Prevention and management of surgical complications

OSRG 421
Dr. Hani Arakji
Oral & Maxillofacial Surgery Department

Beirut Arab University

Types of complications encountered:

INTRA_OPERATIVE COMPLICATIONS

1. Fracture of the crown of the adjacent tooth or lunation of the adjacent tooth

2. Soft tissue injuries

3. Fracture of the alveolar process

4. Fracture of the maxillary tuberosity

5. Fracture of the mandible

6. Broken instruments inside the tissues

7. Dislocation of the temporomandibular joint

8. Subcutaneous or submucosal emphysema

9. Hemorrhage

10. Displacement of the root or tooth into soft tissues

11. Displacement of the impacted tooth, root or root tip inside the maxillary sinus

12. Oroantral communication

13. Nerve injury

POST-OPERATIVE COMPLICATIONS

1. Trismus

2. Hematoma

3. Ecchymosis

4. Edema

5. Post extraction granuloma

6. Painful post extraction socket

7. Fibrinolytic alveolitis (Dry Socket)

8. Infection of the wound

Fracture of Crown or Luxation of Adjacent Tooth

Extensive caries or a large restoration.

Luxation or avulsion of an adjacent tooth occurs when a great amount of force.

The luxation occurs when the adjacent tooth is used as a fulcrum.

When an adjacent tooth is luxated or partially avulsed, the tooth is stabilized for
approximately 40–60 days.

Rct may be needed.

Soft Tissue Injuries

Inadvertent manipulation of instruments (e.g., slippage of elevator).

The areas most often injured are the cheeks, the floor of the mouth, the palate, and
the retromolar area.

Treatment:
When injuries are small and localized then no particular treatment is considered
necessary.

Healing is facilitated if the lesion is covered with petrolatum (Vaseline) (e.g., lip
injury).

When the injury is extensive, and there is also hemorrhaging, the surgical procedure
must be postponed and controlling the bleeding with suturing of the wound.

Fracture of Alveolar Process

Extraction movements are abrupt.

If there is ankylosis of the tooth in the alveolar process.

Fracture of the lingual cortical plate is especially significant, because the lingual
nerve may also be traumatized.

Treatment
When the broken part of the alveolar process is small and has been reflected from
the periosteum, then it is removed.

If the broken part of the alveolar process is still attached to the overlying soft
tissues, then it may remain after stabilization and suturing of the mucoperiosteum.

Fracture of Maxillary Tuberosity

1. Weakening of the bone of the maxillary tuberosity, due to the maxillary sinus
pneumatizing into the alveolar process.

2. Ankylosis of a maxillary molar that presents great resistance to movements during

the extraction attempt.

3. Decreased resistance of the bone of the region, due to a semi-impacted or

impacted third molar. (old ).

Treatment
If the fractured segment has not been reflected from the periosteum, it is
repositioned and the mucoperiosteum is sutured.

In this case, the scheduled extraction of the tooth is postponed, if possible, for
approximately 1.5– 2 months

If the bone segment has been completely reflected from the tissues and oroantral
communication occurs, the tooth is first removed and the bone is then smoothed
and the wound is tightly sutured.

Broad-spectrum antibiotics and nasal decongestants are then prescribed.

Fracture of Mandible

The use of excessive force with the elevator, for removal of the impacted tooth.

large pathological lesions in the area.

Treatment
When a fracture occurs during the extraction, the tooth must be removed before any
other procedure is carried out, in order to avoid infection along the line of the
fracture.

Afterwards, depending on the case, stabilization by way of intermaxillary fixation or

rigid internal fixation of the jaw segments.

Broken Instrument in Tissues

Dislocation of Temporomandibular Joint

Occur during a lengthy surgical procedure.

In unilateral dislocation the mandible deviates towards the healthy side.

In bilateral dislocation, the mandible slides forward in a gaping prognathic position.

The patient is unable to close their mouth (open bite).

In order to avoid such a complication, the mandible must be firmly supported during
an extraction and patients must avoid opening their mouth excessively.

Reduction of TMJ dislocation

Reduction occurs through downward pressure with the thumbs on the external
oblique ridges, and upward pressure with the fingers.

Subcutaneous or Submucosal Emphysema

Occur as a result of air entering the loose connective tissue, when an air-motor is
used for the removal of bone or for sectioning the impacted tooth.

Clinically, the region swells, sometimes extending into the neck and facial area.

There is no specific treatment. It usually subsides spontaneously after 2–4 days.

Hemorrhage

Patient will experience tenderness to palpation near the surgical site.

Trismus and limited opening may also be a problem.

The diagnosis of persistent bleeding may be made after any clot formation has been
removed and after reapplying pressure dressings for a period of 15 to 20 minutes.

Bone or soft tissue cause?

Treatment
Step 1 Reanesthetize the patient to allow careful examination and manipulation of
the tissues in the surgical site.

Step 2 Following application of local anesthetic, thoroughly irrigate, suction, and

inspect the surgical site.

If a single bleeding source can be identified, obtain control using electrocautery or

hemostatic agents such as Surgicel or Gelfoam or Bone wax.

Treatment

Step 3 After the placement of hemostatic dressings and suturing, observe the area
15 to 20 minutes to confirm hemostasis.

If bleeding persists, the site should be packed and patient referred to an oral and
maxillofacial surgeon or emergency facility for blood testing.

Step 4 If the patient shows any signs of hypovolemia or hemorrhagic shock, vital
signs should be obtained and the patient should be referred to an emergency
treatment facility.

Displacement of Root or Root Tip into Soft Tissues

When the buccal or lingual cortical plate eroded.

In this case, the root or root tip may easily be displaced during luxation towards the
buccal soft tissues or the floor of the mouth, or between the bone and mucosa of
the maxillary sinus.

Treatment ( Caldwell-Luc operation)

Nerve Injury

1. Neurapraxia:

This type of damage has the most favorable prognosis and may occur even after
simple contact with the nerve.

Nerve conduction failure is usually temporary and there is complete recovery,

without permanent defects.

Recovery is quite rapid and occurs gradually within a few days to weeks.

2. Axonotmesis:

This is a serious injury of the nerve resulting in degeneration of the nerve axons,
without anatomic severance of the endoneurium.

Regeneration and recovery of sensation is slower than in neurapraxia and usually

begins as paresthesia 6–8 weeks after injury.

3. Neurotmesis:

This is the gravest type of nerve injury, resulting in discontinuation of conduction due
to severance of the nerve.

This type of injury may cause permanent damage to nerve function.

POST-OPERATIVE COMPLICATIONS
Trismus

Hematoma

Ecchymosis

Edema

Post-extraction granuloma

Painful post-extraction socket

Fibrinolytic alveolitis (dry socket)

Infection of wound

Trismus

Trismus usually occurs in cases of extraction of mandibular third molars, and is

characterized by a restriction of the mouth opening.

Due to spasm of the masticatory muscles.

This spasm may be the result of injury of the medial pterygoid muscle caused by a
needle (repeated injections during inferior alveolar nerve block) or by trauma of the
surgical field.

Other causative factors are inflammation of the post-extraction wound, hematoma,

and postoperative edema.

Treatment
Heat therapy, i.e., hot compresses extraorally.

Gentle massage of the temporomandibular joint area

Administration of analgesics, anti-inflammatory and muscle relaxant medication.

Physiotherapy lasting 3–5 min every 3–4 h, which includes movements of opening
and closing the mouth, as well as lateral movements, aimed at increasing the extent
of mouth opening.

Hematoma

Frequent postoperative complication due to prolonged capillary hemorrhage.

In this case blood accumulates inside the tissues, without any escape from the
closed wound or tightly sutured flaps.

Distinguished it from an ecchymosis, which is the spread of blood under the skin in
a small/thin layer.

Depending on the operation, the hematoma may be submucosal, subperiosteal,

intramuscular or fascial.

Treatment
If a hematoma is formed during the first few hours after the surgical procedure,
therapeutic management consists of placing cold packs extraorally during the first
24 h .

Then heat therapy to help it to subside more rapidly.

Administration of antibiotics to avoid suppuration of the hematoma, & analgesics for

pain relief.

Ecchymosis

The subcutaneous discoloration resulting from escape of blood within the contused
tissue.

It may result from damaged capillaries during flap retraction.

In order to avoid such a complication, retractors must be handled gently, especially

in the region of the mental foramen

Treatment

No particular treatment is required.

Gradually subside within a few days, changing color in the process.

Edema

Edema is a complication secondary to soft tissue trauma.

It is the result of extravasation of fluid by the traumatized tissues because of

destruction or obstruction of lymph vessels, resulting in the cessation of drainage of
lymph, which accumulates in the tissues.

Swelling reaches a maximum within 48–72 h after the surgical procedure and
begins to subside on the third or fourth day postoperatively.

Post-extraction Granuloma

Occurs 4–5 days after the extraction of the tooth.

Result of the presence of a foreign body in the alveolus, e.g., amalgam remnants,
bone chips, small tooth fragments, calculus, etc.

Painful Post-extraction Socket

Occurs immediately after the anesthetic wears off.

It occurs mainly at the post-extraction wound of mandibular posterior teeth, due to

the anatomy of the bone (dense).

sharp bony spicules so injure the soft tissues of the post-extraction socket leading
to severe pain & inflammation.

Treatment
Smoothing of the bone margins of the wound, especially the intra-radicular bone

Analgesics

gauze impregnated with eugenol should be placed over the wound margins for 36–
48 h.

Fibrinolytic Alveolitis (Dry Socket)

This postoperative complication appears 2–3 days after the extraction.

During this period, the blood clot disintegrates and is dislodged, resulting in
delayed healing and necrosis of the bone surface of the socket.

Characterized by:

Empty socket.

Fetid breath odor a bad taste in the mouth.

Denuded bone walls.

Severe pain that radiates to other areas of the head.

The etiology of dry socket:

Dense and sclerotic bone surrounding the tooth.

Infection during or after the extraction.

Injury of the alveolus.

Infiltration anesthesia.

Bad oral hygiene.

Treatment
Irrigating the socket with warm saline solution.

Placing gauze impregnated with eugenol, which is replaced approximately every 24

h, until the pain subsides.

Alveogel.

Antibiotics & analgesics.

good oral hygiene is emphasized.

Infection of Wound

The use of infected instruments and disposable materials during the surgical
procedure.

Defective bone substrate secondary to diseases of the skeletal system

(osteopetrosis), and radiotherapy of the jaw and facial area.

Systemic diseases which lead to increased susceptibility to infection (e.g., leukemia,

agranulocytosis).

 Preprosthetic surgery
Dr. Hani Arakji
Oral & Maxillofacial Surgery Department
Beirut Arab University

Introduction

Preprosthetic surgery involves operations aiming to eliminate certain lesions

or abnormalities of the hard and soft tissues of the jaws, so that the subsequent
placement of prosthetic appliances is successful.

Objective of the Preprosthetic surgery:

¥ To provide a better anatomic environment and to create proper supporting

structures for denture construction.

¥ To reform/redesign soft/hard tissues, by eliminating biological hindrances to

receive comfortable and stable prosthesis.

Characteristics of Ideal Denture Base Area:

1. Adequate bone support - broad U-shaped alveolar ridge with buccal and
lingual/palatal cortices as parallel to each as possible.

2. Adequate firm soft tissue

3. No sharp ridges.

4. No bony or soft tissue undercuts or prominces.

5. No presence of peripheral fibrous tissue bands (scars) to prevent proper

seating of a denture.

6. No high muscle or frenal attachments at the crest of ridge to dislodge the

denture.

7. No soft tissue hypertrophies on the ridges or in the sulci.

8. No intraoral or extraoral pathology.

3. Proper alveolar ridges relationship

Intraoral Examination

I) Ridge form and contour.

¥ Height and width of the ridge.

¥ Quality of the ridge-whether flabby, mobile tissue is present over the ridge.
II) Presence of any gross irregularities in the ridge.

III) Presence of any exostosis, undercuts, prominences, tori, sharp mylohyoid ridge
with severe resorption of external oblique ridge.

IV) Buccal and labial, as well as lingual vestibules evaluation for depth and type of
soft tissue.
v) Examination of palatal vault.

VI) Tuberosity area - undercuts, hyperplastic tissue, flabby ridge, etc. Height, width,
fibrous or excess bony tuberosity can impair the arch space for fabrication of full or
partial denture.

VII) Inter-arch relationship.

Supporting Soft Tissue examination

1. The amount of keratinized tissue& poorly keratinized or freely movable tissue.

2. Inflammatory areas, scars, ulcers, hyperplastic tissues due to ill-fitting dentures

should be looked for.

3. Frenal attachments in relation to the alveolar crest.

4. On the lingual aspect, mylohyoid muscle attachment and genioglossus muscle

attachment should be checked.

5. Tongue size and movement is also important for the stability of the denture.

RADIOLOGICAL EVALUATION

1. Panoramic x-ray

2. Lateral cephalometry.

3. Computed tomography - dental CT scan

4. 3-D CT can be used.

5. CBCT

DIAGNOSTIC MODELS

Diagnostic models are taken & mounted on articulator with proper vertical
dimension to be studied.

Hard Tissue Lesions or Abnormalities

The abnormalities associated with hard tissues are classified into two
categories:

a. Those that may be smoothed with alveoloplasty immediately after extraction of the
teeth (sharp spicules, bone edges), or those detected and recontoured in an
edentulous alveolar ridge.

b. Congenital abnormalities, such as torus palatinus, torus mandibularis, multiple

exostoses.

Alveoloplasty:
Alveoloplasty is the surgical procedure performed to smooth or recontour the alveolar
bone, aiming to: 1- Facilitate the healing procedure.

2- The successful placement of a future prosthetic restoration.

After tooth extractions, appropriate recontouring of the alveolar process is necessary
prerequisite for placement of a prosthetic appliance.

Sometimes, the residual crest presents irregularities, undercuts, or bone

spicules ,which, if not removed they lead to injury and stability or retention problems.

Alveoloplasty After Extraction of Single Tooth

When a tooth is over-erupted due to the absence of an antagonist, bone irregularity

is usually observed after its extraction.

This may cause problems for the normal healing process and abnormality of the
alveolar bone, resulting in obstruction of the placement of a prosthetic restorative
appliance.

In such cases, immediately after extraction of the tooth, recontouring of the bone in
the area must be performed.

Technique

After extraction of the tooth, a flap is created and a rongeur is used to cut the
protruded parts of the tooth socket, until a clinically appropriate inter-arch space is
created.

Afterwards, the bone surface is smoothed using a bur and bone file and excess
gingivae are trimmed with soft tissue scissors.

The area is irrigated with plenty of saline solution.

The wound is sutured with interrupted sutures.

Alveoloplasty After Extraction of Two or Three Teeth:

The same procedure……………. BUT

More specifically, after extraction of the teeth, if there are irregular alveolar margins
or if the alveolar ridge is high, parts of the mucosa are first removed with wedge-
shaped incisions mesial and distal to the post-extraction sockets.

Alveoloplasty After Multiple Extractions ( Intraseptal Alveoloplasty ) (Dean's

technique)

This procedure includes:

a. Scheduled extractions.

b. Reflection of the gingivae.

c. Removal of interseptal bone.

d. Smoothing of alveolar bone.

e. Fracture labial cortex in palatal direction by digital pressure.

f. Care of wound.

g. Suturing of the mucoperiosteum.

 Bony abnormalities
1. Torus palatinus.

2. Torus mandibularis .

3. Multiple bony exostosis.

4. Prominent Genial tubercles.

5. Prominent mentalis tubercles.

6. Sharp mylohyoid ridge.

7. Bony enlargement of maxillary tuberosity reduction.

8. Knife edge ridge.

9. Inadequate Vertical Space

1- Torus Palatinus

This exostosis is localized at the center of the hard palate formed entirely of
compact bone and the exact causes remain unknown.

Clinically, they are common asymptomatic bone protuberances, covered by normal

mucosa.

They vary in size, and shape ranges from a single discrete exostosis, to
multiloculated, to irregular in shape.

They usually do not require any special therapy, except for edentulous patients in
need of prosthetic rehabilitation, and in cases where the patient is greatly bothered
by the exostosis.

Surgical Technique

Incisions:

Full thickness envelope flap

Midline incision

Y shaped incision

Double Y shaped incision which is composed of 2 anterior & 2 posterior oblique

incisions.

The incisions are designed so as to avoid injuring the branches of the palatine artery.

After reflection, the flaps are retracted with the aid of sutures or broad periosteal
elevators.

After complete exposure of the lesion, it is sectioned with a fissure bur and the
segments are individually removed using a monobevel chisel.
After smoothing the bone surface, excess soft tissue is trimmed.

After copious irrigation with saline solution, the flaps are repositioned and sutured
with interrupted sutures.

Post- Operative Stent to Prevent:

Infection

Necrosis of the flap

Gravity will pull the flap down interfering with the blood supply

Hematoma Formation

The body will attempt to fill in the space creating a hematoma that may lead to
infection.

2- Torus mandibularis

Torus mandibularis is an exostosis of unknown etiology.

It is formed of cancellous bone covered with compact bone.

It is localized in the lingual aspect of the body of the mandible, either on one side or
more commonly on both sides, and as a rule in the canine and premolar region .

Clinically, it is an asymptomatic bony protuberance covered by normal mucosa.

Radiographically, it presents as a circumscribed radiopacity in the lingual aspect of

the mandible (occlusal film )

Torus mandibularis does not require any therapy except in cases where complete
dentures are to be constructed.

Surgical Technique

An incision is made at the crest of the alveolar ridge.

After extensive reflection of the flap lingually, the lesion is removed using a chisel,
bone file, or bur.

The wound is then irrigated with plenty of saline solution and is sutured with
interrupted sutures.

3- Multiple Exostosis

Rare asymptomatic bony projections usually localized at the buccal surface of the
maxilla and mandible.

The causes are unknown, although they may be due to bruxism as well as chronic
irritation of the periodontal tissues.

No therapy is usually required, except for those cases where, due to the large size of
the exostosis, severe esthetic and functional problems are created.
Surgical Technique

After administration of a local anesthetic, an incision for the creation of a trapezoidal

flap is made.

The mucoperiosteum is then reflected.

The exostosis are removed with a rongeur or special bur, under a steady stream of
saline solution, in order to avoid overheating of the bone.

The bony wound is then smoothed with a bone file and is inspected to ensure the
smoothness of the alveolar ridge.

After this procedure, the surgical field is irrigated with saline solution and the excess
soft tissues are trimmed.

Suturing with interrupted sutures

4- Prominent Genial tubercles

The genioglossal muscle attaches to the genial tubercle located at the lingual aspect
of mandible.

As the mandible resorbs, the genial tubercle becomes prominent.

During fabrication of dentures, the activity of the genioglossal muscle and

protuberance of the genial tubercle complicates wear of dentures by causing
dislodgement during function.

Surgical Technique:

A crestal incision is performed with a #15 scalpel along the anterior ridge.

Subperiosteal dissection is continued under the lingual mucoperiosteum until the

genial tubercles and muscles become evident.

Sharp dissection of the genioglossal muscles is performed with electrocautery in

order to control any hemorrhage from the muscle.

The genial tubercle is resected with a fissure or round bur.

Strict hemostasis should be obtained prior to closure of the lingual flap otherwise life-
threatening airway restriction may occur due to hematoma formation in the floor of
the mouth.

5- prominent mentalis tubercles

Mentalis tubercles are situated down in the lower labial sulcus in the lateral incisor
canine region.

But as the mandibular alveolar process resorbs and the height of the ridge
diminishes the powerful mentalis muscle may interfere with the retention and
stability of the denture.

Surgical technique
The surgical approach is made through a vertical incision over the tubercle which is
then extended upwards towards the crest of the ridge and the tubercle is removed
with surgical bur.

6- Sharp mylohyoid ridge

It is also termed as lingual balcony.

In extensive resorption of the mandible, the mylohyoid ridges become prominent and
contribute significantly to denture displacement.

Pain is felt because of mucosal impaction of dentures at the sharp mylohyoid ridges.

Surgical Technique
Inferior alveolar, buccal, and lingual nerve blocks are required for mylohyoid ridge
reduction.
A linear incision is made over the crest of the ridge in the posterior aspect of the
mandible.
A full-thickness mucoperiosteal flap is reflected, which exposes the mylohyoid ridge
area and mylohyoid muscle attachments.

The mylohyoid muscle fibers are removed from the ridge by sharply incising the
muscle attachment at the area of bony origin.
After reflection of the muscle, a rotary instrument with careful soft tissue protection or
bone file can be used to remove the sharp prominence of the mylohyoid ridge.
Immediate replacement of the denture is desirable, because it may facilitate a more
inferior relocation of the muscular attachment

7- Bony enlargement of maxillary tuberosity reduction

Horizontal or vertical excess (or both) of the maxillary tuberosity area may be a result
of:
1- Excess bony Enlargement.

2- Soft tissue Enlargement.

3- Or both.
The difference could be detected through:
-A preoperative radiograph
-Selective probing with a local anesthetic needle are often useful to determine the
extent to which bone and soft tissue contribute to this excess.

Recontouring of the maxillary tuberosity area may be necessary to remove bony

ridge irregularities or to create adequate inter-arch space, which will allow proper
construction of prosthetic appliances.
A crestal incision that extends up the posterior aspect of the tuberosity area with a
no. 12 scalpel blade.
Reflection of a full-thickness mucoperiosteal flap is completed in both the buccal and
palatal directions to allow adequate access to the entire tuberosity area.
Bone can be removed using either a side-cutting rongeur or rotary instruments, with
care taken to avoid perforation of the floor of the maxillary sinus.
After the bone has been removed, the area should be smoothed with a bone file and
copiously irrigated with saline.
Excess, overlapping soft tissue resulting from the bone removal is excised.
Closure.

8- Knife edge ridge

This condition occurs in the lower anterior region beneath a full lower denture.

The patient complains of inability to wear the denture.

The ridge is usually very narrow and covered with thin atrophic mucosa which is
inflamed and tender to palpation.

Surgical Technique

1) Conservative trimming of the ridge (not recommended)

2) Bone graft or Hydroxyapatite crystals (the ideal solution esp. if the ridge has
undercuts)

9- Inadequate Vertical Space

Causes

Malunited fractures.

Over eruption of the teeth.

Treatment:

1- Trimming the alveolar process in the upper jaw.

2- Reducing the height of the lower ridge through an incision along the crest of the
ridge.
 Soft Tissue Lesions or Abnormalities

Lesions or abnormalities associated with soft tissues and which require

alteration are classified into two categories:

a. Congenital abnormalities, such as a hypertrophic frenum, etc.

b. Abnormalities created after the use of dentures (e.g., fibrous hyperplasia of

the mucosa).

Soft Tissue Lesions or Abnormalities

1. Short labial frenum

2. Short lingual frenum

3. Denture induced fibrous dysplasia (denture fissuratum / granuloma

4. Fibrous enlargment of maxillary tuberosity

5. Gingival Fibromatosis

6. Flabby ridge

7. Fibro-epithelial polyp of the palate

1- Short labial frenum

The placement of a complete denture of the maxilla, or orthodontic procedures in

younger persons requires the removal of the labial frenum, especially if it is
hypertrophic.

Frenectomy

After local anesthesia, the lip is pulled upwards, and the frenum is grasped using two
curved hemostats, which are positioned at the superior and inferior margins of the
frenum.

The lip is then further retracted and a thin scalpel blade incises the tissue found
behind the hemostat, first behind the lower hemostat and then behind the upper
hemostat.

If the frenum is hypertrophic and there is a large space between the central incisors,
the tissues found between and behind the central incisors are also removed.

Interrupted sutures are placed along the lateral margins of the wound in a linear
direction, after the mucosa of the wound margins is undermined using scissors.

Frenectomy by z-plasty technique

The Z-plasty technique may produce less scar than the ordinary previous operation.

An incision is made directly along the length of a frenum. Superior and inferior
incisions are placed to form triangles.

After supraperiosteal undermining, the apex of the inferior triangle is rotated upwards
and conversely the apex of the superior triangle is rotated downwards.
2- Short lingual frenum

Also, in the mandible, the lingual frenum may create problems, causing partial or
complete ankyloglossia .

Ankyloglossia greatly limits movements of the tongue, resulting in speech difficulties.



Lingual Frenectomy

After local anesthesia, the tongue is retracted upwards and posteriorly with a traction
suture that is passed through the tip of the tongue.

The frenum is then grasped approximately at the middle of the vertical length with a
straight hemostat, which is parallel to the floor of the mouth.

Using a scalpel the clasped portion of tissue is excised, first above the hemostat and
then below.

The wound margins are then undermined with scissors and interrupted sutures are
placed.

3- Denture-Induced Fibrous Hyperplasia

Fibrous hyperplasia of the mucosa (formerly known as epulis/denture fissuratum or

inflammatory hyperplasia).

Usually due to chronic trauma of the mucosa of the mucolabial or mucobuccal fold,
due to ill-fitting complete or partial dentures.

dentures, or after a period of time, when, due to resorption of the alveolar process,
the anatomy of the region changes and the necessary adjustment of the prosthetic
appliance is neglected.

Treatment is surgical and consists of excision of the hyperplasia.

Surgical Technique

After local anesthesia, the lesion is grasped with surgical forceps and is gradually
excised along the length of the lesion.

Suturing of the wound margins with periosteum that has not been reflected, which
remains exposed, avoiding a decrease in the depth of the mucobuccal fold.

Replacement of old denture, immediately after the end of the operation, retaining the
depth of mucosa of the newly created sulcus.

The internal surface of the denture is lined with tissue conditioner.

4- Fibrous Hyperplastic Tuberosity

Fibrous hyperplasia of the soft tissues of the alveolar process is reactive in nature,
usually observed in the retromolar edentulous area of the maxilla and is the result of
constant irritation during mastication.

Clinically, bilateral asymptomatic symmetric lesions with a smooth surface are noted,
which are elastic and firm during palpation.
Size varies and sometimes the lesion may grow to be so big that it occupies all of the
interarch space during occlusion, creating serious problems for construction of a
partial or complete denture.

Surgical Technique

After administration of a local anesthetic, the portion of hyperplastic tissue to be

excised is demarcated.

Two elliptic incisions are then made along the length of the fibrous hyperplasia, one
buccally and the other palatally.

The incisions begin at the site of formation of hyperplastic tissue, and are wedge
shaped, with the scalpel proceeding until it touches bone.

The elongated wedge shaped portion of the hyperplasia is then removed and the
periosteum is reflected buccally and palatally, in order to readapt the wound margins.

Thereafter, the buccal and palatal parts are sutured at the midline of the alveolar
ridge using a continuous suture.

5- Gingival Fibromatosis

This is a benign condition, which is characterized by slow progressive swelling of the

attached gingiva and alveolar mucosa.

The lesion may be generalized or localized.

Hereditary or acquired causes.

Incision along the alveolar ridge and reflection of buccal and lingual gingivae.

Excision of the lesion is performed in segments.

The alveolar ridge is then smoothed and, then the wound margins are re
approximated.

Closure with interrupted sutures.

6- Flabby Ridge

Flabby tissue means ‘excessively mobile tissue’.

This arises because of unplanned dental extractions that result in maxillary complete
dentures opposing mandibular anterior natural teeth.

Bone disappears and the body fills the space with flabby tissue.

Surgical technique

Treated by excision and extraction of the opposing teeth.

7- fibro-epithelial polyp of the palate

Common under the upper denture.

May grow to a considerable size.

Better Removed either by diathermy or cryoprobe.

 Management of flat ridge
I. Relative Heightening Procedures (Sulcus deepening/ vestibuloplasty)

II. Absolute Heightening Procedures

III. Implant Procedures

IV. Distraction osteogenesis

I. relative heightening procedures (sulcus deepening or vestibuloplasty)

Aim:

To uncover the basal bone surgically by repositioning of overlying mucosa, muscles,

and attachments.

Indicated:

If adequate underlying bone is present.

Contraindicated:

In cases of severe ridge resorption

Concept

The size of the denture-bearing area can be increased by deepening the sulci
providing there is adequate underlying bone.

Deepening of the buccal sulcus in the maxilla is seldom necessary as the palate
provides a large denture-bearing area.

Retention and support for the lower denture would often benefit from deepening of
the sulci particularly where muscle attachments have come to lie near the crest of the
ridge.

Anteriorly the mentalis muscle, laterally the buccinator muscle, and lingually the
mylohyoid muscle are involved.

To deepen the sulci effectively these muscles must be detached from the mandible
and the mucosa made to heal with a new reflection at a lower level.

I. Relative Heightening Procedures


(Sulcus deepening OR Vestibuloplasty)

1) Submucosal Vestibuloplasty (Obwegeser 1959)

2) Secondary Epithelialization Vestibuloplasty

a- Kazanjian’s Technique (Raw Lip).

b- Clark’s Technique.

3) Grafting Vestibuloplasty

4) Fenestrated Mucosal Flap Vestibuloplasty

(1) Submucosal vestibuloplasty (Obwegeser 1959)

Indication:

Adequate underlying bone is present but the clinically apparent ridge is diminutive in
height.

The presence of adequate healthy mucosal tissue at or near the alveolar crest.

The mucosal tissue must not be scarred or exhibit surface hyperplasia.

This attempts to divide the muscle attachments and deepen the buccal sulcus
without making a flap or leaving raw area.

Achieved by removing redundant connective tissue between the mucosa and the
periosteum on the labio-buccal aspect of the ridge and by re-attaching the mucosa to
the periosteum at a higher level.

OPERATIVE PROCEDURE

1. A vertical incision is made in the midline mucosa from the anterior nasal spine
to the crest of the alveolar ridge.

2. Scissor is then passed between mucosa and periosteum. The muscle

attachments on the buccal aspect are cut, as far back and upwards as
possible to free the mucosa.

3. The connective tissue inside the formed tunnel is either removed or displaced
superiorly.

The tunnel formed extends from the midline, posteriorly on each side and is
bounded externally by the mucosa interiorly by the periosteum.

4. The incision is then sutured.

5. The mucosa is held against the bone in it’s new position by a preoperative
prepared denture with long flanges:

Lined with soft liner.

Fixed by circumferential wire for the lower jaw and per-alveolar

wire for the upper jaw.

A new denture is constructed and inserted as soon as possible.

Advantages:

The technique is relatively simple, yet effective method of increasing the functional
alveolar ridge.

Minimal post operative complications.

Disadvantages:

Somewhat limited surgical access through the vertical midline incision

Relapse due to improper tissue displacement is quite common

Possibility of nerves injury (infraorbital / mental ) is frequent (Blind operation).

(2) Secondary Epithelialization Vestibuloplasty

Indication:

In case of sufficient bone resorption but the mucosa is insufficient in quantity or

quality such as inflammatory hyperplasia, ulceration, or scars.

A] Kazanjian’s Technique (Raw Lip).

B] Clark’s Technique.

A] Kazanjian’s Technique (Raw Lip).

A labial mucosal flap is raised and transferred to line the osseous side of the
deepened vestibule

1. An incision is made in the mucosa of the lip.

2. Submucosal /(supraperiosteal dissection is done from the inner aspect of the

lip removing muscle connective tissue attachments to the desired
vestibular depth .

3. The raised mucosal flap is adapted to the depth of the new vestibule and
fixed with sutures. The raw area on the lip is left bare.

4. Rubber catheter stent is then placed in deepened sulcus It’s function is to

hold the flap in its new position and maintain the depth of the vestibule it
is removed after 7 days.

Disadvantages:

- Severe scaring of the lip.

- Decrease of lip flexibility.

B] Clark’s Technique (Raw Periosteum)

A flap of the alveolar mucosa is raised and transferred to line the soft tissue side of
the vestibule

1. A circumvestibular incision is made 3mm away from the crest labiobuccally from
right retromolar area to its corresponding area on the left.

2. Supraperiosteal dissection is done and the mucosal flap is reflected and the
mentalis and buccinator muscles are disinserted and pushed downward

3. The mucosal margin is sutured at the new depth THEREFORE leaving the
periosteum to granulate and epithelialize

4. Insert a preoperatively prepared denture lined with soft liner which is kept in place
by circummandibular wiring.

Disadvantages of 2ry Epithelialization Technique

More than 50% of the established depth is lost within 1 year (relapse).

Patient experiences postoperative discomfort, since the raw mucoperiosteum is very

painful.

(3) Grafting Vestibuloplasty


A] Autograft (Skin, Mucosa, Dermis)

Advantage

Decrease in the incidence of relapse.

Decrease in the discomfort and faster healing & early construction of the prosthesis.

Disadvantage

A secondary wound can develop at the donor site.

Principles of Skin Grafting

1. Skin should be taken from a hair free area, for example the upper arm.

2. Recipient area must have good blood supply, free from infection, with good
haemostasis.

3. The graft must be applied over periosteum and NOT bare bone.

4. The graft must cover the entire raw area especially portion liable for
contracture (ex. Base of vestibule).

5. The graft is immobilized by a stent for 7-10 days however, small skin flaps
can be sutured in place without stents.

6. Skin grafts avoided in patients with keloid tendency or a dermatological

disorder such as psoriasis.

Operative Procedure

The procedure is done in the same way as Clark’s technique EXCEPT the raw
periosteum is covered by graft material.
 1. The donor site (thigh or upper arm) is disinfected using iodine and alcohol.

2. skin is stretched and split thickness skin graft is taken by dermatome.

3. The graft is meshed to prevent haematoma formation under the graft and kept
in saline.

4. The skin wound is covered with compress of Sufratull, sterile gauze, and
bandage for 10 days.

5. The graft is then applied to the raw area and fixed by interrupted sutures to
the mucosal margin.

6. Denture with liner is placed and held by circummandibular wiring for 7-10
days.

B] Allograft (Zenoderm, Lyodura, Lyoplant)

Considered to be satisfactory for healing of denuded areas of the mucosa with

decreased granulation tissue formation.

Satisfactory mechanical properties.

Low rate of infection.

No evidence of hypersensitivity.

No need for a donor site.

(4) Fenestrated Mucosal Flap Vestibuloplasty

Aim :

Overcome relapse problems.

Guarantee proper repositioning of tissues and muscles.

Provide rapid epithelization of raw areas without grafting material.

OPERATIVE PROCEDURE

1. Mucosal incision around mandibular alveolar process 3-5 mm away from

mucobuccal fold.

2. Supraperiosteal dissection of fibrous tissue and muscles all around the

mandible.

3. Lip cheek mucosal flap and muscles sutured and reattached to periosteum at
inferior border of mandible by interrupted suture 000 black silk.

4. Alveolar mucosal flap fenestrated by 4-5 oblique full thickness incisions

stretched to cover most labial raw periosteum and fixed to it with
interrupted sutures.
 5. Preoperative prepared lower denture with long flanges lined with soft liner is
inserted and secured in place by circumferential wiring.

6. Circumfrential wiring removed after a week, Patient uses old denture for
2-3weeks with good oral hygiene then new denture is inserted after 1
month.

Absolute heightening procedures Ridge augmentation

The height or width of the ridge can be increased by the introduction material under
the mucoperiosteum. This may be achieved by:
-Bone grafting (autogenous versus synthetic as H.A)
-Onlay bone grafting
-Inferior and superior border augmentation of the mandible
-Interpositional bone grafting
-Sinus lift procedures.
I) Maxillary bone augmentation:

A) Onlay bone grafting:

Maxillary autologous onlay bone graft (Rib / iliac crest)

ϖ Severe maxillary alveolar atrophy.

ϖ Flat palatal vault form.

ϖ Mild to moderate antero-posterior ridge discrepancy.

Advantages:

ϖ Augments alveolus.

ϖ Improves vault form.

ϖ Improves antero-posterior relations.

Disadvantages:

ϖ Secondary donor site required.

ϖ Unpredictable resorption.

ϖ Delay in wearing dentures 6-8 months.

B) Augmentation with synthetic graft materials. (Hydroxyapatite)

Bone substitutes have the advantage of avoiding a second surgical site for
harvesting of bone.

II) Mandibular Ridge augmentation

A) Mandibular superior border augmentation(Rib or iliac crest):

Significant postoperative resorption, from one-half to two-thirds with rib, up to 70%
with iliac crest bone.

b) Mandibular inferior border augmentation (Rib):

Prevention and management of fractures of the atrophic mandible.

Disadvantages:

It does not treat abnormalities of the denture bearing area.

scar

III) Interpositional bone graft

Can be used to augment the atrophic maxilla or mandible.

To overcome the main disadvantage of mandibular onlay grafting, i.e., rapid

resorption.

The maxilla or mandible is "split", elevated, positioned and supported by interposed

grafts of autogenous bone or cartilage, freeze dried bone, alloplastic material, or
combinations of these grafts.

IV) Sinus lift procedure

This is performed to increase bone depth prior to implant insertion in the posterior
maxilla.

Bone graft is placed to lift the sinus lining and effectively increase the depth of
alveolar bone.

c) Osseointegrated Implants

Titanium : Screws of specific design placed in the ridge.

bridge is attached or overdentures.

d) Distraction osteogenesis
 Odontogenic diseases of the maxillary sinus
Dr. Hani Arakji
Oral & Maxillofacial Surgery Department
Beirut Arab University

- The maxillary sinuses are air containing spaces that occupy maxillary bone
bilaterally.
- The paranasal sinuses are :
1- Maxillary air sinus
2- Ethmoidal air sinus
3- Frontal air sinus
4- Sphenoid air sinus
θ The sinuses are lined by respiratory epithelium (mucous secretin
pseudostratified, ciliated, Columnar epithelium).
θ The cilia & mucous are necessary for the drainage of the sinus.
θ The maxillary sinus opening is called Ostium.
θ It opens into the posterior or inferior end of the semilunar hiatus which lies
in the middle meatus of the nasal cavity between the inferior and middle
nasal conchae.
θ Apex: Lateral nasal wall
θ Base: laterally into zygoma
θ Roof: floor of the orbit
θ Floor: the alveolar process
θ Posterior: infra temporal wall of the maxilla
θ anterior: extends to the first premolar/canine


Teeth related to the maxillary sinus are
1- First molars
2- Second molars
3- Second premolars
4- Third molars
5- First premolars

θ Because of this close relationship , sinus problems can be mixed up with

maxillary dental problems
θ One of the most common manifestations of sinusitis may be acute pain and
tenderness of maxillary teeth of the same side.

Diagnostic Aids For Maxillary Sinus Diseases

I) History
II) Clinical Examination
III) Radiographic Examination
IV) Sinoscopy

I) History: a diffuse toothache with history of common cold

II) Clinical examination: Percussion
Palpation
Transillumination

✴ The normal sinus shows a well-marked infraorbital crescent of light &

the pupils present a luminous glow.
✴ These features are absent if there is a pathology.

III) Radiographic Examination

1- Intraoral periapical films
 θ Detect approximation of the teeth to the sinus.
θ Detect root tips or foreign bodies in the sinus.
2- Panoramic view
θ Give an overview of the maxillary sinuses bilaterally
3- Water’s view (15 degree Occipitomental view)
θ Produce a very clear unobstructed view of both sinuses.
θ It is the best demonstrable view to the sinuses.

4- Computerized Tomography Scanning (C.T )

θ Done either in a coronal, sagittal or Axial planes to give more accurate
diagnosis to the sinus pathology in a three dimensional way.
5) Sinoscopy
θ It is a recent investigation method which have an important role in the
diagnosis of the malignancy and other pathological conditions of the
maxillary antrum.

Odontogenic Infections
of
The Maxillary Sinus
1- Maxillary Sinusitis
a- Acute
b- Chronic
2- Mucus – Retention Phenomenon
3- Oroantral Communications
4- Neoplastic & Cystic lesions

Maxillary Sinusitis
Causes
A) Nasal origin (Non odontogenic causes)
Common cold, influenza, rhinitis.
B) Dental origin (Odontogenic causes)
1- Spread of infection from a dental abscess of related teeth.
2- Infected benign cystic lesion of related teeth.
3- Faulty RCT (Overextended filling).

4- Tooth or roots pushed into the sinus.

5- Oroantral fistula.
6- Facial fractures involving the sinus.
7- Spread of infection from a dry socket.

Acute Maxillary Sinusitis

1- Pain referred to the cheek side, increased by bending the head downwards.
2- Interference with smell.
3- Pain & tenderness to the teeth related to the sinus.
4- Foul unilateral nasal discharge & nasal obstruction.
5- Little constitutional symptoms.
θ Water’s view reveals opaque sinus & sometimes fluid level is seen.
θ CT scanning also reveals opacified sinus in case of maxillary sinusitis.
Treatment
1- Humidification of the inspired air to aid in the removal of dried secretions from
the nasal passage.
2- Antibiotics (penicellin or broad spectrum).
3- Decongestant nasal drops to shrink the mucous lining & help the drainage.
(ephedrine 1 % in saline )
4- Analgesic to relief the pain.
5- Removal of the cause.

Chronic Maxillary Sinusitis

1- Continuous dull pain and intermittent headacke.
2- Sense of smell is impaired.
3- Foul odor.
4 – Oroantral fistula or prolapse of reddish mass on the gum.
Radiographically: Shows opacity of the sinus with marked thickening of the
lining.
Treatment:
! In some cases the lining will return to normal after removal of the cause.
! If the lining damage is irreversible with the presence of antral polyps, it
should be removed through caldwell Luc operation or sinoscopy.

Complication of Maxillary Sinusitis

1- Orbital cellulitis
2- Cavernous sinus thrombosis
3- Meningitis
4- Osteomyelitis
5- Intracranial abscess
6- Death

Mucus Retention Phenomenon (Mucocele , mucosal cyst ):

θ It is a chronic expansile secretory cyst that is lined with respiratory
epithelium.
! Causes: It is not certain.
! It probably represents a collection of mucus within the sinus membrane
caused by cystic dilatation of a mucus gland.
Radiographic appearance
θ Homogenous curved radiopaque area that is oval or dome – shape.
θ The cyst has a smooth and uniform outline.
θ Most of them arise from the floor of the sinus.
 θ They vary in size from a few millimeters to occupying the majority of the
sinus cavity.

Oroantral Communication
θ It is the communication between maxillary sinus cavity and oral cavity
through a perforation in the sinus wall.
Etiology
1- Accidental antral opening during extraction of a tooth or root or pushing into the
sinus.
2- Massive trauma to the middle 1/3 of face.
3- Post operatively (e.g. After surgical excision of a large cyst or tumor)
4- Malignant tumor affecting the sinus.
5- Osteomyelitis of maxilla.
6- Dental implants.
7- Unhealed Caldwell Luc operation.

Clinical picture
1- Regurgitation of fluids from the mouth into the nose.
2- Unilateral epistaxis.
3- Alteration in vocal resonance.
4- Inability to blow out the cheeck.
5- Difficulty in smoking.
6- Foul or salty unpleasant test.
7- Painless lump at the site of the extraction.
8- With compression of the anterior nares & patient blow with open mouth there is
Bubbling of the blood from the socket occur.
9- Later on there is superimposition of infection on the topof the fistula.

Radiographic appearance
Reveals the presence of a tract connecting the oral cavity with the maxillary sinus.
Treatment
! The treatment of oroantral communications is accomplished either
immediately, when the opening is created or later, as in the instance of
long standing fistula or failure of an attempted primary closure.
Immediate Treatment
θ When perforation of the antrum occurs, the least invasive therapy is
indicated initially.
θ If the opening is small & the sinus is disease free, efforts should be made to
establish a blood clot in the extraction site and preserve in place.
θ Sutures are placed to reposition the soft tissues, and a gauze pack is placed
over the surgical site for 1-2 hours.
θ The patient is instructed to use nasal precautions for 10-14 days including :-
1- Avoid heavy sneezing.
2- Avoid sucking objects.
3- Avoid smoking.
4- Avoid nose blowing & any situations that may produce pressure changes
between the nasal passage and the oral cavity .
•The patient is placed on an antibiotic , an antihistaminic & a systemic
decongestant for 7-10 days to :
1- Prevent infection.
2- Shrink mucous membrane.
3- Lessen nasal & sinus secretions.
•The patient is seen postoperatively at 48 to 72 hours intervals & is instructed
to return if an oroantral communication becomes evident i.e. (leakage of air
into the mouth or fluid into the nose).
Treatment of long standing communications (OAF)
ϖ Successful treatment and closure of the oroantral communication requires
extensive surgery.
ϖ Aggressive antibiotic therapy is also necessary.
ϖ Surgeons can use various technique to close this communication as :
1- Technique for very small pinhole fistula.
 2- Buccal sliding mucoperiosteal flap.
3- Palatal pedicle flap
4- Membrane assisted closure.
5- Caldwell-Luc operation.

Post-operative instructions
Avoid blowing, coughing with open mouth.
Antibiotics to control infections for 5-7 days.
Analgesic to relief pain.
Decongestant nasal drops.
Soft diet.
Warm normal saline mouthwash.
Sutures are removed after 7-10 days postoperatively.
Failure to close oroantral communications
Incomplete elimination of infected tissue.
Presence of root fragment inside the sinus.
Placement of soft tissue flap under tension.
Inadequate length of the flap.
Improper approximation or closure of the flap.
Haematoma formation inside the sinus and it’s infection.
Inadequate nasal drainage.
Inadequate postoperative care & instructions.
Mechanical interference with sutures by the patient.

5-Caldwell Luc
The most successful technique to get out the root from the antrum as it gives direct
vision & access to the root.
Indications:
1- Removal of root or tooth forced into the sinus.
2- Chronic sinusitis.
3- Chronic oroantral fistula with polyp formation.
4- Cysts or tumors involving the sinus.
5- Bleeding or haematoma inside the antrum from trauma to the face.

Technique:
1- The forced tooth or root is located carefully using x-ray.
2- Operation may be done under local or general anaesthesia.
3- The upper lip is elevated with a retractor then a semilunar or pyramidal
mucoperiosteal flap from the canine to the 2nd molar tooth is done.
4- The flap is reflected to expose the anterior wall of the sinus avoiding injury to
the infraorbital nerve.
5- An opening is made above the premolars’ roots to permit inspection of the sinus
cavity.
6- Removal of the tooth or foreign body & if there is an evidence of infection, the
lining of the sinus is removed to avoid recurrence.
7- The cavity is cleaned then intranasal antrostomy is performed to prevent
recurrence & haematoma.
8- Repositioning of the mucoperiosteal flap and sutured with interrupted black silk
suture (water tight).
9- Put a stent after suturing for 2 days as to decrease the contamination of the field
& accelerate the clotting action.
10- Give the patient the postoperative instructions.

Complications
1- Anesthesia of the lip, cheeck & gum.
2- Devitalization of the teeth in the operating field.
3- Uncontrolled bleeding.
4- Bone infection (osteomyelitis).
 Diseases of Salivary Glands
Dr. Hani Arakji
Faculty of Dentistry
Beirut Arab University

Saliva is supplied by three pairs of major salivary glands, the

parotid, submandibular, sublingual, and numerous minor salivary glands
of the lips, palate, and tongue.

¥ It may contain either mucous cells or serous cells.

¥ Mucous cells consisting of large granules precursor of mucin.
¥ Serous cells have opaque small zymogen granules (consisting of a
precursor of ptyalin)

¥ Mucin secreted by the mucous cells is a useful lubricant.

¥ Ptyalin secreted by the serous cells is an amylase which initiates
the digestion of starch.

The functions of saliva are mainly mechanical. It assists mastication

and swallowing, and it aids speech. It minimizes the risk of infection and
caries by its washing effect.

Salivary secretion is provoked either by the taste of food (inborn

reflex), or by the thought of food (psychic or conditioned reflex).
Diminished flow result in xerostomia (dry mouth). Excessive salivation is
termed sialorrhea.

Gross anatomy of Parotid gland

! The apex lies between the sternomastoid muscle and the

mandibular angle.
 ! The base lies near the zygomatic bone and the condylar neck of the
mandible.

! Laterally, the gland may present a detached portion known as the

accessory parotid gland.

! Medially, the gland contacts the medial pterygoid muscle and

approximates the lateral pharyngeal wall.

! The anterior surface is grooved by the mandibular ramus and

masseter muscle.

! The posterior surface is grooved by the mastoid bone and styloid

process and sternomastoid and digastric muscle.

! The entire parotid gland is invested with a connective tissue

capsule or sheath that is driven from portions of deep cervical
and masseteric fascia.

! The facial nerve, emerging from stylo-mastoid foramen, enters the

gland and courses ventro-laterally, forming the parotid plexus
within the gland.

! It empties into oral cavity by way of Stenson`s duct, which

terminates intra-orally at the parotid or Stenson`s papilla
opposite the crown of maxillary second molar.

Innervation of Parotid gland

•Parasympathetic (secretory) fibers from otic ganglion via the

auriculo-temporal nerve.

•Sympathetic innervation of all salivary glands is probably entirely

vasomotor.

The secretion is purely serous.

Gross anatomy of Submandibular salivary gland

 •It is the second largest of the three main salivary glands.

•It consists of a larger superficial part and a smaller deep process.

•The two parts are continuous with each other around the posterior
border of the mylohyoid muscle.

•The larger portion lies in the digastric triangle.

•It is bounded superficially by the skin and platysma muscle,

laterally by the mandible and medial pterygoid muscle, and inferiorly
by mylohyoid, stylohyoid, and digastric muscles.

•The entire gland is surrounded by a capsule similar to the one that

surrounds the parotid.

•This capsule is derived from portions of the external cervical,

digastric, and styloid muscle fascial layers.

•Its excretory duct is Warton`s duct. It arises from the junction of the
superficial and deep processes. It turns at right angle superiorly and
courses under oral mucosa. The Warton`s duct open at the sublingual
caruncle (papilla) located at the side of lingual fenulum.

•The diameter of the duct is 1.5 – 3.5 mm.

•Parasympathetic secretory fibers derived from the submandibular

ganglion.

•Its secretion is mixed (mucous and serous).

Gross anatomy of Sublingual salivary gland

•Is the smallest of the major salivary glands.

•It is a group of glands forming an elongated mass in the floor of the

mouth, lateral and inferior to the tongue.
 •The superior border of this gland forms a ridge called the plica
sublingualis in the floor of the mouth.

•Inferiorly the gland rests on the mylohyoid muscle.

•Its lateral surface contacts the mandible and medially it is related to

genioglossus and submandibular duct.

•The principal excretory duct is Bartholin`s, which may fuse with

submandibular duct to share a common opening on sublingual
caruncle.

•More commonly, Bartholin`s duct opens independently on the

sublingual caruncle.

•In addition to Bartholin`s duct, from 5-30 smaller ducts (the duct of
Rivinus) drain the sublingual gland.

•These ducts of Rivinus, drain the sublingual gland and open along
the crest of the plica sublingualis at the superior border of gland.

•Para sympathetic innervation from submandibular ganglion.

•Secretion is mucous and serous; mucous being predominant.

Minor salivary glands

Numerous additional and smaller salivary glands (450-750) are

located within the mucosa throughout the oral cavity.

•On anatomical basis are classified into; labial, buccal, glossopalatal,

and palatal.

•Labial and buccal are mucoserous, glossopaltive and palatal are

mucus.

•The tongue also contains minor salivary glands.

•Near the apex on the inferior tongue surface is the gland of Blandin-
Nuhn, which secretes mucus and serous saliva.
 •Ebner`s glands located near the vallate papillae, produce serous
secretion.

Disorders of salivary glands

1. Inflammatory disorders.

2. Obstructive disorders

3. Developmental disorders.

4. Functional disorders.

5. Cysts and cyst-like lesions.

6. Benign neoplasms.

7. Malignant neoplasms.

Inflammatory disorders:

1. Acute bacterial sialadenitis.

2. Sialectasia

3. Mumps

4. Toxic Parotitis

5. Specific infections of the salivary glands

1. Tuberculosis

2. Syphilis

3. Actinomycosis

4. Post-irradiation chronic sialadenitis

1- Acute bacterial sialadenitis

ϖ Symptoms: it is a painful swelling of the gland accompanied by a

decrease in its function.

! Low grade fever, malaise, and headache.

 ! The overlying skin appears reddened and tens due to glandular
edema

ϖ Etiology: The microorganism involved represent a wide range of

normal oral bacteria; staphylococcus aureus, staph. Pyogenes,
streptococcus viridance, and pneumococci, or fungal forms.

ϖ Mixed infection; ascend to the gland from oral cavity.

ϖ Specific bacterial forms; are commonly blood borne

ϖ Treatment

5. Antibiotic therapy

6. Surgical drainage and the use of lacrimal probes.

ϖ The orifice of Stenson`s duct may be simply slit open with surgical
scissor. After acute phase has subsided, the duct may be dilated
using lacrimal probes to facilitate drainage.

ϖ Salivary washing action should be instituted using a sialagogue

such as citric acid or lemon extract.

ϖ Throughout treatment, the patient hydration condition should be

maintained.

ϖ Prognosis: this condition tends to recur, in the form of a sub-acute

or chronic form of the disease.

2- Sialectasia

•Sialectasia or swelling of the salivary glands. It represent the end

stage of chronic, recurrent sialadenitis.

•Clinically the patient complain of diffuse swelling of salivary gland

usually parotid. The swelling increases in size over months or even
years.
3- Mumps (Epidemic parotitis)

•Before routine vaccination againist the disease began, viral parotitis

occurred in epidemics during the winter and spring.

•Is a viral disease that primarily affects salivary glands but also affects
other organs (pancreas, ovaries, testis).

•It is the most common of salivary gland diseases.

Symptoms : fever, headache, and malaise.

Usually one gland is affected followed by the other in 3-6 days.

The onset of symptoms is usually sudden.

The swelling of glands reaches a maximum within 2 days and diminishes

over an additional week.

Painful non- erythematous swelling in one or more salivary glands that

begins 2-3 weeks after exposure to virus, most commonly parotid, and
occasionally the submandibular.

Dry mouth with inflamed orifices of the parotid duct.

This clinical enlargement is due to glandular inflammation precipitated

by the virus.

Complications: include orchitis, testicular atrophy, and sterility in

approximately 20% of young men affected by mumps.

Treatment: symptomatic with isolation of patient for 6-10 days to prevent

contagion.

4- Toxic Parotitis

Toxic parotitis due to copper, lead, and mercury poisoning or allergic

parotitis caused by the presence of bacterial antigens.

5- Specific infections of the salivary glands

a -Tuberculosis :

Tuberculosis of salivary glands is a very rare occurrence and is to be

distinguished from tuberculosis of contained lymph nodes.

There have been very few cases reported of apparently primary infection
of the salivary gland

The treatment is excision.

b - Syphilis

Is also extremely rare and has usually occurred in cases of the more
virulent type.

A positive wassermann would of course be suggestive, and the

disappearance of the swelling under antisyphilitic treatment is almost
conclusive.

c - Actinomycosis

This may be part of a neighboring infection, or it may have gained

entrance to the gland through the duct.

The diagnosis in the later stages after sinuses have formed, is to be made
by finding the fungus.

The treatment is as for the same infections at other sites.

6- Post-irradiation chronic sialadenitis

Patients who receive therapeutic irradiation for malignancies of the head

and neck region complain of a dry mouth for a period of 2-6 hours after
treatment.

There is pain and enlargement of parotid and submandibular gland during

the same period.

This enlargement increases for 12-24 hours, then rapidly subsides without
treatment.
These symptoms are due to an acute inflammatory reaction within the
salivary gland.

This is followed by progressive degeneration and loss of acini which ends

up with atrophy of glandular element and development of xerostomia.

Obstructive Disorders (Sialoliths)

Salivary secretions contain water, amylase enzyme, electrolytes, urea,

ammonia, glucose, fats, proteins, and other substances.

Calcium content in submandibular saliva is twice its content as in parotid.

Due to the high contens of calcium, and the anatomic variation in duct
system (double bend), obstruction phenomenon are most commonly
found in submandibular gland.

Etiology: ductal obstruction may be caused by mucous plugs, calculi

within the duct (sialolithiasis), ductal strictures or ulcerations, or by
neoplasm.

Mucous plugs may be treated with strong sialagogue.

The contrast medium used in sialography may also break up a mucous

obstruction.

If both methods failed, it is treated as sialolith.

Symptoms: partial ductal obstruction causes pain and swelling in the

gland region which are evident in immediately prior to, during, and
immediately following meals.

Partial obstruction may lead to glandular infection; bacteria may ascend

to reach the stagnant pool of saliva proximal to obstruction.

Degree of obstruction plays an important part on glandular tissue.

Partial obstruction results in sialoangiectasis (Dilation of salivary ducts).

Obstruction with rupture of the duct produces retention cysts

Partial obstruction are usually accompanied by infection.

Complete obstruction produces atrophy.

Parotid Obstruction (Papillary Obstruction)

Stensen`s papilla and duct orifice may be traumatized by the dentition, a

faulty restoration, a dental prosthesis, or erupting second and third
molars.

The edema associated with this trauma may cause ductal obstruction.

Chronic fibrotic papillary stenosis may occurs with partial or total closure
of ductal orifice.

Parotid duct sialoliths are not as common as submandibular sialoliths (6%

only of salivary calculi).

These calculi are usually smaller but more symptomatic than Warton`s
duct calculi. Patients therefore seeks treatment earlier.

Treatment: If the calculus lies immediately subjacent to the ductal orifice,

the orifice may be simply slit open with surgical scissor.

It may be necessary to `milk` the calculus out with salivary flow.

The papilla and ductal orifice heals well without the use of sutures.

Treatment also consists of removal of the cause of trauma.

If stenosis has occurred, dilatation of the ductal orifice with graded

lacrimal probes or surgical removal of papilla and distal duct portion.

Following milking of the gland, the tissues behind the papilla may
assume a bluish color due to a pool of saliva.

Care must be taken to suture the duct walls to oral mucosa if the buccal
pad of fat was herniated to the oral cavity.

Submandibular Obstruction
Etiology:

1. Following surgical procedure in the anterior floor of the mouth (as

biopsy).

2. Sialoliths are the most frequent cause of obstruction of Warton`s

duct.

The most common site is just distal to the body of the gland , Calculi in
this posterior segment of the duct may remain asymptomatic for
sometimes due to the relatively large size and elasticity of the duct.

If the stone increased in size, symptoms starts due to impaired salivary

flow.

Symptoms: pain, swelling, or infection.

Diagnosis: most stones within at least the distal portion of Warton`s duct
may be palpated, and it is possible to locate the obstruction .

Fibrosed gland feels firm and inelastic while normal gland feels elastic.

Enlarged sub-mandibular salivary gland with retention of salivary flow

following sialolith.

Palpation of sbmandibular salivary gland is useful

Occlusal radiograph is mainly used for diagnosis.

Sialography also can be used. Sialography should be used with caution; a

sialolith may be forced proximally due to the contrast medium injection
pressure. And certainly CT scan and CBCT are useful nowdays.

Treatment: If the obstructive stone lies in the extra-glandular portion of

the duct, and if the gland itself has suffered no damage, the stone is
removed surgically.
Surgical technique

A suture is passed around the duct posterior to the stone and tied gently;
this prevents proximal displacement of the calculus.

Excision of stone in posterior region of Warton`s duct

The assistant must forcibly elevate the gland so that it projects into the
mouth as far as possible.

Silver lacrimal duct probe is passed into the duct, and the floor of the
mouth retracted upward, in order to tense the tissues over the duct.

Incise directly over the stone after it is felt with the lacrimal probe.

If the stone lies in the intra-glandular portion of the duct or if the gland
has become fibrosed due to long-standing obstruction or infection, the
entire gland is removed ( Sialadenectomy)

Sublingual and minor gland obstruction

It is rare condition.

The buccal mucosa and upper lip are the most common sites for minor
glands stones.

Symptoms: sublingual edema; minor glands obstruction present as hard

swelling.

Treatment: is identical to that of mucocele and ranula.

Congenital anomalies

1. Aplasia or agenesis: congenital absence of salivary gland.

2. Atresia: congenital occlusion or absence of salivary gland ducts.

Both conditions give rise to xerostomia, increased caries rate, and
retention cyst formation.

1. Submandibular salivary gland depression (Stafne`s bone cyst)

Stafne`s bone cavity

It is constantly situated beneath the mandibular canal and adjacent to the

lower border of the jaw between the cuspid region and the angle.

Stafne`s bone cavity

Also called: Mandibular salivary gland depression; or Static bone cyst.

It is inclusion of salivary gland tissue adjacent to the lingual surface of

the mandible in a deep, well-circumscribed depression.

Although not actually cysts of the jaw, they have been included because
of their clinical and radiographic similarity to cystic lesions.

Functional disorders Sialorrhea (ptyalism)

Increased salivary flow may result from two main categories:

1. Factors affecting the central nervous system.

2. Local factors which reflexly stimulate flow.

It may occur in mentally retarded individuals, schizophrenia, epilepsy,

Parkinsonism, mercury poisoning, and other mental, psychiatric, and
neurological disturbances.

The most common causes are acute inflammations of the oral cavity as it
causes reflex stimulation.

It is common in acute herpetic or aphthous ulceration and acute

necrotizing gingival stomatitis.

Ill fitting dentures and eruption of teeth in young individuals.

Treatment:
The underlying cause of excessive salivary flow should be treated.

Symptomatic relief may be frequently obtained with the antihistaminic

drugs as methantheline promide (Banthine 50mg) or atropine sulfate
(1/150 grain).

Xerostomia

It occur when salivary secretion is less than 0.2 ml per 15 minutes (19 ml
per day).This flow rate is less than 4% of the average salivary flow rate
for persons under 65 years of age.

Note: total quantity of salivary secretion produced per day estimated from
500-1500 ml, (5-15ml per 15minutes).

Signs and Symptoms:

Dry mouth, pronouncing reddening of tongue coupled with total papillary

atrophy, lobulation or deep fissuring.

Glossdynia, chellosis of the lip commissures, dysphonia, dysphagia, taste

disturbances, and denture difficulties.

Increased caries rate in cervical areas.

Etiology:

May be idiopathic or local causes such as mouth breathing, inflammation

of salivary glands, irradiation, or aging changes.

May be associated with systemic conditions as anemia, certain syndromes

(Sjorgen`s, Mickulicz`s,), lupus erythromatosis, hormonal disturbances,
drugs, emotional and anxiety states, and fluid loss.

Treatment:

Removal of the cause.

Symptomatic (non of it has gained universal success or acceptance).

This include; Mouthwash containing citric acid (12.5 gm), essence of

lemon (12 ml) and glycerin.

Mucus retention cyst

It is regarded as a cyst because it is lined by an epithelium; unlike mucus

extravasation phenomenon, which contains mucus pool surrounded by
granulation tissues.

Mucocele is used in the clinical setting as a generic term (before

microscopic diagnosis) to refer to both the retention cyst and the
extravasation phenomenon.

Mucocele

(mucus extravasation phenomenon)

It result from trauma to the ducts of mucus glands with escape of

secretions into the surrounding connective tissue.

The lower lip is the most common site.

Also it may be found in:

1. The buccal mucosa,

2. Ventral surface of the tongue (glands of Blandin-Nuhn).

3. Floor of the mouth.

4. Retromolar region.

Mucocele

(mucus retention cyst)

It result from obstruction of salivary flow.

It is rarely present in the lower lip (3%).

It is found in the palate, cheek, and floor of the mouth as well as
maxillary sinus.

Treatment of Mucocele

1. Complete removal of the mucus retention cyst and the associated

lobules of minor salivary gland is indicated.

2. Marsupialization may be performed prior to excision.

3. The stone is either surgically removed or “milked” through the duct

orifice.

Ranula

Is a clinical term that is used to designate a mucocele that occur

specifically in the floor of the mouth.

It may represent either mucus extravasation phenomenon or mucus

retention cyst.

It is associated with the duct system of the sublingual salivary gland

(Bartholin), less commonly, the submandibular glands (Warton`s duct).

It is usually unilateral.

The walls are thin and don’t pit on pressure.

It may result from trauma or obstruction from sialoliths.

Ranula is a bluish, fluctuant, not pitting unilateral, soft tissue mass in the
floor of the mouth.

Treatment of ranula

Cross section of marsupialized ranula, note the sutures of epithelium and

 Pleomorphic adenoma (benign mixed tumor)

Tumors of salivary glands are relatively rare.

Pleomorphic adenoma is the most common salivary gland tumor of the

major and minor salivary glands (90%).

Clinical features: Most frequently involves parotid, especially the tail that
lies below the ear lobe.

The least frequently involved is sublingual.

The most involved minor salivary glands are the glands of the hard palate
while the least are the glands of the lower lip.

It is more common in females in fifth and sixth decades of life.

Begins as solitary, small, painless nodules that slowly and incrementally

increase in size without fixation to superficial or deeper structures.

The most frequent presenting symptom is a mass that may have been
present for over 5 years.

Treatment and prognosis: surgical excision is the primary treatment.

Recurrence may result from incomplete initial removal.

The tumor is radio-resistant.

Adenolymphoma

It is the most common of the monomorphic adenomas.

Monomorphic adenomas are distinguished from pleomorphic adenomas

by their uniform cells.

Clinical features: It is found most frequently in in the parotid gland in

superficial location especially at the lower pole.

It is the only salivary gland tumor to be frequently found bilaterally.

It has been reported in submandibular and sublingual glands and in minor
glands of the lips, buccal mucosa, palate, and maxillary sinus.

Males over middle age are most commonly affected.

Treatment and prognosis: Surgical excision, the tumor does not tend to
recur.

The excision can be accomplished without damage to adjacent structures

because of the tumor`s superficial location and small size.

Malignant mixed tumor (malignant pleomorphic adenoma)

Clinical features:

The clinical differences between benign and malignant types are slight.

There may be fixation of the malignant tumor to overlying skin or

mucosa or underlying structures.

Surface ulceration and pain may differentiate it from benign lesion.

Most of it found in parotid.

It affect males between 40-50 years

Treatment and prognosis:

Surgical excision, it has a high rate of recurrence, lymph node

involvement, and distant metastases.

Mucoepidermoid Carcinoma

Well-circumscribed to partially encapsulated to un-encapsulated

Solid tumor with cystic spaces

Adenoid Cystic Carcinoma

Gross pathology

Well-circumscribed, Solid, rarely with cystic spaces, infiltrative