the Africans, Europeans and Japanese. Incidence —Incomplete
among the Asians varies from 1 in 400 to 500 life-births —Submucus
and 1 in 1500 to 2000 among the Americans. However, 3. Cleft of both Primary and Secondary Palate
incidence of isolated cleft palate is similar among the Unilateral—Complete
races (0.50 in 1000 life-births). The left-sided cleft lip —Incomplete
has higher incidence than the right. But, the etiology Bilateral—Complete
is unknown. The cleft lip and palate have a higher —Incomplete
incidence among close relatives (Figs 22.1 to 22.11). Midline—Complete
—Incomplete
Classification
There are different methods of classification of cleft Embryology of Cleft Lip and Palate
lip and palate. Cleft lip may be complete or incomplete The face is developed from five processes as a result
and may be associated with cleft of the alveolus and of migration and proliferation of neural crest
palate (figure). The cleft of the lip anterior to incisive mescenchyme. The frontonasal process, a pair of
foramen is called the cleft of the primary palate. This maxillary process and a pair of mandibular arches
primary cleft palate may be unilateral or bilateral and
coalesce together around the stomodeum near the fifth
may be complete or incomplete (figure). The cleft
week of embryo to form the face. The formation of
passes entirely between the lateral incisor and canine
olfactory pits divides the frontonasal process into
teeth and passes in a V-shaped manner. Midline cleft
median nasal process and lateral nasal process. The
lip is a rare occurrence. The cleft of the palate posterior
lateral nasal process forms the alae of the nose. Median
to incisive foramen is called secondary palate. The cleft
nasal process extends caudally and forms bilateral
of the secondary palate may involve both hard and
elevations called globular process. The fusion of
soft palate. However, classification based on Kernahan
and Stark is simple and generally acceptable. globular process and maxillary process gives rise to
the formation of upper lip. The globular process fuse
Kernahan and Stark’s Classification in the midline to form philtrum. The triangular shaped
1. Cleft of Primary Palate area in front of incisive foramen and between the four
Unilateral—Complete incisor teeth constitute the premaxilla (primary
—Incomplete palate). The failure of fusion of the globular process
with the maxillary process or mesenchymal dehiscence
This chapter written by Prof D Basak, MS and Mch. gives rise to different types of cleft lip.
 Cleft Lip and Palate
153

Fig. 22.1: Incomplete cleft lip Fig. 22.2: Complete cleft lip (unilateral) Fig. 22.3: Bilateral cleft lip and
(unilateral) alveolus

Fig. 22.4: Incomplete cleft palate Fig. 22.5: Incomplete cleft palate Fig. 22.6: Complete cleft palate
and alveolus

Fig. 22.7: Complete cleft palate Fig. 22.8: Bilateral complete cleft palate with Fig. 22.9A: Millard repair of cleft lip
premaxilla and nasal septum showing the incision line

Fig. 22.9B: Repair completed with Fig. 22.10A: VY repair of cleft Fig. 22.10B: Repair of the palate
rotation of flap palate-showing the incision line in two layers with posterior
reposition of flap
 Synopsis of Oral and Maxillofacial Surgery
154

Fig. 22.11A: Furlow’s Z-plasty cleft palate Fig. 22.11B: Mobilization and reconstruction of flap by Z-plasty
repair—showing incision line

The palate develops from the primary palate (pre- association, it is imperative to search for other
palate) and secondary palate (palate). The wedge- congenital anomalies associated with cleft lip and
shaped primary palate developed from globular palate specially, in the head and neck. Chromosome
process gives rise to parts of the pre-maxilla, nasal tip abnormality Trisomy D syndrome may cause cleft lip
cartilage, nasal floor, lip, alveolus and triangular- and Wander Woud syndrome a genetic defect is
shaped anterior palate. The lack of mesenchymal associated with lower lip defect. Experimentally, cleft
development of the central or lateral processes leads has been produced in varieties of condition due to
to different varieties of prepalatal cleft. This is also deficiency of vitamin A, Folic acid, Pantothenic acid,
associated with hypoplasia of the maxillary structure. Riboflavin and Nicotinic acid. Cleft has also been
The structure posterior to incisive foramen gives rise produced by excess of vitamin A, hypoxia and
to secondary palate. In a seven-week embryo, palatal ingestion of various drugs like Nitrogen Mustard,
process develops from maxillary process, extends Nucleic Acid Antagonist, Corticosteroid and
from primary palate to tonsilar fossa, and hangs Irradiation during pregnancy. Maternal smoking and
vertically. Between the 8 to 9th weeks palatal shelve alcoholism have also been implicated for the
rotates from vertical position to horizontal position occurrence of cleft lip and palate. The unilateral cleft
due to straightening of the neck from flexed position lip in males has a higher hereditary background than
and dropping down of tongue, thereby separating the the incomplete cleft palate, which is more common in
oral from nasal cavity. The fusion of primary palate females and has a low hereditary background
and secondary palate takes place in a Y shaped manner suggesting different causes in the development of cleft
and the limbs of Y passes anteriorly between the lip and palate.
incisor and canine teeth. The ventral 3/4th of the
secondary palate ossified to form the hard palate and Anatomy of Cleft Lip and Palate
fuses with the nasal ceptum. Dorsal 1/4th of the
secondary palate does not ossify and hangs like a Cleft lip and palates are separate entities. However,
curtain to form soft palate. The cleft of the palate occurs cleft lip may be associated with cleft alveolus and cleft
due to failure of fusion of palatal processes or palate. Severity of the deformity depends on the
subsequent breakdown of mesenchymal structures. abnormal development of median nasal process and
The clinical sequence of cleft palate, glossoptosis and maxillary process. In minor degree of cleft lip the
mandibular hypoplasia as described by Robin is a deformity, involve the front nasal process. Due to
manifestation of early embryological defect. absence of restraining force of orbicularis oris alveolar
segment is displaced outwards and pre-maxilla is
Etiology flaired anteriorly. The alveolar gap varies from mild
The etiology of the cleft lip and palate is multifactorial to severe with varying degrees of collapse of alveolar
involving both genetic and environmental factors. No arch. In bilateral cleft lip the pre-maxilla shows
single gene has been implicated to the causation of marked protrusion giving a grotesque appearance.
facial cleft. The facial cleft has been associated with The teeth adjacent to the cleft are angled, distorted
varieties of genetic syndrome. Because of syndromic and lateral incisor may be absent. Nasal tip and
 Cleft Lip and Palate
155
columella are short with flattening of the alar cartilage be absent or even duplicated. Maxilla is hypoplastic
maxillary hypoplasia. In incomplete unilateral cleft and smaller and alveolus on the lateral side is at a
palate, nasal septum (Vomer) is attached to the uncleft lower level than the medial segment. Teeth on the
side of hard palate. In bilateral complete cleft lip and maxillary side becomes crowded and there may
palate, Vomer is free and septum hangs freely. The be occlusion difficulties due to mandibular
musculature of soft palate is distorted. Levator palati prognathism.
muscle is attached to the posterior age of the hard 6. Respiratory tract Nasal tip is depressed and
palate instead of being directed towards the midline. columella is short in cleft lip. Baby suffers from
Both the tensor and levator palati are attached to the recurrent upper respiratory tract infection due to
eustachian tube causing malfunctioning of the tube. the nasal regurgitation. Otitis media is common
The cleft palate is occasionally associated with due to the malfunctioning of eustachian tube and
retroposition of tongue and mandibular hypoplasia, hearing may be affected.
thus causing obstruction in the air passage and
abnormality in swallowing reflex as described in Management
Peirre Robins sequence. The aim of treatment of cleft lip and palate is to achieve
a. Normal appearance
Clinical Presentation b. Normal swallowing of feeds without
regurgitation
Cleft lip and palate presents with multiple clinical
c. Free airway passage
problems:
d. Normal phonation and
1. Facial deformity is the immediate concern to the
e. Alignment of teeth.
parents and causes psychological problem to the
The general care should be started in neonatal
mother. Parent should be properly guided and be
period to achieve the goal.
assured that the defect in her child is curable.
2. Sucking and eating Sucking of breast is not greatly Neonatal Care
affected in isolated cleft lip deformity as the infant
Feeding
takes the nipple and areola inside the mouth during
breast-feeding. However sucking is affected in case There is not much problems of feeding in babies with
of cleft palate as tongue cannot compress the nipple cleft lip though parents are worried about it. Feeding
against the cleft palate and negative pressure is not in a child with cleft palate is a definite problem as
created during sucking. There will be regurgitation infant is unable to suck properly due to the palatal
of feeds through the cleft palate. gap and there is regurgitation of feeds during
3. Respiratory obstruction Isolated cleft palate swallowing. However, the feeding can be maintained
deformity may cause airway obstruction in if milk is delivered at posterior part of the oral cavity
presence of Pierre Robins sequence due to the by specially created artificial nipple or spoon. Special
falling back of the tongue and retrognathia and type of feeding bottle or plastic bottle can be squeezed
may need immediate interference for oropharyn- to deliver the food at the back of the oral cavity. Baby
geal reflex to develop. also is to be held in 450 to prevent regurgitation of
4. Speech and phonation The complete speech feed.
mechanism is ensured by velopharyngeal closure. An orthodontist who can prepare a plate to cover
Voluntary contraction of soft palate aided by tensor the gap in the palate, which helps in facilitating the
and levator muscle compress the soft palate against feeding, should examine the baby. The base plate can
the nasopharynx and helps in the production of be secured in position to help in the growth of the
speech. Incomplete velopharyngeal closure is the hard palate. Apart from this intra, oral or extra oral
hallmark of the cleft palate. Nasal intonation is orthodontic appliances will be of great help to mould
acquired during production of vowel sounds in- the growth of alveolus and maxilla. Elastic head cap
patients with velopharyngeal incompetence and traction with elastic strapping for the projecting pre-
consonant sounds are distorted. maxilla is of utmost important procedure in new born
5. Teeth Alveolar cleft interfere with the develop- period. This makes the lip repair easy by decreasing
ment of incisor and canine teeth. The incisor may the gap between the lip and alveolus. The dynamic
 Synopsis of Oral and Maxillofacial Surgery
156
palatal appliances are also sometimes required for the oxymeter. The assay of Carbon dioxide in expired air
expansion of the collapse maxillary arches. Care is of added advantage. The specially designed angled
should be taken to secure free air-passage in case of endotracheal tube (RAE Tube) is fixed in the midline
Pierre Robins sequence where glossoptosis impeded of the chin and it facilitates the introduction of mouth
the swallowing reflex and causes airway obstruction. gag.
Specialized surgical technique may be required to
keep the tongue anterior and to prevent the falling Surgery
back the tongue.
Cleft Lip Repair
Surgical Timing
The numerous techniques have been evolved to repair
Cleft lip is traditionally repaired during 3 to 4 months the cleft lip. Early technique involves straight-line
of age. However, the lip is repaired after birth in some closure. However, the modern repair involves the use
centers. Rule of 10’s is a good guide for the lip repair- of lateral flap to fill the medial deficit. Lateral
10 weeks of age, 10 gram of hemoglobin and 10 pounds quadrilateral flap of Le Mesurier or Tennison’s
of weight. This conditions favour safe anesthesia, good triangular flap introduce tissue in the lower medial
wound healing, and the other congenital anomalies part to produce a pouting tubercle. However Millard
in child can be detected by this time. In unilateral cleft in 1955 described an advancement technique in which
lip and palate with wide gap, lip adhesion and lateral flap is advanced in upper medial portion with
simultaneous closure of soft palate is being practiced rotation of the medial segment (Figure). It preserves
in some centers between 6 to 8 weeks of age. Definitive the philtrum and cupids bow. This technique is easy
lip repair is done around 6 to 8 months. Cleft palate is and adjustment can be made during the repair and
usually repaired between 6 months to 18 months collumelar lengthening is appropriate, the tissue loss
depending on the growth of the baby and surgeons is minimum and scar is less promonent. In this
choice. Early repair seems to be results in better technique emphasis has also been given to the
speech outcome. However, repair may be delayed in mobilisation of the alar cartilage and repair of the base
babies with respiratory problems. Majority of cleft of the nose. In recent technique of repair of cleft lip
alveolus is repaired during cleft lip repair taking emphasis has also been changed from design of flap
mucoperiosteum flap from medial side. Wide alveolar to mobilisation and accurate functional closure of
gap may require bone graft between 5 to 6 years of orbicularies oris muscle and skin is closed by Z plasty
age. The anterior segment of the cleft palate is usually to avoid vertical closure. The critical factors for
repaired along with the repair of the cleft lip. evaluating the success of the unilateral complete cleft
lip repair are position of the alveolar segment and
Preoperative Preparation vertical height of the lateral lip segment. The pre-
surgical palatal expansion device is required in case
Elective surgical procedure is undertaken when the
of wide-collapse alveolus. The alveolar cleft is repaired
child is free from respiratory infection and attains a
by mobilisation of the mucoperiosteal flap from
good health. The upper respiratory infection is
medial segment. Associated anterior cleft palate is
controlled before the repair. A complete blood count,
repaired during the repair of cleft lip. The nasal
Prothrombin times are routinely done before
deformity is corrected mobilising the alar cartilage
operation. Culture from nasopharynx is carried out
depending on the severity of the deformity.
in case of repeated respiratory tract infections. Blood
Bilateral cleft lip repair involves multiple problems
grouping and cross-matching is done before the repair
of the shortening of the columella, protrusion of
of the cleft palate.
premaxilla and exflair of alar cartilage, which make
the lip repair different from unilateral cleft lip repair.
Anesthesia
Decision regarding the staged repair or bilateral repair
A safe endotracheal general anesthesia is a prerequisite in one sitting depending on the columellar length,
of repair of cleft lip and palate. This helps in better protrusion of premaxilla and alveolar gap. Millard
closure and reduces the postoperative complications. rotation flap augment the central prolabial vermillion.
Monitoring is done by electrocardiogram and pulse Recent technique concentrates on using the entire
 Cleft Lip and Palate
157
prolabium for central position. The Millard technique Lip and Nose
or modified Manchester technique (Straight line In spite of different methods of techniques of the repair
closure) can be used satisfactorily if the bilateral of cleft lip revisional surgery is required for scar
closure is contemplated. The alveolar closure and
contracture, vermillion realignment, philtrum
repair of the base of the nostril is done concurrently.
lengthening. Depressed nasal tip can be corrected by
In case of short columella, lengthening of columella is
cartilage graft. columellar lengthening can be done by
undertaken by V-Y Plasty at a later period.
V-Y plasty in cases of short columella.
Repair of Cleft Palate Palatal Revision
Controversies exist in the surgical treatment of the cleft The incidence of post-operative fistula is very high 10
palate repair regarding timing and technique of staged percent to 20 percent even in experienced hands. The
versus complete repair. Early repair has a better common site of fistula formation is anteriorly at the
influence on the speech and skeletal deformities. The junction with the pre-maxilla and posteriorly at the
basic goal of treatment is muscular closure of soft junction of the soft and hard palate. Different local
palate and closure of gap in the hard palate. This can flaps are created to close the fistula. However, buccal
be achieved by side-to-side closure across the cleft in mucosal flap or other distant flaps may be used
two layers by mobilizing the mucoperiostial flap and depending on the site and size of the fistula. In cases
relaxation incision along the alveolar margin to release of short palate with velopharyngeal incompetence
the tension in the suture line. The time old technique baby suffers from nasal intonation. Musculomucosal
of Von Langenbeck is a straightforward closure but flaps are taken from the posterior pharyngeal wall to
adequate palatal lengthening is not achieved. To lengthen the palate and to diminished the nasopharyn-
achieve the lengthening of the palate oblique anterior geal openings. This pharyngeal flaps can be taken
incisions are made on both side of the alveolar groove either superiorly or inferiorly based to repair with the
and mucoperiosteal flaps are mobilised from the hard posterior palatal margin. This technique is improved
palate, the levator muscles are separated from free age the nasopharyngeal incompetence and diminished the
of hard palate and the muscles are closed in the air-leak via the nasopharyngeal openings.
midline. The palatal flaps are pushed back and
repaired in V-Y arrangement. This technique of Veau- FURTHER READING
Wardill Kilner repair helps in achieving the length of 1. American Cleft Palate-Craniofacial Association. Parameters
the short palate. The addition of Z plasty in the short for the evaluation and treatment of patients with cleft lip/
palate helps in the gain of additional length. Two Z palate or other craniofacial anomalies. Cleft Palate
plasties described by Furlow are made in the oral and Craniofacial J 1993;30(Suppl 1):4.
2. Brauer RO, Cronin TD. The Tennison lip repair revisited.
nasal side of the muscular and mucus tissue. The
Plast Reconstr Surg 1983;71:633.
palatal length is gained with the reconstitution of 3. Byrd HS. Cleft Lip. In: Smith JW, Aston SJ (Eds). Grabb &
muscle and mucosa of the soft palate. In huge gap the Smith’s Plastic Surgery (4th edn) Boston, Little Brown and
palate can be repaired taking flap from the tongue and Company. 1991;271.
Buccal mucosal flap. 4. Clarren SK, Anderson B, Woef LS. Feeding infants with cleft
lip, cleft palate or cleft lip and palate. Cleft Palate J
1987;24:244.
Secondary Surgery
5. Cohen MM, Jr. Syndromes with cleft lip and palate. Cleft
Palate J 1978;15:306.
Alveolar Gap
6. Davis D. The one stage repair of unilateral cleft lip and
The alveolar gap is generally repaired concurrently palate. Plast Reconstr Surg 1966;38:129.
with the cleft lip repair. But in case of huge gap bone, 7. Dorf DS, Curtin JW. Early Cleft palate repair and speech
grafting is required to fill up the gap. The autologus outcome. Plast Reconstr Surg 1982;70:74.
8. Fara M, Dvorak J. Abnormal anatomy of the muscles of the
bone graft (Rib) or costal cartilage is undertaken at
palato pharyngeal closure in cleft palate. Plast Reconstr Surg
five to six years of age. This procedure helps in the 1970;46:488.
closure of residual oronasal fistula and provides 9. Fraser FC. Etiology of the cleft lip and palate. Am J Hum
support for the subsequent eruption of teeth. Genet 1970;22:125.
 Synopsis of Oral and Maxillofacial Surgery
158
10. Furlow LT Jr. Cleft Palate repair by double opposing Z 19. Nicolau PJ. The orbicularis oris muscle. A functional
Plasty. Plast Recnostr Surg 1986;78:724. approach to its repair in the cleft lip. Brit J Plast Surg
11. Furlow LT. Double reversing Z plasty for cleft palate. In: 1983;36:141.
DR Millard (Ed), Cleft Craft, Vol. 3: Alveolar and palatal 20. Randall P, LaRossa D. Cleft Palate. In: Smith JW, Aston SJ
deformities. Boston: Little Brown, 1980 (Eds) Grabb and Smith’s Plastic Surgery (4th edn). Boston,
12. Jone MC. Facial clefting; etiology and developmental Little Brown and Company. 1991;281.
pathogenesis. Clin Palst Surg 1993;20;599. 21. Sadove AM, Eppley BL. Cleft lip and palate. In: O’Neil JA
13. Kernahan DA, Bauer BS. Functional cleft repair: A (Jr), et al. Pediatric Surgery (5th edn). St. Louis: Mosby,
sequential, layered closure with orbicularis muscle 1998;693-700.
alignment. Plast Recnostr Surg 1983;72:459. 22. Sedove AM, Eppley BL. Timing of alveolar bone grafting: a
14. Kernahan DH, Stark RB. A new classification for cleft lip surgeons view points. Prob Plast Recnostr Surg 1992;2:39.
and cleft palate. Plast Reconstr Surg 1958;22:435. 23. Stark RB. The pathogenesis of hare lip and cleft palate.
15. Kraus O. Anatomy of the velopharyngeal area in cleft palate. Plast Reconstr Surg 1954;13:20.
Clin Plast Surg 1975;2:261. 24. Tennison CW. The repair of unilateral cleft lip by stencil
16. LeMesurier AB. Method of cutting and suturing lip in method. Plast Reconstr Surg 1952;9:115.
complete unilateral cleft lip. Paslt Reconstr Surg 1949;4:1. 25. Watson ACH. Classification of cleft palate. In: Edward M
17. Millard DR, Jr Cleft craft: The evolution of its surgery, The and Watson ACH (Eds), Advances in the management of
bilateral and Rare deformities. Boston: Little Brown 1977;2. cleft palate. Edinburgh, Churchill Livingstone, 1980.
18. Millard DR. Bilateral cleft lip and a primary forked flap. In:
Millard DR (Ed) Cleft Craft, the Bilateral Deformity. Boston:
Little Brown, 1980;3.
 TWENTY-THREE
Dental Emergencies

• Emergency Drugs • Emergency Kits • Various Emergencies

The medicine, which are used as emergency drugs are Syncope: Factors responsible are:
as follows. • Anxiety
• Therapeutic oxygen • Pain
• Nitrous oxide (very useful analgesic following MI) • Injection
• Adrenaline injection (1:1000 or 1 mg/1 ml) • Fatigue
• Hydrocortisone injection (100 mg), injection • Empty stomach
decadron Clinical features include pale, perspiration, moist skin,
• Antihistamine tablets and injection (e.g. injection dizziness, weakness or nausea and gradually loss of
avil) consciousness.
• Diazepam 5 mg/10 mg (injection valium)
• Flumazenil injection (100 ug/ml.) Preventive treatment includes assurance, diazepam
• Glucose (50% solution) for injection, and powder 5 mg half an hour before surgery and on the night
for oral use before the surgery.
• Glucagons injection (ideally) 1 mg • Therapeutic measures supine position of the
• Atropine injection (100 ug/ml) patient flashing the face with cold water.
• Colloid solution for infusion (e.g. Haemaccel, • Therapeutic oxygen at 10 L flow/min.
plasma expander blood substitute) • Administer spirits of ammonia.
• Monitor and record vital signs.
• Reassure patient.
Emergency Kits
In case of low blood pressure and pulse start
• Portable defibrillator (incorporating ECG print- 5 percent dextrose and lactated Ringer’s by
out) intervenous route.
• Portable oxygen delivery system Administered a vasopressor epinephrine 0.3 to
• Ambu bag (self-inflating with valve and mask) 0.5 mg. SC/IM route. In case of slow pulse < 60 beats
• Oropharyngeal airways (sizes 1,2 and 3) per minute administer 0.4 mg. atropine IV route to
• Cricothyroid puncture needless increase heart rate.
• High volume aspiration with suction catheters and
Cardiac Arrest
Yankauer sucker
• Disposable syringes (2,5,10 and 20 ml sizes) Sudden loss consciousness and absence of arterial
• Needles (19,21, and 23 gauge) and butterflies pulse (the carotid arterial pulse) with avascular
• Tourniquet, sphygmomanometer and stethoscope surgical field, dialated pupils with cyonosis.
• Venous access cannulae (‘venflons’ 16 and 22 Management includes inform immediate for emer-
gauge) gency support. Establishment of airway inflates lungs
• IV infusion sets with mouth-to-mouth resuscitation. If carotid pulse
• ‘BM sticks’ (for rapid assessment of blood sugar is absent compress sternum 1 to 2 inches (2 – 3) finger
levels). widths above xiphoid process.
The emergencies may initiate during dental In case of low blood pressure and pulse start 5
procedure. The various emergencies may have to be percent dextrose and lactated Ringer’s by intervenous
faced summarized as below: route.
 Synopsis of Oral and Maxillofacial Surgery
160
Administered a vasopressor epinephrine 0.5 to • Myocardial infarction likely if breathlessness,
1 ml. 1:1 thousand is may be repeated every 5 minute. nausea, vomiting, loss of consciousness, weak/
In case of slow pulse < 60 beats per minute administer irregular pulse and hypotension accompany pain.
0.5 mg may be repeated every 5 minute atropine IV
route to increase heart rate. Management
Medical emergency consultancy absolutely
• Give patient’s own antiangina medication, e.g.
mandatory to combat to above mentioned acute
GTN spray or tablet sublingually
problems.
• Wait 3 minutes and repeat if necessary, then
The problems or emergency and management
assume MI.
related to bleeding as well as various shock already
• Send emergency message for medical assistance
discussed in detail in Hemorrhage and Shock chapters.
• Do not lie flat as this increases feelings of
Collapse of diabetic patient in dental chair maybe breathlessness and panic
due to hyper glycaemia (excess sugar in the blood or • Administer nitrous oxide and oxygen (50/50) as
hypo glycaemia less sugar in the blood). These two pain relief
features represent by the following signs and • Obtain venous access in case CPR is required
symptoms: • Establish verbal encouragement of patient
Hyperglycemia Hypoglycemia • Administer oral aspirin (one tablet) as anti-platelet
agent
Blood sugar high Blood sugar low
Slow onset Rapid onset • Urgent transfer to hospital.
Drowsy and disorientated Aggressive behaviour Asthma: Predisposing factors are anxiety, tension. The
Dry skin Moist skin respiratory tract hyper reactivity consequently
Deep, laboured breathing Normal or rapid breathing
bronchospasm.
Usually, the diabetic patient have often severe
Clinical features dyspnea, wheezing, panic and fear,
artherosclerosis and consequently prone to IHD. The
restless with inability to speak.
collapse may be due to a myocardial perspective.
Hyperglycemia may result form excessive insulin Management
consumption or a missing a meal associated with
excitement and anxiety attending the dentist, stress • Give reassurance but do not crowd the patient
or changing insulin requirements due to dental • Allow the patient to use his/her own inhaler or
infection. supply a salbutamol inhaler
Management includes: • The patient should assume the most comfortable
• The conscious administer oral glucose position (usually erect)
• The supine position of the patient. • Give nebulized salbutamol (2.5 mg) if a portable
• If unconscious and uncooperative nebuliser is available. Otherwise use high flow
• Obtain venous access oxygen and deliver sulbutamol (6 – 8 actuations)
• Administer 50 ml of glucose IV or 1 mg glucagons into the oxygen mask and allow the patient to
IM breathe this mixture
• Urgent transfer to hospital. • Continue high flow oxygen and repeat the above
• Obtain IV access and give hydrocortisone 100 to
Acute chest pain: This is usually mhyocardial (but 200 mg IV
exclude collapsed lung or pulmonary embolus). • Urgent transfer to hospital.
Differential diagnosis: Adrenal crises may be initiated during surgical pro-
• Angina pectoris cedure in those patients are not covered prophylactic
• Myocardial infarction (MI). corticosteroides is not given. It is usually seen the long-
Symptoms and signs: term steroid users in case of asthma rheumatic disease
• Severe, crushing retrosternal pain (‘heavy, and inflammatory bowel disease.
crushing or constricting’) The clinical features include pallor of skin, rapid
• Radiations to arm, neck or jaw with pulse, low blood pressure and subsequently
• Angina normally relieved by GTN tablet or spray rapid loss consciousness.
 Dental Emergencies
161
Management includes preventive, prophylaxis Management
steroid.
Therapeutic supine position and raise the legs. • Injection Diazepam 10 to 20 mg IV
Therapeutic oxygen with steady flow. • Therapeutic oxygen with high flow
Injection decadron IV urgent transfer to hospital • Check blood sugar
and assess for other cause of collapse. Example – • Urgent transfer to hospital.
myocardial infraction. Accidental inhalation of foreign bodies: In supine
Epilepsy may present by various forms. A properly dentistry inhaled foreign bodies are hazard problems.
controlled patient with epilepsy does not create The precautions and preventive measures may avoid
problems to the dental surgeon. these problems. The simple coughing does not
Predisposing factors includes stress, anxiety, dislodge the offending article. The Heimlich maneuver
fasting, hypoglycemia and fainting and all cause a fit helps the problems, the patient is encircled by your
in the surgery. arms from behind at the level of the lower border of
Tonic-clonic seizures are often preceded by an aura, the rib cage; a sudden forceful squeeze is exerted by
followed rapidly by loss of consciousness and a rigid, pulling your arms together with the hands directed
extended body (tonic phase) and jerking or flailing upwards towards the chest. With small children,
movements (clonic phase). Postictal drowsiness and swinging the patient around by the legs may be
the desire to sleep follow. Most fits last less than 5 sufficient to dislodge the article.
minutes and require no intervention except protecting Where the article is lying at the laryngeal inlet, a
the patient from self-inflicted damage. Where the fit cricothyrotomy may allow breathing until the
is prolonged or repeated, status epilepticus results and obstruction can be physically dislodge. In all cases, a
intervention is required to prevent brain hypoxia. follow-up chest X-ray is mandatory.
TWENTY-FOUR
AIDS and Oral Surgery

• Etiology of AIDS • Dental Importance and Consequences • Oral Manifestations

of AIDS

ACQUIRED IMMUNODEFICIENCY Group II

SYNDROME (AIDS)
Atypical ulceration: HIV associated salivary gland
Etiology disease (HIV-SGD); Xerostomia and/or swelling of the
major salivary glands; necrotizing ulcerative
Retrovirus identified as the human T lymphotropic stomatitis; thrombocytopenic purpura.
virus III (HTLV – III).
Viral infections: Cytomegalovirus; Herpes simplex
virus; Human papillomavirus; Varicella zoster.
DENTAL IMPORTANCE AND CONSEQUENCES
• Bleeding tendency Group III
• Breathing difficulty Bacterial infection: Drug reactions, Fungal infections.
• Inhalation anesthesia risk.
Neurological disturbances: Facial nerve palsy,
trigeminal neuropathy.
Causes of Consequences
1. Some patients with AIDS experience idiopathic Laboratory Investigation
thrombocytopenic purpura. The enzyme-linked immunosorbent assay (ELISA
2. Dyspnea evolves as a consequence of chronic Test).
pneumocystis pneumonia and may pose a risk for Western blot analysis.
inhalation anesthesia.
The oral manifestations of AIDS are summarized Erythematous and Pseudomembranous Candidosis
as follows:
Group I: Lesions strongly associated with HIV Most commonest oral fungal infection with all the
features present association with HIV infection.
infection.
Erythematous candidosis seen early in the disease
Group II: Lesions less-commonly associated with HIV
process whereas pseudomembranous candidosis seen
infection.
in later stage when immunodepression is severe. Both
Group III: Lesions seen in HIV infection.
forms are highly predictive of the development of
AIDS.
Group I
Hairy leukoplakia: Usually asymptomatic characte-
Candidosis: Varieties available – erythematous; rized by bilateral vertically corrugated white patches
pseudomembranous, angular cheilitis, median on the lateral margins on the term. It is considered to
rhomboid glossitis. be pathognomonic of HIV infection.
Hairy leukoplakia: Kaposi’s sarcoma, non-Hodgkin’s Diagnostic features include detection of presence of
lymphoma. EBV within the lesional tissues by in situ hybridi-
Periodontal disease: Liner gingival erythema, acute zation.
necrotizing ulcerative gingivitis, acute necrotizing Koposi’s sarcoma: KS is mainly seen in the elderly
ulcerative periodontitis. person almost exclusively in male homosexuals and
 AIDS and Oral Surgery
163
rare for among other risk categories for HIV infection. pain, bone loss, tooth mobility and periodontal
Presents as rate or purple maculopopular lesions. pocketing.
Commonest site the junction of hard and soft palate.
KS is usually very responsive to radiotherapy HIV salivary gland disease: More common in HIV
alternative measures includes chemotherapy infected children than adults. Characterized by
(systemic and interlesional), surgical excision and laser xerostomia and/or swelling of the major salivary
cryosurgery. glands. Clinical parallels with Sjögren’s syndrome
although characteristic autoantibody profile is lacking.
Non-Hodgkin’s lymphoma: Uncommon may present Histological features similar to Sjögren’s syndrome.
as rapidly enlarging, firm rubbery lump. Intraoral sites Some important surgical dictum for treating HIV
include fauces, palate and gingivae. Lesions maybe patient in oral surgical clinic:
ulcerated associated with destruction of tooth support. 1. Consult and clearance from medical specialist prior
Treatment includes radiotherapy and chemo- to surgery.
therapy. 2. Keep the patient last of the list in case of minor
Liner gingival erythema: Characterized by an intense oral surgery.
linear band of erythema along the gingival margin, 3. In case of major surgery keep the patient without
which may also extend onto the attached gingivae. any appointment to other patients on that
Severity of inflammation is out of proportion to the particular date.
state of oral hygiene. Spontaneous gingival bleeding 4. Careful about use of sharp instrument, disposable
may also be a feature. needle and syringe, suture needle with thread and
SS Wire for wiring.
Acute necrotizing ulcerative gingivitis: Characterized
5. Careful about destruction of disposable gauge,
by gingival pain, bleeding on probing or spontaneous
cotton, syringe, needle, blade, sucker tube and
bleeding and interdental ulceration with craterlike
disinfection of oral surgical room.
defects.
6. Operator as well as assistant careful about
Acute necrotizing periodontitis: Rapid localized or precautionary measures during and after treating
generalized periodontal destruction with severe this sort of patient.
TWENTY-FIVE
Maxillofacial Trauma and Management

• Introduction • Healing of Jaw Fractures • Maxillofacial Injuries • Maxillofacial

Trauma • Complication of Maxillofacial Injuries • Dentoalveolar Injuries
• Mandibular Fractures • Condylar Fractures • Fracture of Zygomatic Complex
• Mid-face Injury Including the Middle-Third Fractures of the Facial Skeleton
• Fracture of Nasal Bone and Nasoethmoidal Injuries • Blowout Fractures
• Superior Orbital Fissure Syndrome

INTRODUCTION HEALING OF JAW FRACTURES

Fracture may be defined as breach of continuity of Bleeding at the site of fracture → formation of hema-
bone due to trauma or injury, which may be incomp- toma → formation of clot → formation of fibrous tissue
lete or complete. Difference between facial bone → the broken ends of the bone are united by the
fracture and other bones of human skeleton in three collagenous fibers called fibrous or temporary callous
important parts: → immature callous replace by the mature callous
1. Risk to the airway—directly compromised. known as secondary callous → in secondary callous
2. Presence of teeth, which helps the stabilizing, transform into bone or osteoid tissues → the excess
fractures. bone is reabsorbed and the normal outline achieve,
3. Excellent vascular supply of facial bones, which the process known as remodeling.
promotes rapid healing.
The facial bone may be divided into three parts: Factors which Delay Healing
a. Lower-third mandible, Local
b. Middle-third maxilla and allied bones, and
c. Upper-third, frontal, temporal and parietal bones. • Infection
Previously, the oral surgical trauma pertaining to • Foreign bodies
middle-third and the lower-third of the facial skeleton. • Mobility
But after the reported study of Pape K of Germany of • Poor vascularity – irradiation.
extended Lefort fracture drew attention to the problem Systemic
associated with anterior cranium. Downward
displacement of the frontal bone precludes adequate • Increasing age
reduction of the middle-third of the face. The frontal • Disease, e.g. diabetes
bone and orbital roof must then be reduced prior to • Deficiency, e.g. malnutrition.
reduction of the facial bone. The extended Lefort
Applied Surgical Anatomy
fracture exposed via coronal scalp flap (cited from
Peter Bank). We have already discussed the face is divided into
The displacement of the fracture will depends on: three parts—lower-third is the mandible and the
a. Degree and direction of force. muscles and the soft tissue which covered. The
b. Point of impact. middle-third is bounded below the occlusal line of the
c. Type of injury—blunt or sharp. maxillary teeth and above by a line drawn through
d. Muscular pull—particularly important in the the pupils of the eye. The upper-third lies above.
mandibular fracture. The mandible or the lower-third of the facial
e. Presence or absence of teeth in both fragments. skeleton, prone to fracture sites are the condylar neck,
 Maxillofacial Trauma and Management
165
the angle the canine region. The condyle may fracture Presentation
via thin neck either within the capsule or outside the
a. Pain.
capsule. It maybe unilateral or bilateral. Fractures of
b. Swelling.
the coronoid process are most uncommonly seen.
c. Tender on palpation. Loss of function, e.g. trismus,
The angle of the mandible is a weak part because
limited eye movement causing double vision.
there is a change in direction of the grain of the bone
d. Malocclusion.
which occurs where the vertical ascending ramous
e. Altered sensation – nerve damage.
and the horizontal body meets. The impacted third
molar may occupied two-thirds of the depth of the Background
bone.
The body is the strongest part of the mandible but a. Time of injury.
is weakened by the presence of the tooth alveolar b. Mode of injury.
socket of which the canine is elongated root and the c. Loss of consciousness.
socket is very prone to fracture. d. Treatment prior to admission.
Middle-third of the facial skeleton composed of
various bones of which includes: Medical History
a. Two maxillae. a. Allergies.
b. Two zygomatic bones. b. Drugs, e.g., insulin, steroids, anticoagulants.
c. Two zygomatic process of temporal bones. c. Illnesses—past and present.
d. Two palatine bones. d. Previous surgery.
e. Two nasal bones. e. Smoking and alcohol intake.
f. Two lacrimal bones.
g. The vomer. General Assessment
h. The ethmoid and its attached conchae.
i. Two inferior conchae. a. Airway.
j. Pterygoid plates of the sphenoid. b. Shock.
The spaces between the buttresses are closed by c. Hemorrhage.
thin bone plates which enclose several large cavities, d. Level of consciousness.
the maxillary air sinuses, the nasal cavity, and the e. Overt infection.
orbits. The base of the complex is strengthened by the
alveolar bone the plate. These varieties of construction Clinical Examination
provide resistance to upper force but very little stress a. Lacerations.
to combat from a horizontal blow. b. Swelling.
c. Ecchymosis.
Clinical Features of the Maxillofacial Injuries d. Visible or palpable deformity.
e. Abnormal mobility and crepitus.
Etiology
f. Palpable tenderness.
a. Assaults—most common in western society. g. Impaired function, e.g. trismus, diplopia.
b. Road traffic accidents—most common in deve- h. Malocclusion.
loping nations. i. Nerve injury.
c. Sports injuries.
d. Falls. Radiographic Investigations of
e. Industrial accidents. Maxillofacial Injuries
Plain X-rays must be taken in at least two planes at
Predisposing Factors right angles to each other.
a. Alcohol.
Standard Projections
b. Epilepsy.
c. Bone pathology, e.g. cysts, tumors. Orbits and antra–occipitomental 15 and 30 degrees.
 Synopsis of Oral and Maxillofacial Surgery
166
Maxillary Bones Treatment Priorities Includes the
Above in Addition to
• Occipitomental 15 and 30 degrees
• Lateral skull. a. Relief respiratory obstruction.
b. Cardiac arrest.
Zygomatic/Malar Bones c. Control of massive bleeding if present.
• Occipitomental 15 and 30 degrees Treatment Require Urgently
• Submento-vertex.
a. Intra-abdominal bleeding.
Mandible b. Head injuries-significant head injuries, deterio-
ration.
• Posteroanterior of mandible c. Chest injuries.
• Orthopantomogram d. Compound fractures of limbs.
• Right and left lateral obliques.
TREATMENT THAT CAN WAIT:
Frontal Bones MAXILLOFACIAL TRAUMA
• Occipitomental 15 and 30 degrees Treatment of Soft Tissue Injuries
• Lateral skull
• Brow-up lateral skull. a. Tetanus prophylaxis.
b. Antibiotics.
Other Projections Sometimes Used c. Irrigation with normal saline or povidone iodine
solution.
• Dental/intraoral films d. Debridement—careful removal of severely
• Tangential skull views—soft tissues for contused tissue and foreign bodies.
emphysema or a foreign body—depressed e. Haemostasis (local application of styptic solution).
fractures f. Primary closure—infiltrate local anesthetic solution
• Transcranial and transpharyngeal views of via the wound and then accurately approximate
temporomandibular joint freshened wound edges with careful suturing to
• CT scans—complex midface fracture, e.g. naso- minimize scarring.
ethmoidal fractures—three dimensional recons- g. Skin loss—avoid secondary healing of facial
truction, coronal views for blowout fractures. wounds: 1) Undermine skin edges and advance;
2) Skin grafts; 3) Local flaps; 4) Suture skin to oral
Other Important X-rays mucosa – gunshot wounds.
• Cervical spine—to show fractures: Lateral,
Transoral view of odontoid pet GENERAL PRINCIPLES OF
• Chest—for chest injury or aspiration: Postero– FRACTURE TREATMENT
anterior, lateral. a. Debridement
b. Reduction:
Principles of Management 1. Closed manipulation
2. Traction
Immediate Intervention
3. Open reduction.
a. Establish and maintain airway with care of cervical c. Fixation:
spine. 1. External:
b. Establish the patient breathing, if necessary i. External pin fixation
intubate oxygen. ii. Halo frames
c. Control arrest bleeding, management of conse- 2. Internal:
quence of bleeding and trauma (shock if present). i. Non-rigid: suspension wiring; circum-
d. Examination of injuries if possible temporary mandibular wiring; transosseous wiring;
immobilization of suspected fracture. intramedullary pins
e. Prophylaxis control of infection by suitable ii. Rigid: adaptational—plates or bicortical
antibiotics and relief of pain (avoid suggestion). screws; compression—plates or lag screws
 Maxillofacial Trauma and Management
167
d. Immobilization: Intermaxillary fixation. Infection
e. Functional rehabilitation.
Causes of Fracture Site Infection
Specific Injuries Requiring Specialist Attention a. Compound injury.
a. Eyes and eyelids. b. Foreign bodies.
b. Nasolacrimal apparatus—severed ends must be c. Devitalized teeth.
realigned and splinted internally with fine silastic d. Pre-existing oral infection—e.g. diabetes, steroids,
tubing. anemia.
c. Parotid duct—alignment and suturing. e. Radiotherapy—previous treatment.
d. Facial nerve—repair in case of proximal injuries. The role antibiotic therapy in maxillofacial injuries
e. Bites—human bites have high infection rates and as follows:
should only be loosely sutured. a. Intraoral breach—Amoxycillin and metronidazole.
f. Gunpowder and grease injuries. b. Involvement of skin cephalosporin, in case of local
application needed for the skin, soframycin
COMPLICATION OF MAXILLOFACIAL INJURIES ointment or nebasulf powder maybe used.
c. In case of contaminated wound—Amoxycillin and
Problems Related to Healing of Fracture metronidazole.
d. CSF leak-antibiotic which crosses blood—brain
Mal union: Mal position of fracture fragments due to
barrier includes sulphadimidine, septran and
inadequate reduction and fixation.
cephalosporin.
Management may need osteotomy in future to
correct.
Dentoalveolar Injuries
Delayed union: Disturb and prolong healing process,
example, resulting from localized and systemic factors. Predisposing Factors

Non-union: No bony healing at all. a. Trauma.

b. Fall mainly in the stair case of the village ponds
COMPROMISED AIRWAY due to slippage.
c. Accidental injury to the chin by the tube well
Causes handle.
d. Females are affected more than the male.
a. Inability to open the mouth.
e. Inter personal violence.
b. Gross edema of the tongue and the floor of the
f. Cycling.
mouth.
g. Epiletic and handicapped patient.
c. IMF.
d. Lying on back—allows tongue to obstruct
Classification
oropharynx.
e. Aspirate loose debris and tooth fragments if any. Ellis classified dentoalveolar injury involving tooth
f. Blocked nasal and oropharyngeal tubes. or teeth.
Class – I fracture: A fracture of only the enamel cap
Management of Compromised Airways
of the crown of the tooth.
a. Patient positioning: Management: Enameloplasty and/or bonding.
1. Conscious—sitting up and leaning forwards.
2. Unconscious—recovery position with chin lift. Class – II fracture: An injury extending into the
b. Airways—oropharyngeal or nasopharyngeal dentine but with no exposure of the pulp.
tubes. Management: Dentin coverage with calcium
c. Endotracheal tube. hydroxide and bonded restoration or reattachment of
d. Cricothyroidotomy—for complete airway obs- fractured segment.
truction.
Class – III fracture: An extensive injury to the coronal
e. Tracheostomy—especially with chest and head
portion of the tooth with a pulp exposure.
injuries.
 Synopsis of Oral and Maxillofacial Surgery
168
Management: Pulp therapy via pulp capping or Investigation includes X-rays—periapical occlusal,
partial pulpotomy. OPG, examination of soft tissue particularly lips to
Class – IV fracture: A fracture occurring at or below see any foreign bodies, tooth fragments.
the cementoenamel junction of the tooth. Chest X-ray includes any aspirated tooth or tooth
fragments.
Management: If the fracture is supragingival, remove
the coronal segment and perform appropriate pulp Management includes stabilizing tooth or teeth along
therapy, then restore. If the fracture is subgingival, with the alveolar bone by splint or periodontal wiring.
remove the coronal segment and perform appropriate Control of bleeding by sutures.
pulp therapy, the reposition the remaining tooth Relief of pain by suitable analgesic anti inflam-
structure coronally either orthodontically or matory usually injection Voveran, IM Stat and suitable
surgically. The surgical approach results in loss of antibiotic for prevent infection specially Amoxycillin
pulpal vitality and therefore requires a pulpectomy. 500 mg. three times daily, Metronidazole 400 mg. two
Haily classified the changes of the tooth within the times daily for five to seven days.
socket and its surroundings, which again modified by Suitable antiseptic mouthwash specially chlor-
George Dimitroulis on the basis of impact of injury. hexdine after each semi solid meal.
Haily classified the traumatic displacement of a In case of the fracture tooth and teeth and exfoliated
tooth from the socket alveolar socket and the dentoalveolar fragments
a. Luxated that means the tooth has been loosened totally detached from the surrounding it is better to
and move. remove the fragments along with the teeth.
b. Avulsion means the tooth has been displaced from Trimming of the bone and toileting of the wound
the apical region from the socket towards occlusal and placement of sutures followed by the above-
plane. mentioned medicine.
c. Intrusion -tooth has been intruded into the alveolus Mandibular Fractures: Surgical anatomy already
d. discussed in previous chapter.
d. Exfoliation that mean tooth totally removed from
the socket. Classification of Mandibular Fracture on the
Basis of Anatomical Consideration (Fig. 25.1)
Dimitroulis Summarized the Injuries as
Condylar neck 35%
a. Concussion—compression injury to periodontal
Angle 20%
membrane with tooth retained in original position.
Body 20%
b. Subluxation—tooth partially displaced from socket
Parasymphysis 13%
without injury to socket walls.
Symphasis 11%
c. Displacement—tooth partially displaced from
Coronoid 1%
socket with associated injury to alveolar walls.
d. Avulsion—complete loss of tooth from socket.
However, above classification is the recent one but
present author prefer Haily classification cited from
Kruger substantive and transparent.
The alveolar bone injuries, which includes
crushing, or compression associated with tooth
displacement and fracture alveolus. The injuries to the
gingiva include contusion, abrasion and laceration.
Clinical features: Tooth sensitive to hot and cold;
bleeding; mobility of tooth or teeth with fracture of
tooth and alveolar bone; mal position of the tooth and
bony fragments. Fig. 25.1: Various types of mandibular fractures
 Maxillofacial Trauma and Management
169
Rowe and Killey also classified on the basis of Greenstick fracture: A fracture in which one cortex
anatomical location of the bone is broken with the other cortex being bent.
a. Fractures not involving the basal bone – are termed It is an incomplete fracture seen in the children.
as dentoalveolar fractures.
Pathological fracture: Spontaneous fracture of the
b. Fractures involving the basal bone of the mandible.
mandible result from mild injury due to pathological
Subdivided into following:
disease process.
i. Single unilateral.
On the basis of potential injury to the mandible
ii. Double unilateral.
classified as
iii. Bilateral.
a. Horizontally-favorable or unfavorable.
iv. Multiple.
b. Vertically-favorable or unfavorable (Fig. 25.2).
Kruger classification of mandibular fracture: Simple
or closed. The linear fracture which does not have LINDAHL, 1977 CLASSIFIED
communication with the external surface. It may or THE CONDYLAR FRACTURES (Fig. 25.3)
may not be displaced. Fracture of the condyle,
A. Fracture Level (Fig. 25.3)
coronoid process, ascending ramous are the examples
of these categories. The three levels at which fracture of the mandibular
condyle may be seen:
Compound or open: This fracture has communication
1. Condylar head (intracapsular), which maybe
with external surface via the mucosa, periodontal
vertical, compression, and comminuted.
membrane and the skin. All the fractures involving
2. Condylar neck.
the tooth bearing area of the mandible belongs to these
3. Subcondylar that means below the condyle.
categories. There is extraoral and intraoral wound is
present. B. Relation of Condyle to Mandible
Comminuted: A fracture in which the bone is crushed 1. Non-displaced—linear fracture.
or shattered into multiple pieces. The high velocity 2. Deviated.
impact usually gun shot wound or missile injury. 3. Displaced maybe medial or lateral overlapping.
Complicated or complex: The fractures associated 4. Anterior/posterior overlapping.
with the damage to the important vital structures 5. No bony contact.
which may be involvement of the nerves of mandible
and the facial skeleton and the facial vessels, condylar C. Relation of Condyle to Glenoid
fractures with involvement to middle cranial fossa. Fossa of Temporal Bone

Impacted: Rarely seen in the mandible. 1. Non-displaced.

2. Displaced—condylar head still related to glenoid
fossa.

Fig. 25.2: Effects of muscle pull for mandibular fracture. Arrows

indicate the direction of the muscle pull.
(a) Horizontal view of mandible showing horizontally-favorable
fracture (dotted line) and horizontally-unfavorable fracture
(continuous line). (b) Vertical view showing vertically-favorable
(dotted line) and unfavorable (continuous line) fractures Fig. 25.3: Fracture level
 Synopsis of Oral and Maxillofacial Surgery
170
3. Dislocation—condylar head completely out of 2. Persistent—malocclusion or severe pain – A short
glenoid fossa and lies anteromedial. period of intermaxillary fixation (7-10 days) until
edema and muscle spasm disappear.
Clinical Features 3. Bilateral fractures—A longer period of inter-
maxillary fixation (3-4 weeks) with posterior
Fracture Unilateral Condyle distraction blocks e.g., Stent compound, acrylic
Affected side wedges. Elastic traction may be necessary to close
a. Pain in joint, worse of movement. anterior open-bite very much effective measures.
b. Tenderness on palpation and swelling.
c. Absence (or abnormality) of movements of the Surgical Indications
condyler head. 1. Compound and comminuted fractures.
d. Deviation of the mandible towards this side. 2. Condylar displacement including fracture—
e. Gagging of molar teeth. dislocations with gross occlusal disruption.
3. Multiple facial fractures where mandible is used
Opposite side
to stabilize mid-face.
a. Open-bite.
b. Limitation of lateral excursion to that side. Surgical Approaches
1. Preauricular Rowes modified.
Clinical Features of Fracture Bilateral Condyle 2. Submandibular Risdon’s incision.
a. Pain. 3. Intraoral difficult approach.
b. Tender of palpation and swelling over the both TM Reduction: Difficult to reposition because of the
Joint areas. muscular attachment.
c. Posterior teeth gagging and an anterior open bite.
Fixation: Wires, plates, pain and sutures (Fig. 25.4).
d. Restricted lateral movements.
e. Absence of movement of condyle heads. Conservative vs surgical approach: On the pers-
1. Temporomandibular joint effusion/hemarthrosis pective of famous study of Walker of United States in
a. Ipsilateral posterior open-bite. the year 1960.
b. Middle shift to contralateral side. The observations are as follows:
2. Unilateral fracture 1. Clinical data shows that bony union occurs
a. Ipsilateral premature contact posteriorly. condylar fractures regardless of whether
b. Ipsilateral midline shift. intermaxillary fixation is used or not.
3. Bilateral fracture dislocations
a. Anterior open-bite due to shortening of both
mandibular ramus.
4. Bilateral dislocation of condylar heads
a. Pseudoprognathism.
b. Inability to occlude teeth.
c. Elongated face.
d. Condyles palpable anterior to articular emience
with preauricular hollow.

Management

Conservative
1. Minimal displacement—No active treatment. A
Fig. 25.4: Two transosseous wire used to hold the distal portion
normal occlusion is maintained which allows of K-wire which sits in groove made on lateral aspect ramus of
bonny union occur. In fracture-dislocation, a the mandible to fix a fracture condyle (Brown and Obeid
functional pseudarthrosis maybe produced. Technique, 1984)
 Maxillofacial Trauma and Management
171
2. Studies on Rhesus monkey found no difference Relative indications for removal of a tooth from the
between surgical and non-surgical treatment of fracture line:
condylar fractures. 1. Functionless tooth, which would eventually be
removed electively.
Complication of condylar injuries: Only the T.M.
2. Advanced caries.
Joint contusion that means injuries to soft tissue
3. Advanced periodontal disease.
around the joint or an effusion within the joint.
4. Doubtful teeth, which could be added to existing
Management includes soft diet, analgesic and anti dentures.
inflammatory for relief of pain and exercise. Bite – 5. Teeth involved in untreated fractures presenting
raising appliances may be used to distract the joints. more than 3 days after injury.
Short-wave diathermy may help. Other injuries It is desirable that all teeth not covered by these
associated with condylar regions mainly TM conditions should be retained.
dysfunction syndrome, problems related to mandi-
Management of teeth retained in fracture line:
bular growth, dislocation and ankylosis discussed in
1. Good quality intraoral periapical radiograph.
detailed in Vol. I.
2. Institution of appropriate systemic antibiotic
A simple guideline recommended by Peter Bank
therapy.
for immobilization of tooth bearing area of
3. Splinting of tooth if mobile.
mandible.
4. Endodontic therapy if pulp is exposed.
Young adult
5. Immediate extraction if fracture becomes infected.
with
6. Follow-up for 1 year with endodontic therapy if
Fracture of the angle
there is demonstrable loss of vitality.
receiving 3 weeks
Early treatment
in which Clinical Features of Fracture
Tooth removed from fracture line Angle of the Mandible

If: a. Pain.
a. Tooth retained in fracture line: add 1 week. b. Tender on palpation.
b. Fracture at the symphysis: add 1 week. c. Discontinuity of the fracture side.
c. Age 40 years and over: add 1 or 2 weeks. d. Dearranged occlusion.
d. Children and adolescents: subtract 1 week. e. Deviation of the mandible.
Applying this guide, it follows that a fracture of f. Restricted movements of the mandible and partial
the symphysis in a 40-year-old patient where the booth trismus.
in the fracture line is retained requires 6 weeks’ g. Crepitus.
immobilization (basic 3 weeks + 1 week for less
favorable site + 1 week allowed for age + 1 week for Clinical Features of Body of the Mandible
tooth retained in the line of fracture). a. Pain or moving jaw.
Teeth in the fracture line: Peter Bank summarized a b. Trismus.
consideration of the tooth or teeth present in the c. Movement and crepitus at the site of fracture.
fracture line which is as follows: d. Step deformity of lower border of the mandible.
e. Dearrangment of the occlusion.
Absolute indications for removal of a tooth from f. Mental anesthesia.
the fracture line: g. Lingual hematoma and ecchymosis of buccal
1. Longitudinal fracture involving the root. mucosa.
2. Dislocation or subluxation of the tooth from its
socket. Clinical features of the fractures of parasymphysis
3. Presence of periapical infection. (midline and canine regions): A midline fracture is
4. Infected fracture line. very rare and displacement is much less. This fracture
5. Acute pericoronitis. present obliquely to the one side of the genial tuber-
 Synopsis of Oral and Maxillofacial Surgery
172
cle. Because of uneven pull of the muscle attached to Direct fixation or osteosynthesis: This can be
the genial tubercle the fragment overwriting or describe as the retaintion elements which grip the bone
overlapping to other fragments. This may be immediately at the fracture ends. Osteo mean bone
associated with the condylar fracture opposite side. synthesis means joining or putting together (Figs 25.5A
Bilateral fracture of the middle fragment is pushed and B).
down words and inwards due to pull of suprahyoid Osteosynthesis or rigid internal fixation comprises
group of muscles. of:
A. Adaptational—miniplates, monocortical screws
Concept of the Reduction of and plates (Maxim Champy). Monocortical plate
the Fracture Fragment is plating system in which the screw engages only
one cortical plate (the outer cortical plate).
1. Reduction of the fracture is correct anatomical B. Compression
position based on to restore premorbid occlusion I. Bicortical screws and plates (AO/ASIF).
The various methods of close reduction and indirect Plating system in which the screws are long
skeletal fixation enough to be fixed to the external as well as
1. Direct interdental wiring (Gilmer, 1887). the internal cortical bony plates.
2. Interdental eyelet wiring (IVY, 1922). This is most II. Lag screws osteosynthesis is essentially a form
popular routinely used till today. It is a simple and of compression osteosynthesis in which the
effective method of the reduction and immobi- bone fragments are bound to one another
lization of the jaws, provided that each fragments under as a result of traction from the screw.
contain a suitable number of teeth of suitable shape
and quality (Rowe and William’s, 1985).
3. Interdental eye late wiring of William modification,
1968 which is a second loop for the buccal wire in
addition to the eye late for mechanical advantage
for insertion of tie wire.
Other various wiring less commonly used
which includes Risdon Wiring, Kazanjian button,
multiple loop wiring.
4. Arch bar
a. Sauer’s arch bar.
b. Hauptmeyer’s arch bar.
c. Profile arch bar of Schlampp.
d. Acrylated arch bar.
e. Prefabricated arch bar – Jelenko, Winter, Erich
(Row and William, 1985).
5. Metal cap splints.
6. Gunning splints.

Open reduction and direct skeletal fixation, which

includes transosseous wiring, is the surgical union of
two or more bone fragments with aid of wire ligatures
passing via the drill hole made in the bone (Schwenzer,
1986). He also stated that this technique is in use since
the beginning of nineteenth century, was not adopted
and not popularized because of its associated
complication. Schwenzer also mention the various
ligature includes simple ligature, figure of eight
ligature, combination of both double ligature, cross- Figs 25.5A and B: The ideal line of osteosynthesis
ligature, transcircumferentin ligature etc. from Maxim Champy et al 1978
 Maxillofacial Trauma and Management
173
C. Mesh system. AO/ASIF Plating System
Champy et al devised an experimental model of
a. Mandible—used for bridging after resections and
the mandible which mapped out ideal lines of
for compression of fractures
osteosynthesis. By placing plate at most bio-
b. Midface—adaptational miniplates and screw.
mechanically favorable site (along tension bands),
plate thickness could be kept to a minimum and
Compression Principles
yet strong enough to overcome displacing forces.
Screws need only engage outer cortex. 1. Compression plate (2 mm thick) seldom used
a. Retention side (two holes or more).
Adaptational Technique of Fixation of Plate b. Compression side – two or more holes, and
(Figs 25.6 and 25.7) oblong sliding hole and an oval compression
hole.
1. Intraoral or transbuccal approach.
2. Bicortical pre-tapped screws (2.7 mm diameter).
2. Adaptation of plate to bone surface contour.
3. Technique:
3. Monocortical fixation of screw at least two on each
a. Tighten retention screws on one side of fracture.
side of the fracture line.
b. Tighten compression screw on other side of
4. More posterior fracture requires plating at a higher
fracture.
level. More anterior fracture requires plating close
c. Tighten screw in sliding hole on same side of
to the lower border of the mandible.
fracture as compression screw.
3. Limitation—compression can cause significant
Compression Plating System
occlusal and lingual cortex separation and thus
AO—Association of Osteosynthesis. have a limited use in dentate jaws.
ASIF—Association for the Study of Internal Fixation.
Lag screw technique: Compression is achieved with
First introduced by Spiessl et al in Basel,
a normal screw, which has threads along its entire
Switzerland during the early 1970s.
length. The hole in the near cortex is enlarged so that
threads do not engage.

Techniques
1. Fracture reduced and held position.
2. Hole is drilled through both cortices and hole
through near cortex is enlarged.
3. Screw is passed into hole and lingual cortex of
mandible is engaged and pulled towards buccal
cortex for compression.

Fig. 25.7: Screw and plate technique for

Fig. 25.6: Different plate sizes and different shape of plates fixing of bone fracture of face
 Synopsis of Oral and Maxillofacial Surgery
174
4. Ideally, three lag screws should be placed to The Function of Zygoma
prevent rotation.
1. Protection of globe of eye.
2. To give origin to masseter muscle – zygomatic arch.
Material Used for Osteosynthesis
3. To transmit part of masticatory forces to cranial
1. Stainless steel. base.
2. Cobalt-chrome (Vitallium). Knight and Northwood Classification (1961) of
3. Titanium. zygomatic fracture on the basis of occipitomental
4. Bioabsorable (PLLA – poly-L-lactic acid). view:
1. No significant displacement.
Advantages of Bone Plating 2. Fracture zygomatic arch only.
3. Unrotational body fracture.
1. Accurate reduction of the fracture is more easily
4. Medially-rotational body fracture.
achieved and one can be assured of bone to bone
5. Laterally-rotational body fracture.
continuity.
6. Complete rotational body fracture.
2. Overwriting and vertical displacement of fragment
Classification of the Zygomatic Complex Fracture
are eliminated.
(Rowe and Killey 1968):
3. Difficult fracture are rapidly, simply and most
Type I: No significant displacement.
effectively controlled.
Type II: Fractures of the zygomatic arch.
4. With provide complete stability of obviating the
Type III: Rotation around the vertical axis.
need for any maxillomandibular fixation allowing
a. Inward displacement of orbital rim.
early return of jaw function.
b. Outward displacement of orbital rim.
Type IV: Rotation around the longitudinal axis.
Fracture of Zygomatic Complex
a. Medical displacement of the frontal process.
The zygomatic bone closely associated with maxilla, b. Lateral displacement of frontal process.
frontal and temporal bones. They are usually involve Type V: Displacement of the complex bloc.
when a zygomatic bone fracture occurred therefore, a. Medial.
this type of fracture may be referred as zygomatico b. Inferior.
complex fracture. The zygomatic bone usually c. Lateral (rare).
fractures in the sutural line as ZFS, ZTS and ZMS. It Type VI: Displacement of the orbitoantral partition.
usually uncommon the zygomatic bone alone to be a. Inferiorly.
fracture. But in case of extensive trauma the bone may b. Superiorly (rare).
be communicated or split. The isolated zygomatic arch Type VII: Displacement of orbital rim segments.
fracture may occur without displacement of zygomatic Type VIII: Complex comminuted fractures.
bone (Fig. 25.8). The above classification Rowe’s change in 1985 and
present classification on the basis of clinical significant
by dividing the fracture into stable and unstable
varieties. This classification also similar to advocated
by Larsen and Thomsen in 1968 which is very simple
lucid and applied oriented for zygomatic fractures.
• Group A: Stable fracture—showing minimal or no
displacement and requires no intervention.
• Group B: Unstable fracture—with great displace-
ment and disruption at the frontozygomatic suture
and comminuted fractures. Requires reduction as
well as fixation.
• Group C: Stable fracture—other types of zygoma-
tic fractures, which require reduction, but no
Fig. 25.8: Diagram showing the relation of zygomatic bone fixation. Fracture of the zygomatic arch alone not
with the other parts of the facial skeleton involving the orbit can be classified as follows:
 Maxillofacial Trauma and Management
175
1. Minimum or no displacement. Temporal fossa approaches (Gillies et al, 1927) under
2. “V” type in fracture. oral endotrachal zygomatic complex is reduced by an
3. Comminuted fracture. elevator (Bristow’s elevator). The Gillies approach via
Henderson in 1973 recommended classification of temporal incision 45 degree oblique, made in hairline
zygomatic fractures into seven types: parallel to the anterior branch of superficial temporal
Type I: Undisplaced fracture. artery above bifurcation. Temporal fascia exposed and
Type II: Arch fracture only. incised. Howarth eletator passed below zygoma
Type III: Tripod malar fracture (F–Z suture intact). between temporalis facia and temporalis muscle; this
Type IV: Tripod malar fracture (F–Z suture acts as a guide for introduction of an elevator, e.g.
distracted). Rowe’s zygomatic elevator.
Type V: Pure blowout fracture. Firm upward and outward elevation is applied.
Type VI: Orbital rim fracture. Postoperatively pressure on fractured malar
Type VII: Comminuted and other fractures. should be avoided allowing healing with 3 weeks. For
direct access to malar a preauricular incision (Al-Kayat
Clinical Features of Zygomatic Fractures and Bramley, 1979) is based.
1. Initial stage, circumorbital ecchymosis. Intraoral approach via a buccal vestibular imme-
2. Edema and bruising over check. diately behind the zygomatic buttress, curved pointed
3. Trismus. elevator (Taylor–monk’s pattern) passed upwards to
4. Step deformity of the infraorbital margin. contact intra temporal surface of zygoma allowing
5. Double vision. elevation of malar.
6. Sometime exophthalmos.
7. Periorbital ecchymosis and subconjunctival Percutaneous Approach
hemorrhage.
8. Anesthesia or paraesthesia of infraorbital and Stab incision placed at intersection of vertical line
anterior superior alveolar nerve. dropped from outer canthus of eye and horizontal line
9. Paraesthesia or anesthesia of zygomaticofacial extending from alar margin of nostril.
and zygomatic temporal nerve. Posswillo hook is inserted through incision below
10. Bleeding from the nose on the fracture side. and behind the malar prominence. Reduction is
Late complication due to untreated or poorly achieved by strong outward traction of the handle
treated: avoiding infraorbital fissure which may result in
1. Flat check. haemorrhage from vein traversing it.
2. Endophthalmos. Eyebrow incision allows elevation of malar
3. Altered papillary level. together with placing of a plate across zygomatic-
4. Infraorbital paresthesia. frontal suture.
5. Double vision. Bicoronal flap—can be used when flap is raised
for other reasons, e.g. exploration of anterior cranial
X-ray investigation: Occipipomental 15 and 30 fossa.
degree.
Method of Stabilizing Zygomatic Fractures
Sub-mento Vertex Method (Jug Handle View)
1. Osteosynthesis
True lateral view, occlusal view of maxilla, PA view
a. Direct wiring.
of face, I/O Carmody Batson technique.
b. Champy mini-plates or micro-plates.
Surgical Approaches for the Management 2. Antral support of which
of Treating Zygoma Fracture a. Packs
i. White head varnish (Rowe and Killey, 1968).
1. Temporal fossa. ii. Plastic tubing (Altosan et al, 1976).
2. Intraoral approach. b. Balloon catheter (Shear and Anthony, 1952) –
3. Percutaneous approach—Stab incision for usually Follys catheter 30 cc used.
introduction of Poswillo hook to pull the zygoma c. Silicon-wedge Elastomer (Gorman).
uppers, eyebrow incision by coronal flap. 3. External pin fixation, F-Z.
 Synopsis of Oral and Maxillofacial Surgery
176
4. Internal pin fixation
a. Transmaxillary K-wire.
b. Nasomaxillary K-wire.

MID-FACE INJURY INCLUDING

THE MIDDLE-THIRD FRACTURES
OF THE FACIAL SKELETON
The surgical anatomy and the bones affected in this
type of fractures discussed earlier in the introduction
of maxillofacial injuries.
Middle-third of the facial skeleton classified
clinically on the basis of French surgeon Rene Le Fort
(1901) on the basis of experimental trauma applying
to cadaverous head. This classification again modified
by the reported study of Pape K of Germany (1969) of
extended Le Fort fracture drew attention to the
problem associated with anterior cranium. That means
the involvement of middle third of facial skeleton with
the frontal bone and this is called an extended Le Fort
fracture (Figs. 25.9 and 25.10). The modified classi-
fication is as below:
Le Fort I : Guerin or low level fractures (Some
degree of Ecchymosis in region of
greater palatine foramen is called
Guerin sign)
Le Fort II : Pyramidal or subzygomatic fractures
Le Fort III : High level or suprazygomatic
Fig. 25.9: Le Fort fractures
fractures
Extended Le Fort involvement of Le Fort III plus
upper-third of the facial skeleton.
Probably the most precisely documented classi-
fication proposed by Marciani in 1993, which
includes Le Fort, NOE (Naso-orbitalethmoidal) and
zygomaticomaxillary fracture patterns.
Le Fort I : Low maxillary fracture
Ia : Low maxillary fracture/multiple
segments
Le Fort II : Pyramidal fracture
IIa : Pyramidal and nasal fracture
IIb : Pyramidal and NOE fracture
Le Fort III : Craniofacial dysjunction and nasal
fracture
Fig. 25.10: Diagrammatic representation of an extended Le
IIIa : Craniofacial dysjunction and nasal
Fort fracture which involves the frontal bone, frontal sinuses
fracture and orbital roof (a) direct transosseous wiring of each individual
IIIb : Craniofacial dysjunction and NOE fracture site. Recently mini cortical plate (Champy Plate) used
fracture for treatment. This is a case treated by French Surgeon, L.
Le Fort IV : Le Fort II or III fracture and cranial Merville represented in the above diagram (cited from Peter
base fracture Bank) (b)
 Maxillofacial Trauma and Management
177
IVa : +Supraorbital rim fracture e. Bilateral hematoma palpable intraorally over malar
IVb : +Anterior cranial fossa and supra- buttresses.
orbital rim fracture f. Retroposed upper dental arch with anterior open
IVc : +Anterior cranial fossa and orbital bite.
wall fracture g. Cracked pot sound on percussion of teeth.
Another classification recommended for middle- Le Fort III Fractures (High Level Suprazygomatic
third of the facial injuries by Rowe and Williams in Fracture): Craniofacial disjunction or suprazygomatic
the year 1985. This classification is simple, lucid fracture. The fracture line runs from nasofrontal region
and easy to remember covering the mid-face then lacrimal bone then ethmoid bone around the
injuries in detail: optical canal involving infraorbital fissure then greater
wing of the sphenoid then zygomaticofrontal suture,
Fracture involving the occlusion:
along with this, fracture the zygomatic arches of both
1. Central region—key fractures involving:
sides.
a. Nose and/or nasal septum.
b. Fractures of frontal process of maxilla. Clinical features include:
c. Nasoethmoid. a. Tenderness and separation at fronto zygomatic
d. Fronto-orbitonasal. suture.
2. Lateral region – zygomatic complex. b. Tenderness and deformity of zygomatic arches.
c. Lengthening of face.
Fracture involving the occlusion:
d. Depression of ocular levels.
1. Dentoalveolar fractures.
e. Enopthalmos.
2. Subzygomatic:
f. Hooding of eyes (It is due to the whole of the
Le Fort I.
middle third of the face droop downwards with
Le Fort II.
the downwards movement of eye ball leads to
3. Suprazygomatic
hooding of upper eye lid).
Le Fort III.
g. CSF leak from nose with associated signs of head
Clinical Features of Le Fort I (Guerin or Sub- injury.
zygomatic Fracture): h. Mobility of whole of facial skeleton as a single
Fracture line runs horizontally above the all- block.
maxillary teeth at level of floor of nose. Fracture
X-ray investigation includes—occipitofrontal 25o
represent by:
and fronto-occipital 25o. This projection shows the
a. Floating of palate.
petrous bone below the orbital margin hence the
b. Hematoma within the maxillary antrum.
clarity of the orbital borders can be seen.
c. Bilateral hematoma of cheek.
Former projection is preferred but the latter
d. Dearranged occlusion with anterior open bite.
projection is used is used in those patients who cannot
e. Some degree of ecchymosis in the region of greater
sit properly.
palatine foramen (Guerin’s sign).
Occipitomental projection 30o: In this projection, the
Le Fort II Fractures (Low Pyramidal Subzygomatic anterior aspect of all the facial bones seen clearly and
Fracture): The Le Fort II fracture line crosses comparative study of both sides can be made.
piramedially from nasal bone then frontal process of
maxilla then lacrimal bone and infraorbital margin OPG and CT Scan and MRI also recommended for
crosses the zygomatic buttress then move backwards investigation.
and fracture above maxillary tuberosity.
Planning of Surgical Treatment
a. Facial swelling with massive edema.
b. Subconjunctival ecchymosis and diplopia (Double A. Emergency treatment—resuscitate patient
vision), confirm by the Forced duction test and • Stabilize mobile fragments to maintain airway
Hess test. (tracheostomy may be needed).
c. Dish-faced deformity. • Arrest bleeding and transfusion if necessary.
d. Infra orbital anesthesia both side. • Monitor vital signs.
 Synopsis of Oral and Maxillofacial Surgery
178
B. Within twenty-four hours • Reduction and fixation of nasal fractures.
• Repair of lacetrated wounds. • Facial lacerations—give access to fracture sites:
• Impression of teeth if necessary. a. Clean and repair.
• Treatment the less severe maxillary fracture if b. Care of facial nerve, lacrimal apparatus, or
no other major injuries. parotid duct if indicated.
C. Definitive treatment within 2 to 8 days optimum Treatment modalities of maxillary fractures,
time to allow for improvement the medical immobilization by internal skeletal fixation, which
condition of the patient clinical assessment and includes rigid internal fixation, wire suspension
planning and reduction of soft tissue edema. (recommended by Adams, 1942) used to reduce and
The various surgical procedures with multiple suspend a mobile fragment below to a firm’s stable
facial injuries: fragment above the fracture by means of a 0.5 mm
• If require tracheostomy. S S Wire. Frontal suspension approach is made the
• Dentoalveolar injuries: Extract teeth beyond repair. incision lateral-third of eyebrow to expose ZFS. Burr
• Reduction and fixation of dento alveolar fragments
by periodontal or arch bar wiring.
• Reduction of mandibular fracture – act as guide
for correct positioning of maxilla.
• Zygomatic fractures – should be elevated to allow
greater disimpaction of maxillae.
• Disimpaction and reduction of maxillae: a) open;
b) Closed.
• Skeletal fixation:
a. Internal
i. Nonrigid:
— Suspension wiring
— Intramedullary pins
— Transosseous wiring (Fig. 25.11)
ii. Rigid:
— Adaptational plates Fig. 25.12: Placement of mono-cortical screws and plate for
— Monocortical screws (Fig. 25.12) the treatment of the mid-face fractures
b. External:
i. External pin fixation via frame or halo (Fig.
25.13)

Fig. 25.11: Wire suspension of mid-face fracture Fig. 25.13: External pin fixation for maxillary fracture
 Maxillofacial Trauma and Management
179
hole is made above ZFS and emerges in infra temporal FRACTURE OF NASAL BONE AND
fossa. Rowe’s zygomatic awl both ends of the wire NASOETHMOIDAL INJURIES
passed into mouth through upper buccal sulcus. Surgical anatomy: The upper part of nasal framework
Circum zygomatic suspension wire passed and consists of two nasal bones with the frontal processes
attached to arch bar on maxillary teeth. Base of of maxillae and the nasal part of the frontal bone.
zygomatic buttress expose via buccal sulcus and wire Lower part of external nose consists of cartilaginous
inserted through a drill whole. The infra orbital framework comprising of septal cartilage, upper nasal
suspension via upper labial sulcus incisational cartilage and lower nasal cartilages.
approach. Pyriform aperture suspension, bony
pyriform aperture from nose exposed via the same Nasal Septum: Nasal septum is a perpendicular plate
incision made above and wire passed through. Circum of ethmoid, vomer, septal cargilage.
palatal wire a longitudinal wire passed around palate The classification of injuries recommended by
Strane and Robertson in the year 1979 is as follows:
provides good retention for gunning splint to maxilla.
1. Frontal injuries:
Transfixation by K-Wire and trans osseous
a. Plane 1—lower end of nasal bone and anterior
wiring.
nasal spine.
Rigid internal fixation includes direct wiring at the
b. Plane 2—external none.
sites of a fracture recommended by Merville in case
c. Plane 3—nasoethmoidal injury.
of extended La Fort fracture.
2. Lateral injuries:
The RIF now a day mostly used the mini-plates
a. Without septal fracture.
recommended by French Surgeon Champy.
b. With septal fracture.
Approach incision describes to reach the fracture
areas discuss before (Chapter Surgical Dictum). Clinical feature includes:
• Nasal deformity.
External Skeletal Fixation • Nasal bone crepitus.
• Bruising and edema.
a. Halo frame (Partially or completely encircles head,
Royal Berkshire hospital pattern) causes difficulty • In the nasal passage blood clot and bony fragments.
to sleep with. • Mucosal tears and damage to nasal septum may
b. Levant Frame (develop at Royal Melbourne be present.
Hospital in the year 1960) Craniomaxillary fixation Outline of treatment: Preferably within the first 24
between supraorbital ridges and maxilla. hours or any time up to 7 days.
c. Box Frame (circummandibular fixation) middle-
third of face is sandwiched between mandible and Reduction and Immobilization
cranium. In case of emergency the releases of jaws
• Reduction includes closed manipulation. Use of
is difficult.
Walshm’s forceps—left and right forceps to
Complication of major maxillary fractures: Imme- manipulate nasal bone at frontal process of
diate complication includes preoperatively difficulty maxillae. Asches septal forceps—to iron out nasal
in breathing due to posterior displacement of the septum and to elevate the nasal bridge.
maxilla causes soft palate to rest on dorsal surface of • Sub-mucous resection—(SMR) this SMR technique
tongue. Establish airway and removal obstruction. should be reserved for the patient who exhibits
Bleeding is due to injury to the maxillary arteries. airway obstruction due to distorted septum
Ligation of the maxillary artery by transantral ligation (Harrison, 1979).
and replacement of blood by transfusion. • Inter nasal immobilization includes Ribbon Gauze
Inhalation of tooth fragments should be removed BIPP or whitehead varnish. Silastic implant and
carefully. stainless steel inter nasal splint.
Postoperative complication includes control of • External fixation includes Plaster of Paris splint,
bleeding, infection, malocclusion, facial scarring, and gauze and soft metal sheet (Tin/Lead Alloi),
non-vital teeth. Thermoplastic splint and Compression plates.
 Synopsis of Oral and Maxillofacial Surgery
180
Nasoethmoidal Injuries flap, midline vertical incision, degloving of nose
with bicoronal flap. To achieve repair of nasal
Surgical anatomy: An area which lies behind the inter
bridge reattached to the frontal bone. Try to
orbital space and situated between the medial walls
preserve on the bony fragments either directly
of the orbits. This fractures are always comminuted.
wiring at the sites or use of mini plates and also
care should be taken medial canthal ligament.
Classification
Isolated Nasoethmoidal Injury Blowout Fractures
1. Bilateral—central injury resulting from direct blow Fracture of the orbital floor without affecting the
over nasal bridge. Base of nose is driven backwards orbital rim. They can affect orbital floor or medial wall
into interorbital space and nasal tip becomes of the orbit (Fig. 25.14).
upturned. Deep crease at base of nose and skin at
Etiology: Blunt injury to the eye in the direct punch
base of nose frequently lacerated. CFS rhinorrhea
to eye. The impact is transmitted to the surrounding
should always be suspected.
fat and consequently to the orbital wall.
2. Unilateral – unilateral nasal deformity. Side of
It may part or most extensive fracture Le Fort – II,
nose is depressed and there is underlying fracture
III and zygoma, or may be extension of fracture of the
of ethmoid bone.
orbital rim.
Combined Nasoethmoid Injury
Clinical Features
Plus Midface Fractures
1. Ecchymosis of the eye (black eye).
1. Bilateral—nasoethmoid complex fracture
2. Decreased vertical rotary movement.
combined with Le Fort II and Le Fort III fractures.
3. Enophthalmos.
Causes traumatic telecanthus and elongation of
4. Ptosis of the upper eyelid.
midface.
5. Vertical diplopia.
2. Unilateral—nasoethmoid complex injury plus
6. Infraorbital anesthesia or paresthesia.
severe comminution of orbit and zygomatic
complex. Unilateral displacement of medial centhal
ligament resulting in displacement of eye Radiological Investigation
downwards and laterally. Occipitomental 15 and 30° the radiological signs of
blowout fractures include cloudy maxillary sinus due
Clinical Features to hematoma formation.
1. Depression of frontal bone.
2. Nasal deformity.
3. Traumatic telecanthus (increased inter canthal
distance more than 35 mm. Normal range 25 to 35
mm).
4. Double vision.
5. CSF rhinorrhea.
6. Bleeding from anterior or posterior branches
ethmoidal artery.

Outline of Treatment
A. Closed reduction—the use of transnasal wires and
compression plates. The result is not satisfactory.
B. Open reduction—realignment of bony fragments
under direct vision by surgical approach of various
methods via existing laceration ‘H’ shaped incision,
‘W’ shaped incision, bilateral ‘Z’ incision, bicoronal Fig. 25.14: Mechanism of blowout fracture
 Maxillofacial Trauma and Management
181
Hanging droop sign positive due to opacification Superior Orbital Fissure Syndrome
caused by the herniation of soft periorbital tissue and
Injury and damage to the structures, which passes
bony fragments.
through the superior orbital fissure.
Fracture of zygoma and maxillae may present.
The following nerves, superior and inferior
CT scan and orbital tomography may be recom-
branches of III, IV, V (frontal, nasociliary and lacrimal)
mended.
VI are present along with the ophthalmic veins.
Forced duction test and retraction test are positive.
The sign and symptoms include:
Outline of Treatment • Periorbital edema.
• Subconjunctival ecchymosis.
Surgical intervention of various approach consist of
• Proptosis.
trans conjunctival incision—this approach provide
• Dilated pupil.
limited access to the orbital flow (Fig. 25.15).
• Absent of light reflex.
Infraorbital incision includes Blepharoplasty,
• Presence of consensual reflex.
Second crease of lower eyelid incision. Naso-orbital
• Loss of accommodation of eye.
incision.
• Sensory loss of cornea and forehead.
The surgical procedure includes
1. Orbital floor graft, which may be autografts,
Radiographic investigation: CT scan showing the
allografts (processed bovine bone, lyophilized
reduction in size of superior orbital fissure.
duramethod, zenoderm) alloplastic graft which
includes dimethyl siloxane polymer. Treatment includes—wait and watch consultation
2. Antral packing (Rowe and Killy, 1968) includes with opthalmologist. Care should be taken during
ribbon gauze soaked with whitehead varnish and treating fractured zygoma.
plastic tubing (Altoman et al, 1976), Silicon Wedge
Orbital apex syndrome: It is a rare combination of
Elastomer (Gorman, 1979)
superior orbital fissure syndrome with damage to the
Antral balloon, which may be (Shear and Anthony)
optic nerve leads to anterior ischemic optic
balloon or 30 cc Foley’s catheter (1976).
neuropathy.
This treatment modalities discussed above
should be done with the coordination of ophthalmic Clinical features—all the above mentioned for
surgeon. superior orbital fissure syndrome along with loss of
vision.
Treatment—referred immediate for ophthalmic
surgeon’s consultation and treatment modalities.

FURTHER READING
1. Dimitroulis G, Avery B. Maxillo-facial injuries 1994.
2. Experimental study of fractures of the upper jaw
originally written by Rene Le Fort and translated from
French by the Paul Tessier, 1972;
3. Kurt H Thoma. Traumatic surgery.
4. Kazanzian VH, Converse JN. The surgical treatment of
facial fractures.
5. Peter Banks. Fracture mandible.
Fig. 25.15: Surgical approaches to 6. Peter Banks. Middle-third of facial skeleton.
the orbit by various incisions 7. Rowe and Williams. Maxillo-facial injuries.
TWENTY-SIX
Diseases of Salivary Gland

• Mumps • Sialosis • Cat Scratch Disease • Sialadinitis • Sialolithiasis • Bacterial

Sialadenitis • Xerostomia • Mikulicz’s Disease • Fatty Infiltration • Salivary
Gland Neoplasms • Pleomorphic Salivary Adenoma • Monomorphic Adenomas
• Adenolymphoma • Monomorphic Adenomas • Malignant Salivary Gland
Tumors • Acinic Cell Carcinoma • Adenoid Cystic Carcinoma

The salivary glands mainly three paired major glands, The parotid gland releases its secretion into the oral
which includes the parotid, sub-mandibular and sub- cavity via the Stensen’s duct, the submandibular gland
lingual glands. About 500 hundred minor salivary via Wharton’s duct, and the sublingual gland via the
glands which release their secretion into the oral Bartholin’s duct.
cavity. The minor sublingual glands (Rivini’s glands)
The development of the salivary glands consists release their secretions by a number of small
of invagination of oral epithelium and the formation independent ducts into the oral cavity via the
of the duct system. After that, the acini differentiate independent small orifices throughout the mucus
of these ducts. Because of the developmental as well surface.
as functional characteristic belongs to oral mucous The above table clearly shown the salivary glands
membrane. Their secretion are either mucous or serous presents throughout the oral cavity except the gingiva
or mixed but the cells which line their ducts have the and the anterior half of the hard palate.
potentialities of differentiating into either a mucous
or a serous type. The location, name and other features Infectious parotitis: Mumps—common virus
of the major and minor salivary glands given as infection affects children of parotid gland caused by
follows: paramyxo virus. Females and males children and
young adult both are affected may be unilateral or
Gland or glands Type of secretory cell bilateral defuse acute enlargement of parotid gland
Parotid Serous associated fever, malaise, loss of appetite and difficulty
Submaxillary Mainly serous but few mucus in opening the mouth. Usually self-limiting and
Sublingual Mainly mucous but few serous resolves within a week although, rarely, complications
Minor sublingual Mixed but mainly mucus such as pancreatitis, encephalitis, orchitis or oophoritis
(Rivini’s glands)
may develop.
Glands of lip Mixed but mainly mucus
Glands of cheek Mixed but mainly mucus Investigation and diagnosis: Usually based on
Glossopalatine Pure mucus characteristic history and clinical features. Diagnosis
Anterior lingual (Blandin Mixed
can be confirmed by serology (elevated IgM to ‘S’ and
and Nuhn’s gland)
Glands of van Ebner Serous ‘V’ antigens).
(associated with Microscopically edema of the parotid gland with very
circumvallate papillae)
sparse inflammatory exudates.
Glands of root of tongue Mucus
Glands of posterior half Mucus Treatment symptomatic and prognosis is excellent.
of hard palate
Glands of soft palate Mucus Sialosis: Uncommon non-inflammatory, non-
and uvula neoplastic swelling of major salivary glands, most
Glands of retromolar pad Mucus commonly affecting parotid glands although may also
 Diseases of Salivary Gland
183
affect submandibular glands. Generally, idiopathic symptoms of sialolithiasis includes as pain and
although recognized associations include the swelling during meal times. Decrease secretion of
following: saliva with tenderness. Presence palpable stone in floor
• Drug induced (e.g., isoprenaline, phenylbutazone of the mouth. Sialography is a technique in which the
and antithyroid agents) salivary duct is cannulated with a plastic or metal
• Diabetes mellitus catheter, a radiographic contrast medium is injected
• Thyroid disease into the ductal system and the substance of the gland,
• Pregnancy and a series of radiographs are obtained during this
• Malnutrition process. Approximately 0.5 to 1 ml of contrast material
• Anorexia and bulimia can be injected into the duct and gland before the
• Cirrhosis and liver disease. patient begins to experience pain. The two types of
Histological features include serous acinar contrast media available for sialographic studies are
hypertrophy, edema of the interstitial stroma and water-soluble and oil-based. Both types of contrast
striated duct atrophy. material contain relatively high concentrations (25 to
40%) of iodine. Most clinicians prefer to use water-
Management: Identify and correct predisposing
soluble media, which are more miscible with salivary
factors if possible.
secretions, more easily injected into the finer portions
Cat scratch disease is a viral disease initially affects of the ductal system, and more readily eliminated from
the lymph nodes. Parotid and sub-mandibular glands the gland after the study is completed, either by
are involved mostly and it has an incubation period drainage through the duct or systemic absorption from
of one to three weeks. The young adult affected more the gland and excretion through the kidneys.
during the winter season. The regional nodes are Sialography reveals a stricture or obstruction
enlarged and tender patient complain of fever, commonest in the submandibular ducts (Figs 26.1 and
malaise, nausea, headache and chill. The disease is self- 26.2).
limiting, and regresses within six weeks. Others diagnostics includes computed tomo-
graphy, MRI, Ultrasound and sialoendoscopy, FNAC
Microscopically, show the hyperplastic lymph nodes
and salivary gland biopsy.
with minute multiple abscesses. Central area of
necrosis surrounded by a dense aggregate of Bacterial sialadenitis: Usually, occurs in association
neutrophils with a zone of histocytes. with local (e.g. calculus, mucous plug or duct stricture)
or systemic cause (e.g. diabetes mellitus or Sjögren’s
Treatment includes symptomatic and lesions heal syndrome) of reduced salivary flow. Previously a
without complication. relatively common postoperative complication due to
Sialadinitis means inflammation of the salivary gland. dehydration although this is now rare. Ascending
Usually, associated with the formation of salivary infection from oral flora. The main organisms involved
stone (Sialolithiasis) and inflammation of the major are Staphylococcus aureus, streptococci and
duct (Silodochitis). Occasionally, it maybe due to acute anaerobes.
infection from the oral cavity rarely from hemato-
genous route.
Acute sialadenitis is rare it is not associated with
stone or calculus.
Clinical features include swelling redness and pain
of the affected gland. Compression of the gland may
produce discharges of the pus and the symptoms not
precipitated during eating.
Sialolithiasis: Salivary calculi mean the stone or
calculus within the salivary gland. History of recurrent
pain and swelling before and during meals due to
obstruction by the calculus or stone. X-rays shows the Fig. 26.1: Sialography of parotid
presence of radio-opaque stone. The classic sign and (The characteristic sausaglink)
 Synopsis of Oral and Maxillofacial Surgery
184
• Anxiety
• Drug induced (tricyclic antidepressants, pheno-
thiazines, antihistamines)
• Aplasia of the major salivary glands (rare)
• Postirradiation
• Sjögren’s syndrome
• Sarcoidosis
• Dehydration (e.g., diabetes mellitus, renal failure,
fluid loss)
• HIV salivary gland disease.
Sjögren’s syndrome (Sicca syndrome, sicca means
dry): Sjögren’s syndrome consists of enlargement of
the salivary glands, dry mouth (xerostomia), dryness
of the conjunctiva and pharyngeal, nasal and laryngeal
mucosal (conjunctivitis sicca, rhinitis sicca, and
pharyngolaryngitis sicca), and arthritis. The disease
Fig. 26.2: Sialolithiasis: Stone within the is seen most-frequently in middle-aged and elderly
submandibular gland women. Because of the dryness of the mucous
membranes, there is secondary inflammation of those
areas. The involved exocrine glands show infiltration
Clinical features: Pain and swelling of the affected by lymphocytes and atrophy of acini.
gland. Associated pyrexia, malaise and occasional It is a chronic inflammatory disease with probable
erythema of the overlying skin. Pus may be expressed autoimmune disease, represent by two varieties
from the involved gland duct orifice. primary and the secondary.
Investigation and diagnosis: Pus for culture and Clinical features of primary Sjögren’s syndrome
sensitivity. include xerostomia (dry mouth), xerophthaimia (dry
eyes).
Treatment: Antibiotics (Amoxycillin or flucloxacillin
Secondary xerostomia, xerophthalmia, connective
if due to staphylococci). Encourage drainage by use
tissue disorder—most commonly rheumatoid
of sialogogues. After acute infection has resolved,
arthritis. Other possible connective tissue disorders
sialography should be performed to exclude
include systemic lupus erythematosus, primary biliary
predisposing factors such as calculi or duct strictures.
cirrhosis, mixed connective tissue disorder.
The stricture of the salivary gland may due to
obstructive disease with irregular narrowing of duct Investigation and diagnosis: No single test will
due to reparative fibrosis. This may also due to consistently and reliably establish the diagnosis; the
obstructive damaged to the duct and presence of following investigations may provide supportive
calculus or stone. evidence of a positive diagnosis of Sjrogren’s
syndrome;
Treatment: Transoral sialolithotomy.
• Salivary flow rate (stimulated parotid flow rate
1. Placement of stay suture posterior to the stone. It
normally > 1.5 ml/minute)
avoids the dislodgement of the stone posteriorly.
• Schirmer test—assesses lacrimal flow (positive if
2. A gentle incision overlying the palpable stone and
< 5 mm wetting in 5 minutes)
milk the gland to bring out the stone.
• Immunological investigations—rheumatoid factor,
3. Careful about the lingual vessels of the floor of the
anti-nuclear factor, anti-Ro (SS-A) and anti-La (SS-
mouth, see the no obstruction of the gland.
B)
4. Suture may or may not be necessary.
• Sialography—variable degrees of sialectasis are
Certain disorders of the salivary gland in brief:
found in patients with Sjrogren’s although this
Xerostomia: the condition called as dryness of the abnormally is not specific
mouth due to less or least flow of secretion of the • Scintigraphy—both uptake and excretion of the
salivary gland. The probable causes of xerostomia as radioactive isotope sodium pertechnetate is
follows: diminished
 Diseases of Salivary Gland
185
• Labial gland biopsy—histological features, which Microscopically, fatty infiltration of involved
support the diagnosis, include focal lymphocytic gland.
sialadenitis, duct dilation, acinar loss and Salivary gland neoplasms: The salivary tumors are
periductal fibrosis. relatively uncommon comprise only three percent of
Treatment is largely non-specific and simply aimed all tumors of which eighty percent occur in the major
at controlling symptoms. Maintain, adequate glands and twenty percent occur in the minor glands.
hydratin. Salivary substitutes (e.g. ‘Saliva Orthana’ The parotid tumors are common than the sub-
and ‘Glandosane’). Salivary stimulants: chewing gum, mandibular, sublingual and minor glands. The
glycerine and lemon but avoid in dentate patients due classification of salivary gland tumors as follows:
to low pH; pilocarpine. Preventive dental care—
fluoride rines. Denture hygiene measures because of Benign Malignant
increased risk of candidosis. Treat acute episodes of
Pleomorphic salivary Mucoepidermoid carcinoma,
bacterial sialadenitis with appropriate antibiotics.
adenoma Acinic cell carcinoma
Sarcoidosis (Besnier Boeck Schaumann disease) Monomorphic adenomas Adenoid cystic carcinoma
granulomatous disorder of unknown etiology mostly Adenolymphoma Polymorphous low grade
affected young adult specially females. Affected usual adenocarcinoma
location parotid gland manifested unilateral or Oxyphilic, basal cell, Carcinoma arsing in pleo-
bilateral enlargement of the affected gland associated tubular, clear cell, trabe- morphic adenoma
with respiratory distress with fever. cular etc.

Histologically, circumscribed foci of epithelioid cells Pleomorphic salivary adenoma: Most commonest
and giant cells in gland, no necrosis. salivary gland tumor. Ninety percent in the parotid
Mikulicz’s disease (Benign lymphoepithelial lesion) remain in other gland tumors. Affected ages in fifth
parotid is affected glands males are affected more than and six decade of life. Females are affected > males
females usually in younger age. (Figs 26.3 and 26.4).
Clinical features: Slow growing, painless, rubbery
Clinical feature circumscribed area of lymphoid tissue
mass.
or diffuse infiltration of gland by lymphocytes; islands
Histological features include intermingled
of squomoid and glandular epithelium.
epithelial and mesenchymal tissue, as the name
Fatty infiltration: Parotid is affected glands, affected suggested. Connective tissue capsule is poorly-
age third to fifth decade of life. Males and females are developed and some areas with outwards growth of
equally affected. Rare condition; unilateral or bilateral the main tumor mass extending beyond the capsule.
diffuse enlargement of parotid gland; long duration, Treatment includes if cosmetic problems excision
old age, alcoholism, pregnancy, or malnutrition. of the glands. Prognosis is good.

Fig. 26.4: Malignant transformation of

Fig. 26.3: Pleomorphic adenoma pleomorphic adenoma
 Synopsis of Oral and Maxillofacial Surgery
186
Monomorphic Adenomas: It is less common than the basophilic granular cytoplasam. The cell resembles the
Plemorphic adenoma. It is the one of the variety of acinar cells of the serous gland and arranged in
histological pattern. broadsheet. The tumor is low-grade malignancy.
Adenolymphoma: It is one of the varieties of Mono- Treatment includes surgical excision.
morphic adenoma most commonly seen. Affected age
more than fifty years. Male female ratio 1.5:1. Adenoid cystic carcinoma: Usually, affects middle-
aged and elderly; accounts for 15 percent of minor
Clinical features: Painless, firm on palpation clinically gland tumors, 2 to 3 percent of parotid tumors. Slow
indistinguishable from other benign parotid tumors. growing tumor, which may initially be clinically-
Histologically, it is well-capsulated, papillary cystic indistinguishable from a plemorphic adenoma. Local
structures mainly epithelium and lymphoid tissue. pain, ulceration of overlying mucosal, fixation to
deeper structures and facial nerve palsy (in case of
Monomorphic adenomas having several histological parotid tumor) may be features. Widely infiltrative
varieties which includes oxyphilic, basal cell, tubular, with perineural spread. Cribriform or ‘Swiss cheese’
clear cell, trabecular etc. Other than histological pattern.
varieties, clinical features are mostly same.
Microscopic picture: Shows the small, dark, stained
Malignant salivary gland tumors include mucoepi- epithelial which resembles the basal cells of mucous
dermoid carcinoma: It affects mainly the parotid the membrane. Because of this feature, it is sometimes
incidence mostly seen forth and fifth decades of life. called basaloid mixed tumor. The epithelial cells are
Females are more affected than males. The presence
arranged in tubes, islands, columns and acini.
of variable grade of malignancy, which influences the
Microscopic field looks like ‘Swiss cheese’ pattern.
rate of growth. Low-grade tumors usually present as
painless slowly enlarge growth not unlike a Treatment: Wide excision.
pleomorphic adenoma. Tumors are high-grade Carcinoma arises in pleomorphic adenoma: Most arise
malignancy grow rapidly and local pain may be an
in parotid tumors, which have been present for 10 to
early feature. Facial palsy, lymph nodes involvement
15 years. Characteristic sudden increase in rate of
and distant metastases common.
growth.
Acinic cell carcinoma: Uncommon tumor mainly in
Treatment: In case of pleomorphic adenoma involving
parotid. Clinical presentation is similar to that of a
maxillae, subtotal maxillectomy.
pleomorphic adenoma. Behavior unpredictable.
In the malignant transformation, wide excision of
Microscopic appearance a single cell type with a very the tumor. Radiation is contraindicated as the tumor
large cell and the round duct nucleus and deep is radioresistant.
 TWENTY-SEVEN
Preprosthetic Surgery

• Alveolar Surgery for Ridge Correction • Alveolar Surgery for Ridge Extension
• Alveolar Surgery for Ridge Augmentation

‘Pre’ means prior, prior surgery for better prosthetic 4. In the mandible, the mental foramen can open on
rehabilitation (prosthetic means replacement of the ridge and cause pain from pressure of the
artificial teeth in the form denture may be partial or denture due to the resorption of alveolar bone. To
complete). relief the symptoms, the position of the mental
The aim of preprosthetic surgery is to achieve better nerve to be changed at lowers level. A crestal
retention, stability, esthetic and functional ability of incision is made with the buccal extension. The
prosthesis. nerve is gently separated with a hook and
Preprosthetic surgical modalities aid to prostho- protected with blunt instrument. Another nerve
dontist by the oral surgeon for successful prosthetic path is created by means of a Fissure Bur at lower
rehabilitation. level. And the nerve is placed in new position to
The preprosthetic surgical modalities includes to avoid pressure from the denture. Thereby, relief
achieve the criteria as follows: of pain is achieved.
i. Alveolar surgery for ridge correction. 5. Alveolectomy—the removal of alveolar process
ii. Alveolar surgery for ridge extension. following extraction and consequently the removal
iii. Alveolar surgery for ridge augmentation. of sharp margins of inter dental, inter shapetal or
lavio buccal alveolar crest with the rongur and
ALVEOLAR SURGERY FOR smoothened with the bone file.
RIDGE CORRECTION 6. Alveoloplasty—the trimming and reshaping of the
The surgery mainly divided into the soft tissue related knife-edge ridge. The recontouring of the alveolar
and the hard tissue related surgery. ridge is done to reserve of soft tissue and bone for
The hard tissue related surgery includes: the maximum denture support.
1. Excision of Tori (rare)—the palatal exostosis or tori 7. Interseptal alveolectomy or alveoplasty with
rarely seen as bony growth. This excessive bony repositioning of the labial cortical bone recommen-
tissue must be removed from the palatal aspect for ded by Dean’s. This surgical modality is limited to
better adaptation of complete denture prothesis. maxillae mainly to the anterior region. It is
The mandibular tori may be present on the lingual indicated to reduce maxillary overjet. It also
aspect very rarely. The excision of the excessive reduces the volume of cancellous bone to maintain
growth is necessary for the same reason. The toras stress bearing cortical bone (Fig. 27.1).
palatinus is excised via a ‘Y’ shaped midline sagittal
incision and the bony prominence removed with
burs or chisels. A hemorrhagic splint made of clear
acrylic placed after suture to prevent formation of
haematoma.
2. Reduction of mylohyoid ridge is necessary to avoid
displacement of the denture by reducing the ridges.
3. Removal of exostosis in the region of maxillary
tuberosity. Fig. 27.1: Dean’s technique (1941)
 Synopsis of Oral and Maxillofacial Surgery
188
Technique includes: Technique includes an alveolar crestal incision
a. Removal of interseptal bone following is made from lower canine to the opposite lower
atraumatic extraction to the labial cortex. canine. A mucoperiosteal flap is raised on the
b. Placement of labial cortical bone in the new lingual side without raising the labial muco-
position. After obtain local anesthesia and periosteal flap. The muscle attachment is gently
completion of the step (a) mentioned above. The dissected and the excision of the genial tubercle
interseptal bone is removed by surgical bur by rotary instrumentation with copious irrigation
with flashing of the water. A vulcanite bur is of the area. Then the smoothening of the area with
used to make a tunnel from canine to the a bony file. Toileting of the wound, control of
opposite of the canine. Toileting of the bony bleeding and placement of the suture.
socket examine the tunnel the bony bed The soft tissue related surgeries are the following:
completely avascular. Then a vertical oblique 1. Excision of redundant crestal soft tissue.
incision is made both sides of the socket of 2. Excision of denture hyperplasia.
the canine. A Fissure Bur or osteotome is using 3. Excision of epulis fissuramatum.
for bony cut of both sides of the labial cortical 4. Reduction of the fibrous tuberosity.
plate. Then a bony sheers is rotated gently 5. Fraenectomy.
towards the labiocortical plate fracturing the The soft tissue related surgery mainly excessive
labial bony fragments attached with intact hyperplastic tissue or over growth in response to the
mucoperiosteum. After that the labial cortical chronic trauma. This is may be due to over extended
plate pushed palatally and repositioning the denture flange, which transmits the masticatory forces
labial cortical plate and approximation with the to the soft tissues. This situation often occurs following
palatal cortex. Then the suture placed at the the resorption of the ridges. The denture hyperplasia
same. Antibiotics, analgesic and anti-inflam- may present at one fold or a series of folds, which lie
matory drugs are prescribed with mainte- in the buccal sulcus between the alveolus and the
nance of oral hygiene and saline mouth after denture or along the periphery of the flange. The
24 hours. This technique is known as Dean’s reduction of the soft fibrous tuberosities with deep
technique. sulci assists denture retention and stability.
Obwegeser’s modified the Dean’s interseptal Treatment includes:
alveoloplasty by repositioning of both labial 1. Removal of irritation.
and palatal cortex. The Dean’s technique only 2. Excision of the soft tissue that means hyperplastic
the labial cortical plate is involved. The mass.
technique is same as above but palatal cortical 3. Cryosurgery gives satisfactory results.
plate is included by making horizontal cuts are 4. Alternate excision by carbon dioxide laser to excise
made in the both labial and palatal cortex. This hyperplastic tissue.
technique is indicated when the sufficient over
jet is not reduced (Fig. 27.2).
8. Excision or reduction of the genial tubercles—The
attachment of genioglossus muscle with the genial
tubercle sometimes may cause interference of
adaptation of denture due to gross resorption of
the mandibular ridge.

Fig. 27.3: (A) Reduction of fibrous tuberosity and elliptical

incision over tuberosity then excising deep portion (shaded).
(B) To allow flaps to apposed on bone without tension and suture
Fig. 27.2: Obwegeser’s technique (1968) placed for closure
 Preprosthetic Surgery
189
Fraenectomy Maxillary Procedures
Fraenum is a musculofibrous brand attached to the 1. Secondary epithelialization vestibuloplasty
alveolus inserted into the muscle of the face. The most a. Full thickness mucoperiosteum dissection—
important is the labial fraena in the midline of the Collett.
upper and lower jaw. b. Submucosal dissection, periosteum intact—
During the movement of the facial muscles, they Szaba.
lift the dentures and show break peripheral seal. The 2. Submucosal vestibuloplasty—Obwegeser,
denture can usually be relieved round them but where Yrastorza.
the ridges have resorbed this may greatly reduce the 3. Ridge skin grafting vestibuloplasty—Weiser,
possible depth of the flange and even weaken the Schuchardt.
denture, making surgery be excision necessary. 4. Buccal sulcus skin grafting—Esser, Gillies
5. Ridge mucosa grafting vestibuloplasty—
THE SURGICAL TECHNIQUE OF FRAENECTOMY Obwegeser, Steinhauser.

Mandibular Procedures

Buccal Approach
1. Submucosal dissection, periosteum intact
a. Secondary epithelization vestibuloplasty
1. Incision in lip mucosa—Kazanjian
Fig. 27.4: (a) Incision for excision of labial fraenum. (b) Lingual
2. Incision over crest of ridge—Clark
fraenum lengthened by making a horizontal incision A-B and b. Ridge skin grafting vestibuloplasty—
suturing it vertically Obwegeser, McIntosh and Obwegeser
c. Mucosa grafting vestibuloplasty—Propper,
Nabers, Hall and O’Steen.
2. Full thickness mucoperiosteum dissection
a. Incision in lip mucosa—Godwin
b. Incision on crest of ridge with mental nerve
lowering and lingual frenotomy with genio-
glossus transplant—Colley
c. Ridge skin grafting and incision on crest of
ridge, with genial tubercle removal and
repositioning of genioglossus and geniohyoid
muscles—Anderson (Fig. 27.6).

Lingual Approach
Fig. 27.5: Edlan’s (1963) technique is designed to reduce the 1. Submucosal dissection, periosteum intact
amount of scar contraction inherent in the above technique. a. Secondary epithelialization
The mucosal flap, based on the alveolar crest, is dissected off 1. Lingual sulcus extension with resection of
the underlying fraenum. The periosteum is incised around the mylohyoid muscle and with or without
fraenum and both are reflected off the underlying bone. The lingual skin graft—Trauner (Fig. 27.7)
periphery of the mucosa is sutured to the junction of attached
and detached periosteum so separating the fraenum from bone.
It is advisable to excise as much of the muscular fraenal tissues 2. Floor of mouth lowering—Trauner,
as possible to lessen the risk of recurrence Obwegeser
3. Sublingual ridge extension with free mucosa
graft—Lewis
ALVEOLAR SURGERY FOR RIDGE EXTENSION
2. Full thickness mucoperiosteum dissection
Louis H Guernsey and Gustav Kruger excellently a. Lingual sulcus extension with resection of
summarized the various ridge extension procedures mylohyoid ridge, mylohyoid muscle, and
as follows: lingual flap cover of bone—Obwegeser
 Synopsis of Oral and Maxillofacial Surgery
190

Fig. 27.7: Essentially this is a supraperiosteal reflection of the

mucosa and mylohyoid muscle leaving the ridge undisturbed

Kazanjian labial vestibuloplasty in this technique

the inner aspect of the lower lip mucosal flap is raised.
Fig. 27.6: Diagrammatic representation of stage I of Anderson’s To achieve to increase of depth of the anterior
technique (1969) for the lowering of the genial muscles. The mandibular labial vestibule. Surgery is made from pre-
tendinous muscle insertion is transfixed with a strong molar to opposite pre-molar regions and the raw area
absorbable suture which is clipped and lies outside of the mouth is left on the lip site to heal by the secondary intension
keeping the periosteum on the bone intact (Fig. 27.8).
b. Lingual ridge extension—Caldwell Clark’s method of labial vestibuloplasty, the flap
c. Lingual sulcus extension with free skin graft— is pedicle off and lip and bone is left exposed (Fig.
Ashley 27.9).
Labial vestibulor procedure or lip switch
Labiolingual Approach procedure by Howe’s other name is transpositional
flap vestibuloplasty. In this technique, alveolar
1. Sub-mucosal approach, periosteum intact
periosteal flap is raised and subsequently the lip
a. Anterior buccal and sublingual sulcus extension
submucosal flap is also raised and suture inversely.
with fenestration procedure—Baurmash
That means the periosteum is suture-exposed surface
b. Ridge skin grafting vestibuloplasty combined
of lip and submucosal flap is sutured to the bony bed.
with total lowering of floor of mouth—
Obwegeser. Obwegeser’s modified the Clark’s method. The
The above-mentioned various surgical modalities variation is area of alveolar bone with its periosteum
of which the following techniques are commonly used: attachment is covered with a split, thickness, skin graft

Fig. 27.8: Kazanjian vestibuloplasty Fig. 27.9: Clark’s labial vestibuloplasty

 Preprosthetic Surgery
191
and held in position by suture or Stent constructed 3. Interpositional or sandwich bone grafts
preoperatively (A Stent was introduced by an English a. Bone grafts
dentist Charles R. Stent. It is eponym for a device used b. Cartilage grafts
in conjunction with surgical procedure to keep a skin c. Hydroxyapatite blocks.
graft in place: often modified with acrylic resin or 4. Visor osteotomy
dental impression compound that was previously turn 5. Onlay grafting—autogenous, alloplastic, allogenic
Stent’s compound. Stent is used to apply pressure to material.
soft tissues to facilitate healing and prevent
cicatrisation or collapse).

ALVEOLAR SURGERY FOR

RIDGE AUGMENTATION
In case of alveolar resorption, restoration of optimum
or near optimum of ridge height and width and
adequate ridge form with vestibulor depth is
mandatory.
To surgical methods or options are available one
is the augmentation of the alveolar ridge and two is
placement of implants.
Ridge augmentation of various procedures
summarized by Russel Hopkins in his famous pre-
prosthetic oral surgery in the year 1987, which includes
(Figs 27.10 to 27.12): Fig. 27.11: In the visor osteotomy Harle (1975) osteotomized
the mandible leaving each section pedicled by the muscles
inserted into them, so maintaining a blood supply to the bone
Mandibular Augmentations
and periosteum. Prosthetic difficulty in this situation it is
1. Superior border augmentation reasonable to offer ridge augmentation procedures, which will
a. Bone grafts strengthen the jaw as well as increase its dimensions. The
difficulty in writing about this subject is that new techniques
b. Cartilage grafts
appear with great frequency and new materials, e.g.
c. Alloplastic grafts. hydroxylapatite, have accelerated these developments. What
2. Inferior border augmentation is written today maybe out of date by the time it is published.
a. Bone grafts (autogenous or allogenic freeze- All of the following techniques seek to overcome the problem
dried cadaveric mandible) of the rapid resorption of the free onlay bone graft – cited from
b. Cartilage grafts. Russell Hopkins

Fig. 27.10: Corticocancellous bone blocks can augment the Fig. 27.12: The visor osteotomy can be augmented by
visor osteotomy if the preoperative vertical height of the anterior corticocancellous bone blocks if the preoperative vertical height
mandible is less that 2 cm of the anterior mandible is less that 2 cm.
 Synopsis of Oral and Maxillofacial Surgery
192
Maxillary Augmentation of the mandible following resection again modified
by Quinn in the year 1991 for augmenting atrophic
1. Onlay bone grafting—autogenous/allogenic grafts
ridge and subsequent placement of implant.
2. Onlay grafting of alloplastic material
The visor osteotomy and the modified osteotomy
3. Interpositional or Sandwich grafts
the aim to increase the height of the mandibular ridge
4. Sinus lift procedure.
for denture supports.
Augmentation in Combination Sinus lift procedure: It is a popular procedure
with Orthognathic Surgery combined with simultaneous or delayed implants.
1. Mandibular osteotomy procedure After raising subperiosteal buccal flaps, a window is
2. Maxillary osteotomy procedure created to expose antral lining. Lining of the floor and
3. Combination procedure. walls is elevated intact and this space is filled with
The material used for augmentation of alveolar bone from the iliac crest to provide retention for
ridge: implants.
1. Autogenous or autogrft—the living autogenous Prof JR Moore recommended the use of bones
tissue. substitute is calcium hydroxyapatite in the form of
2. Allogenic bone graft—substance from an small granules of about 1 mm. diameter, either solid
individual of the same species but generally or porous. This material produced in the laboratory
unrelated. Example—freeze dried cadver bone. is chemically similar to the inorganic phase of bone.
3. Alloplastic graft—calcium hydroxyapatite. The particles are injected into pockets beneath the
4. Metalmesh with autogenous cancellous bone. periosteum.
5. Metalmesh with calcium hydroxyapatite.
Mandibular augmentation by superior border Ingrowth of fibrous connective tissue and new bone
grafting by Davis in the year 1970. This technique for formation stabilizes the mass of particles and produces
ridge augmentation two fifteen-centimeter auto- a firm support for the denture. However, there is a
genous ridge grafts is used. One rib is placed on the tendency for the particles to migrate from the crest of
cortex and the other contouring the shape of the the ridge into the sulcus, with reduction in the height
mandible and both the graft fixed with transocious of the augmented ridge and obliteration of the sulcus.
and circummandibular wiring. The surgical flap is To prevent this a tissue-expander inserted into the
then closed. The iliac crest as a graft is also used in subperiosteal pocket for two weeks will result in a
this procedure. fibrous tissue-lined tunnel into which the
The inferior border grafting was first described by hydroxyapatite particles are injected. This creates a
Marx and Saunder in the year 1986, for reconstruction more stable augmentation of the alveolar ridge.
 TWENTY-EIGHT
Tidbits of Implants and
the Role of Oral Surgeon

• Implant and the Oral Surgery • Concept of Implants Procedures • Definition

• Weiss Theory of Fibro-osseous Integration • Indications • Surgical Modalities

Implant and the oral surgery: Implants are alloplastic the implant with bone covering its entire surface
materials, i.e. placed into the jaw to provide supportive without an intervening connective tissue. So, the
measure to crown or fixed/removable prosthesis. interface between the tissue and the implant is a strong
The success of implants the factors are responsible one, which can withstand occlusal loads. To
as follows: understand this phenomenon, the structure of this
1. The implant must be bioacceptable and inert. interface and factors affecting this area should be
2. The surgical factors includes the adaptation of studied.
implant is important. Placement of implant must
be attromatic surgical man over, careful about Weiss Theory of Fibro-osseous Integration
thermal injury to the bone. Implant should be Weiss theory states that there is fibro-osseous ligament
correctly placed to ensure optimal loading by the formed between the implant and the bone and this
prosthesis. This requires the careful cooperation ligament can be considered as the equivalent of the
with the prosthodontist. periodontal ligament found in the gomphosis.
He defends the presence of collagen fibers at the
Concept of implants procedures especially for oral bone-implant interface. He interpreted it as the peri-
implants including recommended by the various implantal ligament with an osteogenic effect. He
authority of which P I Branemark in the year 1982, is advocates the early loading of the implant.
the pioneer authenticated, established concept explain The types of implants available in the large
as Barnemark theory of osseointegration. This theory varieties from titanium or hydroxyapatite coated
proposed that implants integrate with bone such that titanium. Bioceramics are also available.
the bone is laid very close to the implant material Types of implants according to placement and the
without an intervening connective tissue. materials components:
Osseointegration can be defined as, “Osseous 1. Subperiosteal
integration (1993) the apparent direct attachment or 2. Transmucosal
connection of osseous tissue to an inert alloplastic 3. Osseointegrated
material without intervening connective tissue. The The last one is most commonly use.
process and resultant apparent direct connection of Indications
the endogenous material surface and the host bone
tissues without intervening connective tissue. The 1. Edentulous jaws unable to retain dentures, partial
interface between alloplastic material and bone.” prosthesis for bridge abutments, single anterior
tooth replacement.
Branemark also stated that the implant should not be 2. Maxillofacial prosthesis following trauma and
loaded and must be and left out of function during cancer surgery.
the healing period for osseous integration to occur. 3. Complete over-denture.
Osseointegration is a clinically asymptomatic rigid Prior to surgical technique X-rays of periapical,
fixation of the implant within bone, during functional OPG, lateral cephalogram, tomogram and CT scans
loading. This means that there is stable anchorage of are required.
 Synopsis of Oral and Maxillofacial Surgery
194
Surgical Modalities overheating must be avoided by constant irrigation.
1. Joint coordination between oral surgeon and In 2-stage procedures, a healing period of 4 months in
prosthodontist is essential for success. the mandible and 6 months in the maxilla is
2. Conventional denture modification should have recommended. In 1-stage procedures a connecting bar
been tried, a balanced occlusion should be can be fitted within 2 weeks but load-bearing or
creatable, and a good oral hygiene is mandatory. retentive studs should for 4 to 6 months.
3. The surgical procedure is required high-specialized In 2-stage procedures, abutment connection is then
instruments and the surgeon is also trained carried out by punch excision of mucosa overlying the
accordingly. implants, removal of cover screws, and insertion of
4. Installation of fixture. A mucoperiosteal flap is the abutment. A postoperative surgical pack is usually
raised, based lingually and receiving channel is used, prosthetic procedures starting about 2 weeks
prepared in bone, using matched spiral drills. after abutment connection.
The entrance to the fixture site is countersunk, and Alveolar augmentation require for placement of
depending on the type of implant, either it is pressed implant by sinus lift procedure by filling with bone
into place or if the channel is threaded, a fixture from iliac crest to provide retention from implant.
screwed in. In 2-stage procedures, the implant is
covered by the flap at the end of the procedure. It is Transmandibular implant: A box frame constructed
helpful when placing multiple implants that a and placed in the mandible from a submental incision.
direction indicator is used to achieve parallelism. Bone Provide to increase bone reposition.
 TWENTY-NINE
Excerpts of Osteodistraction Technique

• Osteodistraction • Aim and Objects

Osteodistraction means the technique by which regenerate once the appropriate amount of distraction
controlled, calculated, lengthening and widening of has been achieved the appliance remains in place this
bone is achieve according to need of the patient as per consolidation phase is allowing the formation of
desired by the surgeon. mature bone and term is remodeling period.
In this technique, an appliance known as distracter, The mandibular lengthening as well as the
applies gradual force for lengthening and widening widening of osteogenesis distraction protocol
of the bone. intraorally summarized by Suzanne U et al as follows:

Concept Osteotomy
The technique of long bone lengthening by Ilizarov After the intraoral distraction has been adequately-
G. A. of Russia and Bastiani, et al of Italy. Snyder in fixed, an osteotomy is completed and the distractor is
the year 1973 reported mandibular lengthening. J. G. activated 2 mm. The soft tissues are meticulously
Macarthy and associate of U.S.A. documented closed, paying special attention to the periosteal layer.
extensive work in the human mandible.
Aim and object of this corrective technique is to Latency Period
achieve symmetry of face due to disproportionate of
the jawbones. The activation of the distractor must be performed 7
This may be placed either extraorally or intra- days after surgery in order to allow primary healing
orally. of the soft tissues to take place, along with collagen
The following investigation and the selection of the fiber type I formation between the bony walls, as a
cases the 4 steps surgical protocol as follows: net to be stretched.
• Gap osteotomy to be made at the area of which
Rate of Distraction
distraction will start
• Placement of distracter and gradual distraction Distraction is performed at a rate of 1 mm daily.
after 7 days of osteomosied gap or site Increasing the rate of distraction could lead to fibrous
• Regular monitoring the area tissue formation, and decreasing the rate could lead
• After desired lengthening and widening is achieve, to a premature consolidation of the bony fragments.
removal of distracter. Orthodontist coordination
may require. Rhythm of Distraction
After latency period of 7 days, the distraction
Distraction osteogenesis is performed at a rhythm of
occurs with a rate and rhythm of 1 mm per day
once a day. This activation should be performed by
(completed by activating appliance 0.5 mm twice
the practitioner or by a well-trained patient or parent.
daily). Once this distraction is complete the appliances
In this way, it is possible to avoid uncontrolled
is left is place for the consolidation phase, which is
activation of the device.
usually 2 to 3 times the amount of time require for the
distraction phase.
Stabilization Period
The amount of activation per day is termed the rate
of distraction, the timing of appliance activation each Any orthodontic movement is postpond until 8 to 12
day is termed the rhythm. During the phase of weeks after surgery. Following appliance removal, the
distraction the new immature bone is called the orthodontist can resume orthodontic mechanics.
 Synopsis of Oral and Maxillofacial Surgery
196
During this period, bone apposition in the osseous gap formation. On the other hand, too much movement
must occur, ensuring normal dental translation into guides the healing process into cartilage and fibrous
newly formed interdental bone. tissue formation, which prevents bone formation.
The following variables may modify the distraction
osteogenesis protocol: Bone Transport Protocol

Patient Age The bone transport protocol is similar to that used

during widening or lengthening of the jaws. A 7-day
Some authors showed that less time is necessary for latency period must elapse before activation of the
an optimal hard and soft tissue response in younger device. Distraction is done at a rate and rhythm of
patients. 1 mm daily, until the bone fragments contact. After
contact, some fibrous tissue can be found between the
Quantity of Bone and Soft Tissues bone fragments, which must be removed with a curet.
When deficient hard or soft tissue is present, the A 703 bur is used to produce bone bleeding, and
latency period is prolonged in order to promote the activation of the distractor is performed to obtain
initial healing phase. compression osteosynthesis. Maximum bone exten-
sion is obtained 48 hours after the completion of the
Quality of Bone distraction, and this is why curettage and device
removal are delayed until 3 or 4 days after the last
Deficient quality of bone influences the latency period appliance activation. During this time, some
as well as the rhythm and stabilization period. elongation is still occurring in the soft tissues, as well
as stabilization of the newly formed bone. On the other
Magnitude of Distraction and hand, if distractor removal and clearing of the
Amount of Bone Gained intersegment fibrous tissue are delayed for a longer
These factors have a direct effect on the stabilization time, a premature bony consolidation can occur,
period, which is extended when expansion is larger. preventing the transport fragment from closing the
remaining gap.
Rigidity of Fixation
FURTHER READING
Following distraction, some intersegment micro-
motion must be present in order to achieve ideal bone 1. Guerrero CA, et al. Intraoral distraction in the year 1999.
2. JJ Macarthy, et al. Lengthening of human mandible by
formation. Some investigators observed that too much
gradual distraction.
rigidity of the plate would cause a mechanical stress 3. Myron RT. Correction of dentofacial deformities by
bypass, which apparently prevents the final stages of distraction osteogenisis.
normal bone reconstitution. The use of a more flexible 4. Samchukov–Distraction osteogenisis.
plate eliminates the occurrence of stress fractures, 5. Suzanne U, et al. Distraction osteogenesis: A Unique
demonstrating that some movement enhances bone treatment for congenital micrognathias.
 THIRTY
Tissue Transplantation, Flap and
Current Concept of Bone Grafting

• Tissue Transplantation • Homogeneous Tooth Transplantation • Autogeneous

Tooth Transplantation • Perspective of Biological Factors of Bone Graft
• Classification • Important Flaps

TISSUE TRANSPLANTATION Autogeneous Tooth Transplantation

Changing position of the tissue from one place to Hale et al and Apfel H. and others describe a detail
other. This may be soft or hard bone tissue. Bone is surgical procedure for the transplantation of
the most commonly utilized in oral surgical developing third molar to the first molar position in
procedures, although skin grafting has become the younger age groups as the first molar is very prone
popular in some areas of pre-prosthetic surgery and to caries. The extraction of third molar removed
post-cancer rehabilitation. Cartilage and fascia are atraumatically from the donor site and placement of
rarely used as tissue graft in oral surgical procedures. the tooth after removal of first molar. Then the tooth
Phillip J. Boyne summarized the transplanted is stabilizing by S S Wire ligatures over the occlusal
substances as follows: surface of the transplanted crown. Some surgeon
1. Autogenous graft composed of tissues taken from prefers acrylic for stabilization.
the same individual; Reimplantation is dental procedures indicated the
2. Homogenous grafts, which are divided into two avulsed or exfoliated tooth reimplanted, or reinserted
types: to the original alveolar socket following root canal
a. Allografts (or allogeneic grafts) composed of treatment.
tissues taken from an individual of the same A graft is transfer tissue which dependent on
species who is not genetically-related to the the donor site capillaries for his survival.
recipient. A flap is transferred tissue, which is, at least
b. Isografts (isogenous or syngenesioplastic grafts) initially, independent of the donor site capillary for
composed of tissues taken from an individual survivor.
of the same species who is genetically-related Skin graft may be split thickness or full thickness.
to the recipient. Split thickness graft (taken by Dermatone from thigh
3. Xenogeneic (heterogenous) grafts, which are and inner arm) and quickly transfers in the mouth and
composed of tissues taken from a donor of another placed with the sutures. Full thickness skin graft
species (for example, animal bone grafted to man).
provided a good color-match when repairing the skin
defects of the face.
Homogeneous Tooth Transplantation Pre-bone grafts from the ribs iliac crest or
In this procedure pulpless, fully-matured teeth from clavarium. Costochondral rid graft, which partially
a homogeneous allogenic source initially achieved the split at 1 cm interval, can be bent to contour in the
acceptance. However, ankylosis and progressive root shape of the mandible.
resorption is the almost universal feature of such Robert A. Bays cited from William Irby, the ideal graft
surgical procedures. system should be:
 Synopsis of Oral and Maxillofacial Surgery
198
1. Exist in unlimited supply without the need for the autograft with a saline-soaked sponge to prevent
violation of a distant donor site; drying without immersion of the graft may be the best
2. Provide immediate osteogenesis for rapid method for autograft preservation. The viable cells
consolidation; transplanted in an autograft include hemopoietic cells,
3. Elicit no adverse host response, such as immune reticular cells (contiguous with the endosteum), and
reactions; undifferentiated perivaseular cells (connective tissue
4. Facilitate revascularization, which assists early cells).
healing and resistance to infection; The insult of transplantation stimulates dege-
5. Stimulate osteoinduction of recipient site cells; neration of the hemopoietic elements, which probably
6. Be adaptable to a variety of physical requirements; make no contribution to osteogenesis. Gray and Elves
7. Present no impediment to growth or orthodontic showed that endosteum-free marrow has little or no
tooth movement; osteogenic potential. Following transplantation, the
8. Provide support and stability where discontinuity reticular cells (osteoprogenitors) are stimulated to
or mobility exists; begin osteogenesis. If these cells are transplanted alone
9. Provide a framework for osteoconduction; and without bone matrix, the bone that is rapidly formed
10. Be completely replaced by host bone of the same is also rapidly resorbed, leaving very little residual
or superior quantity and quality as quickly as bone. Also, these cells do not seem to stimulate much
possible. osteoinduction from the host. Therefore, transplan-
Bone is very popular for correcting contour defects. tation of marrow and endosteal elements without
Grafts may be used in the various forms which is: organic matrix apparently does not ensure lasting
1. Block from tibia, rib or ilium. bone formation. Revascularization of such a graft is
2. Osteoperiosteal graft from tibia. rapid so that resistance to infection and ease of healing
3. Chip grafts from ilium. are facilitated.
4. Pedicle graft from mandible. The undifferentiated perivascular connective tissue
The iliac crest block graft has various advantages. cells that are transplanted with an autograft are
This largely cancellous, and allows rapid transmission mesenchymal-type cells like those in the recipient site,
of tissue fluids and nutritive elements and provides with the potential to differentiate into osteogenic cells
innumerable pathose for ingrowth of growing cell. It if stimulated. This stimulation apparently comes from
can be readily shaped to contour and mortise. organic bone matrix.
Chip grafts may be obtain with a gouge after In summary, under the best conditions most of the
creating a window in the outer cortex, thus leaving viable cells in an autograft are hemopoietic, reticular,
the outer cortex undisturbed. or undifferentiated perivascular cells. The first
Boyne Phillip J specially advocated used of degenerate, the second form bone in a few days if
particulate grafts of marrow of cancellous bone, they survive, and the third must be stimulated to
containing a metal implant nesh device line with a differentiate into bone forming cells over several
microporous filter material for graft reconstruction of weeks.
large defects of mandible. A simple lucid classification of various grafts and
alloplastic material is as follows:
Perspective of Biological Factors of Bone Graft
Autogenous grafts Use the patient’s own tissue:
The viability of cells present in fresh autograft, viable
• Skin grafts—split skin graft, full thickness skin
cells are present only if marrow and endosteal
graft
elements are included and properly preserved. This
• Bone grafts—cancellous, corticocancellous
requirement is met by harvesting autologous
• Grafts grown in tissue culture ‘to order’, e.g. skin
cancellous bone and marrow as close to the time of
for patients with extensive burns.
placement as possible, certainly within 2 hours. Some
investigators have recommended preservation of the Allografts Tissue from a human donor specially
graft in saline or D5W, whereas others warn against prepared to reduce abnormal antigens:
the use of any artifactual solution, including saline, • Bone grafts
lest the osteoprogenitor cells be inactivated. Covering • Cartilage grafts.
 Tissue Transplantation, Flap and Current Concept of Bone Grafting
199
Heterografts Tissue from another species, again Incising the donor tissue in semicircular fashion
treated to reduce any recipient immune reaction. to allow rotation into a defect creates rotation flap.
Specially bred animals, with genetically-manipulated The both advancement and the rotation flap both be
compatibility genes to overcome rejection problems, facilitated by either the cut back or a triangular
may make these grafts more popular. excision of tissue.
A transposition flap is one that is rotated at an
Alloplastic materials These should be biocompatible.
angel, jumping and area of normal tissue to reach the
Materials used in oral surgery include internal fixation
defect.
plates and screws—Titanium, stainless steel, cobalt-
Another variety of local flap is inturned in which
chrome.
the margins of a defect are incised, under minded and
Resorbable materials Sutures, internal fixation screws turn into from the back side of the defect, if a double
and plates: polyglycolic acid (Dexon), polyglycolic/ lining is required such as nasopalatine fistula or
polylactic acid (Vicryl), polydioxanone (PDS). antrofacial fistula.
Pedicle flaps, in general, have the advantage of
Orbital wall/floor reconstruction material Sialastic
possessing subcutaneous tissue as well as skin, thereby
sheet, vicryl sheet.
providing depth and pliability to the repair. Local
Bone substitute Ceramics, hydroxyapatite. flaps have the additional advantages of desirable
Contour materials Gore-tex, proplast. colour and texture we well as simplicity and
Soft tissue crease/wrinkle obliterative materials diminished time requirements. These flaps have wide
collagen. application, and several variations have been use in
The flaps are used to repair reconstructed the closure of oroantral fistulas for many years. The use
defects of the soft tissues of the jaws. Paletta F. X. of a combination of local flaps in repairing an oronasal
advocated the use of advancement or rotation flap is fistula caused by trauma.
probably the best choice of method for reconstruction. Modification of local flaps is the Z-plasty and V-Y
The flaps may be classified: flap. The Z-plasty is a double rotation flap may be
1. Local flap utilized the contiguous tissue and used as a transposition flaps. It is most effective
requirement as (a) advancement, (b) rotation and method for releasing tension on a linear contracture.
(c) transposition Rotation of the flaps allows the direction of tension to
2. Distant flaps are those carried over and area of be changed with consequent relaxation of the tension
normal skin of a pedicle that is later sectioned and of the original axis (Figs 30.1 and 30.2).
return to the donor site. The distant flap again
Uses This is applicable at the corner of the mouth or
divided into two flaps—one is direct and other is
the ala of the nose is depressed or elevated.
indirect. The indirect flap may be migrated in steps
from a distant area to the face and carried on the
arm.
Regarding the local flap it is very much
popularize by a group of French surgeons is
sometimes called as French flap (Pick J. F).
The simplest form is probably exemplified by
undermining the ages of a wound to facilitate closure.
The direct advancement flap is created by under
mining the tissue of one margin of wound defect and
creating parallel incisions at the borders of the under
mined area for the purpose of closing the defect.
Although the lip shave (Vermilionectomy. Vol. I)
in the past has been consider a modification of the
advancement flap. In recent year surgeon has
performed this procedure without a true advance-
ment. Fig. 30.1
 Synopsis of Oral and Maxillofacial Surgery
200
3. Transposition flap, such as the nasal labial flap.
4. Nasolabial flap: Random pattern pedicle flap-
based above and lateral to the upper lip; useful
small local flap. Requires division later.
5. Tongue flaps: Random pattern pedicle flap for lip
and palate repair. Requires division later.
6. Forehead flap: Based on anterior branch of super-
ficial temporal artery and is a very safe flap. Entire
Fig. 30.2: (A) Scar contraction produces lip distortion, (B) Flap length of forehead can be raised, quickly, but leaves
switch naturally and lip distortion relieved, (C) Orientation of bad donor site. Requires division later.
central member turned 90° (Cited from Luis C Cuadros and G 7. Masseter muscle flap: Limited in size, can be used
Gallico III) intraorally.
8. Temporalis flap: Inferiorly based on deep temporal
The V-Y procedure for lengthening the localized branches of maxillary artery. For intraoral
area and Y-V procedure for shortening localized area reconstruction, limited use.
of tissue. 9. Other mucoperiosteal flaps: Buccal advancement
Other important flaps, which include: flap and palatal rotatory flap for repair of oroantral
1. The Abbe or Estlander flap. fistula.
2. Straight advancement with triangular excision of Envelope flap: In case of impacted third molar
skin. surgery.
 THIRTY-ONE
Tidbits of Commonly Used
Therapeutics in Oral Surgery

• Therapeutics—Application • Recent Trends of Antibiotics

Local application by the surgeon is as follows: • Candid mouth paint clotrimazole 1 percent W/V
• Thirty to forty percent of trichloracetic acid. It is solution used as antifungal agent.
used as chemocaute4rization agent. In case of • Kamillosan mouth spray standardized chamomilla
infected operculam in pericoronitis. extract (German remedies) used as oral wound
• Whitehead varnish (composition iodoform 10 G, healer. It is also available as liquid.
benzoin 10 G, prepared storax 7.5 G balsum of tolu • Dentogel, gelora used as application in the tender
5 G, solvent ether add 100 ml) used as pack in case mouth for relief pain. Composition of dentogel and
of post-surgery. the gelora are same, i.e. choline salicylate 8.7
• ZOE pack used in dry socket as an obtundant percent W/V.
agent. • Saliva substitute bio-extra gel 25 mg it containing
• Cornoy’s solution also used as chemocauterizing lactoferrin, lysozyme, lactoperoxidase, immuno-
agent at the end of enucleation of primordial cyst. globulins and colostrums extract (Lykahetero). It
• Surgicel–oxidized cellulose used as local hemo- is used as oral moisturizing gel in case of
static. xerostomia.
• Gelfoam same as previous use. • Saliva stimulant includes pilocarpine hydro-
• Hemolock (feracrylum HCl) used as previously chloride solution 1 mg per ml used as one TSF
mentioned. (about 5 ml 3 times daily) to increase the salivary
• Horsely’s bone wax (bees wax 7 parts olive oil 2 flow in case of xerostomia.
parts, phenol 1 part) used control bleeding from
Recent trends of antibiotics: The endocarditis pro-
the bony bed.
phylaxis, and in the case of diabetic patient who is
• EACA (Epsilon aminocaproic acid) this may be
prone to infection. The minor oral surgical procedure
used locally and systematically.
require the antibiotic regimen which as follows:
• Ethampsylate (it can be used locally as well as
• Amoxicillin 500 mg (novamox, wymox) 6 capsules
systematically).
1 hour before procedure, and 3 capsules after 6
Local used by the patient: Various mouthwash to hours. In case of allergic to above drugs
prevent infection of the mouth following oral surgical erythromycin 250 mg 4 tablets 2 hours before
procedure: procedure, 2 tablets after 6 hours. If the patient is
• Chlorhexidine, povidone iodine mouthwash/ allergic to both of above-mentioned drugs
gurgle. clindamycin 150 mg 2 capsules 1 hour before
• Benzydamine, tantum oral rinac, 0.15 percent procedure, 1 capsule after 6 hours.
W/V in case of painful mouth condition prior to • In case of severe risk adult patient, ampicillin 2 gm.
consume meal. and Gentamicin 1.5 mg per kg body weight not to
• Topical antifungal agents, nystatin or mycostatin exceed 80 mg IV or IM route 1 hour before
oral suspension 1 lakh units per ml used as oral procedure.
rinse 4 times daily for 2 minutes, 2 to 5 ml, then • Moderate infection ciprofloxacin 500 mg with
swallow. Used in candidiasis. tinidazole 300 mg, this combination (ciplox–T Z
 Synopsis of Oral and Maxillofacial Surgery
202
or cifran–T) commonly and routinely used in • In case of severe intractable pain injection
normal orofacial infection for 5 to 7 days. morphine sulfate 10 mg per ml IM to be given.
• Moderate to severe infection, author’s clinical Injection pethidine 25 to 100 mg IM or IV according
experience cefotexime (omnatax, taxim) 1 to 2 gm to the case.
twice daily IM, IV as ceftrioxone (monocef 1 to • In oral surgery, anxiolytics used for phobic patient
2 gm IM or IV twice daily is effective. In addition as short time therapy 1 to 2 weeks. Valium 5 mg,
to that, metronidazole 400 mg 3 times daily in oral i.e. dizepam 1 tablet at bedtime.
route also effective in anaerobic infection in • Injection dizepam also used for sedation
orofacial origin. anesthesia. IV 10 mg slowly pushed.
• In case of bone infection author prefers the use of • Muscle relaxants chlorzxazone with aceta-
lincomycin 600 mg IM daily or divided dose for 5 minophen 500 mg 2 tablets every 4 hourly.
to 7 days. The use of drugs should not be more • Anti-inflammatory medicine to prevent swelling.
than 10 days. Chymoral forte and chymotripcin are used in
• Pain relieving drugs: In case of mild pain aspirin routine practice. Chymoral forte 1 tablets every
325 mg, ibuprofen 300 mg, acetaminophen 325 mg 6 hourly half an hour before meal for 4 to 5 days.
may be used. • Sometimes corticosteroid—injection betnesol IM
• In case of moderate pain double, the dose of above given to reduce severe swelling tailing and tapered
mentioned drugs. In addition to ketorolac 10 mg the doses.
every 6 hourly. • Injection triamcinolone intralesional given in case
• In case of severe pain fortwin (pentazocine an of oral submucous fibrosis and intra-articular
opioid analgesic 25 to 100 mg every 3 to 4 hours injection in case of T.M. joint pain.
after food in case of severe pain. IM and IV or SC • In case of anaphylactic shock, injection adrenaline
30 to 40 mg 6 to 8 hourly as per requirement. 1:1000 (1 mg/ml) in 1 ml ampules, intramuscular
• Injection voveran also a good drug in case of or SC 0.3 to 0.5 ml slowly given.
pain following surgery. Diclofenac sodium 75 mg • In case of antiallergic reaction, injection avil or oral
of 3 ml injected deep IM. Voveran also used as tablets may be prescribed.
tablet for oral use 50 mg tablet 3 times daily after • Sodium tetradecyl sulfate (Sclerozing agent) I/L
food. given to the capillary hemangioma.
 Index

A Another classification of impacted Border’s classification 35

maxillary canine 24 Botryoid odontogenic cyst 60
Abscess 126 Antisepsis 1 Brown node or giant cell lesion
Acinic cell carcinoma 186 Antiseptics 1 (hyperparathyroidism) 106
Acquired immunodeficiency syndrome Apicoectomy 92 treatment 107
(AIDS) 162 contraindications 92 Buccal fat pad transfer surgical
etiology 162 indications 92 procedure 90
oral manifestations 162 recommended procedures 93 Buccally-placed canine 25
Actinomycotic osteomyelitis 114 steps of surgical procedures 93
clinical features 114 Argon laser 143 C
diagnosis 114 Asepsis 1
treatment 114 Aspects of antomy necessary for Calcifying epithelial odontogenic cyst
Acute necrotizing periodontitis 163 operative technique 122 58
Acute necrotizing ulcerative gingivitis Atypical facial neuralgia 80 histological features 59
163 Atypical odontalgia (dental migraine) pathogenesis 59
Adenoid cystic carcinoma 186 80 treatment 60
Adenolymphoma 186 Atypical ulceration 162 x-ray findings 59
Adenomatoid odontogenic tumor Augmentation in combination with Calcifying epithelial odontogenic tumor
(AOT) 100 orthognathic surgery 192 99
histopathology 101 Autogeneous tooth transplantation 197 histopathologically 100
management 101 management 100
pathogenesis/origin 100 radiological apearance 99
B
radiological appearance 101 Caldwell-Luc approach 90
Aims and objectives of surgery 48 Bacillus stearrothermophilus 2 Candidosis 162
Alcohols 2 Bacterial infection 162 Carcinoma in situ 29
Aldehydes 2 Bacterial sialadenitis 183 treatment modalities 29
Allografts 197 Barnemark theory of osseointegration Cardiac arrest 159
Alveolar surgery for ridge 193 Cat scratch disease 183
augmentation 191 Basal cell ameloblastoma 98 Cavernous hemangiomas 109
Alveolar surgery for ridge correction Basal cells naevus syndrome 60 Cavernous sinus thrombosis 129
187 Bayonet-shaped flap 18 treatment 130
Alveolar surgery for ridge extension Benign odontogenic tumor 96 Cemento-osseous dysplasia 104
189 Biological factors of bone graft 198 florid 104
mandibular procedures 189 Biopsy 38 focal 104
buccal approach 189 aspiration biopsy 38 periapical 104
labiolingual approach 190 drill biopsy 38 treatment 105
lingual approach 189 excisional biopsy 38 Central giant cell granuloma 106
maxillary procedures 189 incisional biopsy 38 clinical picture 106
Alveolitis-sicca-dolorasa 10 instruments for 38 diagnosis and histopathology 106
Ameloblastoma 97, 99 principles of 38 prognosis 106
age and sex 98 punch biopsy 38 surgery 106
analytical observation 99 Bleeding 11 treatment 106
clinical features 98 bleeding from the bony bed 12 Central hemangioma 107, 110
histopathological features 98 management of 11 treatment 107
radiological findings 98 paroperative bleeding 11 Cephalometric analysis 133
site 98 postextraction bleeding 11 Cephalometry 133
Anatomy and physiology of maxillary Blood chemistry finding 123 Chemical disinfectants 2
antrum 83 Blood examination 122 Chlorhexidine 2
Aneurysmal bone cyst 63 Blowout fractures 180 Choice of antimicrobial agents 3
clinical features 64 Bone plating 174 Chondrosarcoma 108
etiology 63 Bone screw for anchorage 69 prognosis 108
treatment 64 Bone transport protocol 196 treatment 108
 Synopsis of Oral and Maxillofacial Surgery
204
Chronic syphilitic interstitial glossitis 31 Complications of tooth extraction 9 Envelope flap 18
treatment 32 Compressing plating system 173 Envelope incision 18
Clark’s method of labial vestibuloplasty Compression principles 173 Eosinophilic granuloma 107
190 Compromised airway 167 clinical and x-ray features 107
Classic features of malignant ulcer 35 causes 167 histological features 107
Classification of benign odontogenic management 167 prognosis 107
tumor 96 Concept of implants 193 treatment 107
Classification of impacted maxillary Condensing osteitis 115 Erosive oral lichen planus 30
canine 24 Condylar fractures 169 epidemiology 30
Classification of impacted upper third Contraindication of extraction of teeth etiologic factors 31
molar 24 6 treatment modalities 31
Classification of mandibular impacted Control of bleeding 22 Erythematous and pseudomembranous
canine 25 Corticotomy or cortical osteotomy 69 candidosis 162
Classification of odontogenic cyst 52 Cryosurgery 139 Ethylene oxide 2
developmental 52 analytical observations 141 Etiology of extracapsular ankylosis 47
inflammatory 53 indications and contraindications Etiology of intracapsular ankylosis 48
Classification of odontogenic tumor 97 141 Etiology of pseudoankylosis 47
Classifications of lower third malar 14 Cyst 52 Etiopathological observation of oral
Clear cell odontogenic tumor (CCOT) Cyst of the papilla palatine 61 squamous cell CA 35
100 Cysts associated with the maxillary Exfoliative cytology 39
histopathology 100 antrum 64 Exodontia or exodontics 6
management 100 Extraction of carious tooth 67
radiological appearance 100 D Extraction technique 7
Cleft lip and palate 152
Demands intensive immediate F
anatomy 154
antibiotic therapy 130
anesthesia 156 Facial cellulites 128
Dental cyst 57
classification 152 treatment 128
mechanism of formation of 58
clinical presentation 155 Facial palsy and Bell’s palsy 80
treatment method 58
embryology 152 Factors influencing healing 5
Dental importance and consequences
etiology 154 Factors which delay healing 164
162
management 155 local 164
Dentigerous cyst 56
neonatal care 155 systemic 164
analytical observation 57
palatal revision 157 Fascial spaces 127
diagnosis and investigation 57
preoperative preparation 156 Fatty infiltration 185
pathogenesis and growth 56
secondary surgery 157 Fibro-osseous lesions of the jaws 103
treatment 57
alveolar gap 157 classification of 103
Dentoalveolar injuries 167
lip and nose 157 Fibrous dysplasia 103
classification 167
srugical timing 156 analytical observation 104
management 168
surgery 156 clinical and radiological features
predisposing factors 167
cleft lip repair 156 103
Detergents 3
repair of cleft palate 157 etiology 104
Dettol 3
Clinical panaroma and diagnostic histopathologically 104
Development of laser technology 142
criteria of PTN 77 investigation 104
Diagnosis and management of the
differential diagnosis 78 management/treatment 104
displaced root 85
etiology 77 Filtration 1
Differential diagnosis of orofacial pain
surgical modalities of treatment 77 Fine needle aspiration cytology 39
73
treatment modalities 77 Fistulae 126
Dipstick method 140
Closed method: principles of extraction Flaps 199
Discharging sinus 126
8 Abbe or Estlander flap 200
Disinfection 1, 2
Common investigation for routine distant flap 199
practice 122 E envelope flap 200
Common precancerous lesions 28 forehead flap 200
Complication of maxillofacial injuries ELISA 162 local flap 199
167 Emergency drugs 159 masseter muscle flap 200
problems related to healing of Emergency kits 159 mucoperiosteal flaps 200
fracture 167 Emphysema 11 nasolabial flap 200
 Index
205
temporalis flap 299 Hydrogen peroxide 3 Lewis modifications 20
tongue flaps 200 Hypermobility 41 Liner gingival erythema 163
transposition flap 200 Hypochlorites 3 Lingual split bone technique 20
Z-plasty and V-Y flap 199 Lipoma 109
Fracture 164 I Localized osteitis 112
Fracture angle of the mandible 171 Immunostaining procedure 39 ‘L’-shaped flap 18
Fracture fragment 172 Impacted canine 25 Lymphangiomas 110
Fracture line 171 Impaction 14 clinical features 111
Fracture of bilateral condyle 170 local causes 14 prognosis 111
Fracture of nasal bone 179 systemic causes 14 treatment 111
Fracture of parasymphysis 171 Implant and the oral surgery 193 types 111
Fracture of unilateral condyle 170 Incision 143 capillary 111
Fracture of zygomatic complex 174 Incision and creation of the cavernous 111
Fraenectomy 189 mucoperiosteal flap 21 cystic 111
Frontal bones 166 Indication of extraction of teeth 6
Function of zygoma 174 Infection 126, 167 M
causes of fracture site infection 167
G Infection of nondontogenic origin 130 Major complication of oral cancer
analytical observations 130 treatment 37
Garre’s osteomyelitis 114 Malignant salivary gland tumors 186
assessment of infection 130
prognosis 115 Management of bleeding 148
treatment 130
treatment 115 Mandible 166
Infectious parotitis 182
Globulomaxillary cyst 61
Inflammation 126 Mandibular augmentations 191
Growth and development of
Injury to the TM joint causes 43 Mandibular fracture 169
odontogenic cyst 54
arthritis 44 Maxillary augmentation 192
arthrosis 43 Maxillary bones 166
H rheumatic arthritis 44 Maxillofacial injuries 165
Haematoma 146 Intranasal antrostomy 90 background 165
Hairy leukoplakia 162 Iodine 3 clinical examination 165
Halogens 2 Irritation fibroma 108 clinical features 165
Hand-Schuller christian disease 107 Isografts 197 etiology 165
clinical and x-ray features 107 general assessment 165
histological features 107 K medical history 165
prognosis 107 Kazanjian labial vestibuloplasty 190 predisposing factors 165
treatment 107 Knot tying 117 presentation 165
Healing of bone 5 Koposi’s sarcoma 162 radiographic investigations 165
Healing of fracture 5 Mechanism of tissue destruction 139
Healing of jaw fractures 164 L Median alveolar cyst 60
Hemagiomas 109 Median mandibular cyst 61
capillary type 109 Lag screw technique 173 Median palatine cyst 60
cavernous type 109 Laser surgery 142 Medical history 120
ligation in hemangioma 109 Laser surgical environment 143 Method of extraction 7
technique for 109 Laser types 142 Mid-face injury 176
treatment of 109 Latency period 195 Mikulicz’s disease 185
tuberous type 109 Lateral trepanation technique 19 Moist heat 2
Hemolock 148 Le Fort I fractures 177 Monomorphic adenomas 186
Hemophilia 12 Le Fort II fractures 177 Multiple cystic lesions of the jaws 60
Hemorrhage 146 Le Fort III fractures 177 Multiple myeloma 107
Heterografts 199 Letter-Siwe disease 107 clinical pictures 107
Hilton method 128 clinical and x-ray features 107 diagnosis 107
treatment 129 histological picture 107 histological pictures 107
HIV salivary gland disease 163 treatment 107 prognosis 108
Homogeneous tooth transplantation Leukoplakia 28 treatment 108
197 treatment modalities of 28 Mumps 182
 Synopsis of Oral and Maxillofacial Surgery
206
N Osteoradionecrosis 115 Primordial cyst 54
clinical features 115 clinical features 54
Nance’s technique 67
investigation 115 concepts of recurrences 55
Nasoalveolar or nasolabial cyst 61
treatment 115 investigation: electorphoresis study
Nasoethmoidal injuries 179, 180
Osteosarcoma (osteogenic sarcoma) 56
Nasoplatine or incisive canal cysts 61
108 pathogenesis 55
Necrotizing fasciitis 129
prognosis 108 radiological featuress 55
Neodymium YAG 142
treatment 108 treatment 56
Neuralgias 76
Osteosynthesis 172 Principles of elveator in exodontia 9
Neurological disturbances 162
Osteotomy 195 Principles of extraction 7
Non-Hodgkin’s lymphoma 163
Principles of fracture treatment 166
Non-odontogenic fissural cysts 60
P Principles of primary tooth extraction 9
Non-odontogenic lesions of the jaws
Psychogenic pain 79
102 Paget’s disease of bone (osteitis Pus and purulent exudates examination
deformans) 115 125
O clinical and radiographic features Pyogenic granuloma 108
Objective of clinical history 120 115 prognosis 108
Odontogenic fibroma 101 treatment 115 treatment 108
managemet 102 Pain 10, 70
origin 102 anatomy and physiology of 70
Odontogenic myxoma 102 components of 72
Q
histopathology 102 pain perception 72 Q-switched Nd 144
management 102 pain reaction 72 Quality of bone 196
radiological appearance 102 pain threshold 72 Quantity of bone and soft tissues 196
Odontogenic tumors 97 concept of basic pain physiology 70 Querat’s erythroplakia 31
Odontoma 101 diagnosis 73 treatment 31
histopathology 101 gate control theory 71
management 101 pattern theory 70
Palatally-placed canine 25
R
Operative techniques for correction of
anterior maxillary segment Papanicolaou and trum stain 39 Radiation 1
135 Pasteurization 2 Radiology of maxillary sinus 84
Oral and maxillofacial surgery 6 Patient age 196 extraoral 84
Oral cancer 32 Pattern of microbial death 1 intraoral 84
radiological appearance 32 Periapical (dental) abscess 126 Rate of distraction 195
Oral dysaesthesia 74 pathophysiology 126 Recent trends of antibiotics 201
Oral submucous fibrosis 29 treatment 126 Reimplantation 197
clinical classification 30 Pericision or circumferential Relapse 50
clinical features 29 supracrestal fibrotomy 68 Relative mandibular retrognathism and
treatment modalities 30 Pericoronitis 26, 127 maxillary protrusion 135
Order of extraction 9 clinical features 127 Residual cyst 58
Osseointegration 193 treatment 127 treatment 58
Ossifying fibroma 102 Periodontal abscess 127 Retraction of the flap 22
clinical features 102 treatment 127 Rhythm of distraction 195
histopathology 103 Periodontal disease 162 Rigidity of fixation 196
management 103 Periostitis 112 Role of orthodontics 132
radiological appearance 102 treatment 112 Routes of spred of orofacial infection
treatment 103 Peripheral giant cell granuloma 108 127
Osteodistraction 195 Phenols 3 factors influencing spread 127
Osteomyelitis 112 Photocoagulation 143 local factors 127
analytical observation 114 Physiologic norms of blood 123
clinical and radiological features Physiological norms of urine 125
S
113 Pleomorphic salivary adenoma 185
acute 113 Postoperative edema 11 Salivary gland neoplasms 185
chronic 113 Postoperative swelling 11 Salivary glands 182
etiology 113 Predisposing factors for precancerous Secondary intention of healing 4
microbiological perspective of 113 conditions 32 Secondary neuralgias 78
modified treatment modalities 113 Primary intention of healing 4 Serial extraction 66
 Index
207
Shock 149 Surgical modalities of PTN at a glance Trismus 13, 46
cardiogenic 149 78 Rowe’s classification of 47
hypovolemic 149 Surgical, ciliated cyst of the maxilla 64 Trotter’s syndrome 79
management of vasovagal shock 151 clinical features 64 Tumor immunology 34
prevention 151 etiopathogenesis 64 Tunable dye laser 143
treatment 151 histopathology 64 Tweed’s technique 67
neurogenic 149 treatment 64 Type of implants 193
septic 149 Sutures 117 Type of secretory cell 182
Sialadinitis 183 analytic observation 119 Types of hemorrhage 146
Sialosis 182 horizontal mattress suture 118 arterial bleeding 146
Sicca syndrome 184 prinicple of suturing 117 bony bleeding 146
Sideropenic dysphagia 32 requirements of suture materials capillary bleeding 146
treatment 32 117 venous bleeding 146
Silolithiasis 183 suture removal 119 Types of incision 18
Sinus lift procedure 192 vertical mattress suture 118 Types of intraoral malignancies 32
Sjögren’s syndrome 184 Suturing technique 118
Skin test 125 continuous suture 118 U
Soft tissue cysts of the oral cavity 62 interrupted suture 118
etiological factors 62 mattress sutures 118 Ultraviolet light 2
mucocele 62 Syncope 9, 159 Upper motor neuron lesion 81
ranula 63 Urine examination 124
site 62 T
treatment 62 V
Spray technique 140 Technique of fixation of plate 173
Temporal incision 121 Various modalities of healing 4
Spread of infection 127
Various operative procedure 132
Squamous odontogenic tumor 100 Theories of carcinogenesis 33
genetic theory 33 alveolar ostectomy 132
histopathology 100
immune surveillance theory 34 alveolar osteotomy 132
management 100
corticotomy 132
pathogenesis or origin of monoclonal hypothesis 34
multistep theory 33 Vascular pain 79
development 100
Therapeutic extraction 66 Viral infections 162
radiological appearance 100
Squamous papilloma 109 Therapeutics 201
histopathological features 109 Tissue response 140 W
prognosis 109 Tissue transplantation 197 WAR lines of winter 16
treatment 109 TM joint 40 Ward’s incision 19
Stabilization period 195 anatomical consideration 40 Weiss theory of fibro-osseous
Standard projections 165 physiological concept 40 integration 193
Sterilization 1 TMJDS/MPDS/facial arthomyalgia 44 Wilkinson’s theory 67
Sterilization or disinfection of dental cardinal signs 45 Wound healing 4
equipment 2 clinical features 45 phases 4
Streptococcus pyogenes 111 diagnosis 45 inflammation 4
Subluxation 41 physical therapy 45 proliferative phase 4
Submandibular incision 121 therapeutic exercises 45 remodeling phase 4
Submental sublingual incision 121 treatment procedure 45
Superior orbital fissure syndrome 181 Transalveolar extraction 8
principal modalities of 8
X
Supine hypotensive syndrome 10
Surgical dictum 121 Transmandibular implant 194 Xenogeneic (heterogenous) grafts 197
Surgical modalities for removal of Transplantation of tooth 68 Xerostomia 184
upper third molar 25 Treatment modalities of oral cancer 36
Surgical modalities of impacted canine Treatment of bleeding disorders 149 Z
25 Treatment of soft tissue injuries 166
Surgical modalities of jaw tumors 99 Triage of lesions 33 Zygomatic fractures 175