ORAL &

MAXILLOFACIAL
SURGERY 521

PROF. Dr. DALIA RADWAN

2022-2023
 MTI UNIVERSITY
FACULTY OF DENTISTRY
ORAL AND MAXILLOFACIAL DEPARTEMENT

ORAL & MAXILLOFACIAL

SURGERY 521

2022-2023
 :‫اﻟﺮؤ�ﺔ‬

‫ﺗﺗطﻠﻊ اﻟﻛﻠﯾﺔ إﻟﻰ أن ﺗﻛون ﻣن أﻛﺛر اﻟﻛﻠﯾﺎت ﺗﻣﯾزا ً ﻋﻠﻰ اﻟﻣﺳﺗوى اﻟﻣﺣﻠﻲ و اﻹﻗﻠﯾﻣﻲ ﻓﻲ ﻣﺟﺎل طب اﻟﻔم و‬
‫اﻷﺳﻧﺎن ﻣن ﺧﻼل وﺿﻊ ﺑراﻣﺞ و أﺳﺎﻟﯾب أﻛﺎدﯾﻣﯾﺔ ﻣﺗطورة ﻓﻲ ﺗﻌﻠﯾم طب اﻷﺳﻧﺎن و دﻋم اﻟﺑﺣث اﻟﻌﻠﻣﻲ‬
‫ﻓﻲ ھذا اﻟﻣﯾدان و أن ﺗﻘدم ﻣﺳﺗوى ﻣﺗﻣﯾز ﻣن ﺧدﻣﺎت اﻟﻣﮭﻧﺔ ﻟﻠﻣﺟﺗﻣﻊ اﻟﻣﺣﯾط ﻣن ﺧﻼل ﻛوادر اﻟﻛﻠﯾﺔ ﻣن‬
.‫اﻟﺧرﯾﺟﯾن واﻟﻘﺎﺋﻣﯾن ﻋﻠﻲ اﻟﻧﺷﺎط اﻟﻌﻠﻣﻲ‬

:‫اﻟﺮﺳﺎﻟﺔ‬

‫ﺗﻠﺗزم اﻟﻛﻠﯾﺔ ﺑﺈﻋداد أطﺑﺎء أﺳﻧﺎن ﯾﺗﻣﯾزون ﺑﺎﻟﺟدارة اﻟﻣﮭﻧﯾﺔ ﻣن ﺧﻼل ﺑراﻣﺞ ﺗﻌﻠﯾﻣﯾﺔ ﻣﺗطورة ﻗﺎدرﯾن ﻋﻠﻰ‬
‫اﻟﺗواﻓﻖ ﻣﻊ ﻣﺗطﻠﺑﺎت ﺳوق اﻟﻌﻣل و ﻣواﻛﺑﺔ اﻟﺗطور اﻟﻌﻠﻣﻲ و اﻹﺳﮭﺎم ﻓﯾﮫ ﺑﺎﻷﻧﺷطﺔ اﻟﺑﺣﺛﯾﺔ ﻣﻊ ﺗﻠﺑﯾﺔ‬
.‫إﺣﺗﯾﺎﺟﺎت اﻟﻣﺟﺗﻣﻊ ﻣن ﺧدﻣﺎت طب اﻷﺳﻧﺎن‬

Vision:

The college aspires to be one of the most distinguished colleges at the local and
regional levels in the field of oral and dental medicine through the
development of advanced academic programs and methods in dental
education and support for scientific research in this field, and to provide an
outstanding level of professional services to the surrounding community
through the college cadres Alumni and associates of the activity

Mission:

The college is committed to preparing dentists of professional merit through

advanced educational programs who are able to comply with the requirements
of the labor market, keep pace with scientific development and contribute to it
through research activities while meeting the community’s needs of dental
services.
 CONTENTS

1. ORAL AND MAXILLOFACIAL TRAUMA ...................................................... 1

2. MANAGEMENT OF ORAL Tumors ........................................................... 44

3. SALIVARY GLAND DISORDERS................................................................. 69

4. Management of TMJ disorders .............................................................. 93

5. QUIZ SHEET ........................................................................................... 124

6. PRACTICAL EXAM SHEET........................................................................ 125

 CHAPTER ONE

Oral and Maxillofacial Trauma

1
Emergency management:

A= Airway management and cervical spine control

B=Breathing and adequate ventilation

C=Circulation and shock management

D=Drugs for control pain and infection

E= Exposure of the patient

I. Airway management and cervical spine control

Causes of airway obstructions after trauma:
1. Falling back of tongue in unconscious patient

2. Accumulation of blood clot in mouth and oropharyngeal region

3. Broken teeth, dentures, parts of jaw bone in oropharyngeal space

4. Obstruction by foreign body from the accident

5. Regurgitation of the stomach contents

6. Posterior displacement of tongue in bilateral parasymphyseal fractures (flail

mandible)

7. Maxillary fracture that cause the soft palate to fall on posterior part of
tongue that cause obstruction

Management of airway obstruction:

1. Positioning of the patient: post-tonsillectomy or prone position.

2
2. Mouth clearance by suction if available, or swab with index for blood and
secretion.

3. Tongue pull by finger, tongue forceps, stitch.

4. Push palate upward in cases with maxillary fracture.

5. Jaw thrust: by placing the hands behind angle of the mandible and push the
mandible downward and forward (safest method).

3
6. Chin lift: by pulling the chin forward done by one hand.

7. Nasal airway: by suction through nostrils to keep a patent airway.

8. Oropharyngeal and nasopharyngeal airway that contraindicated in basilar

or cribriform plate fractures.

9. Surgical airway:

A- Tracheostomy: surgical creation of opening into trachea through

the neck then insertion of tube to facilitate air passage to lungs

4
 B- Cricothyrodotomy: between cricoid and thyroid cartilages then
connected to ambu bag or ventilator

10. Cervical spine control: using head mobilizer or even sand bag.

5
II. Breathing and adequate ventilation
After assuring patent airway, breathes has to confirmed by look, listen, and feel

If breath shallow, rapid spontaneous: supplemental oxygen

If no breath: Mouth to mouth breathing, or using mask to mouth

III. Circulation and shock management

• Hemorrhage could be external or internal
• Internal hemorrhage like in abdomen as spleen or chest leads to
hypovolemic shock
• Hemorrhage from maxillofacial regions are from:
o Carotid artery and its branches
o Facial artery
o Superficial temporal artery

6
 o Lingual artery
o Soft tissues

Control of bleeding
1. Position of the patient

2. Soft tissues laceration care (suturing)

3. Major blood vessels ligation

4. Anterior or posterior nasal packs

5. Monitor blood pressure or skin perfusion test

• Systolic B P 140 mm Hg……. blood loss not exceed 20%

• Systolic B P 100-140 mmHg…. blood loss 30%
• Systolic B P less than 100 mm Hg…blood loss more than 30% and
patient needs blood transfusion

Shock
It is circulatory deficiency due to peripheral circulatory collapse, characterized by
decrease cardiac output and haemoconcenterate

Manifestations of the shock:

1. Pale clammy cold skin

2. Restlessness

7
 3. Face expressionless

4. Disorientation

5. Deep respiration due to air hunger

6. Weak rapid thready pulse and decrease systolic pressure

Treatment of the shock

1. Place the patient in shock position

2. Cover the patient with warm blanket

3. Sedative and analgesics

4. Oxygen supply

5. Immobilization of the fractured jaw

6. Replacement therapy e.g. fresh blood or blood substitute

7. Corticosteroids e.g. Dexamethazone 1 gm IV

IV. Drugs to control pain and infection

• Local infection controlled by proper wound care and antibiotics.
• Pulmonary infection controlled by prevention of aspiration and vomitus,
blood, and mucous secretion
• Meningeal infection controlled by parenteral administration of suitable
antibiotics that can cross blood brain barrier
• Tetanus infection controlled by giving the non immunized patient tetanus
antitoxin (antititanic serum), and the immunized patient a booster dose of
toxoid
• Analgesics to control pain

V. Disability and Neurologic assessment

By Glasgow Coma Scale (GCS) which is a neurological scale to assess the level
of consciousness of the patient after head injury, patient assessed in points given in
a score between 3 (deep unconsciousness) and 14-15 points (original scale)

8
Glasgow Coma Scale

Mandibular fractures

Fracture is the loss of the continuity of that bone caused by a force beyond its
normal physiologic limit.

Etiology of mandibular fractures:

1. Road traffic accident (RTA)

2. Falls

3. Sports

4. Blowing during fight (interpersonal violence)

5. Wars

6. Industrial accidents

7. Gunshots

8. Horse kicks or camel bites

9
9. Pathological fractures e.g. osteomyelitis, tumors or cyst

Predisposing factors:
1. Local factors: presence of impacted teeth, jaw cysts, tumors, and
osteomyelitis.

2. General or systemic bone diseases: like hyperparathyrodism, renal

osteodystrophy, and osteoporosis.

Classification of mandibular fractures

I- According to site:
1. Symphyseal

2. Parasymphyseal

3. Body

4. Angle

5. Ramus

6. Coronoid

7. Condylar

8. Dent-alveolar

II- According to nature of fracture

1. Simple

A fracture that does not produce a wound open to the external environment,
whether it be through the skin, mucosa, or periodontal membrane

2. Compound
A compound fracture is one that communicates with the external environment. In
the case of mandibular fractures, communication may occur through the skin of
the face or with the oral cavity.

10
 Mandibular fractures that involve the tooth-bearing portion of the jaw are by
definition compound fractures, because there is at least a communication via the
periodontal ligament with the oral cavity and with more displaced fractures there
may be frank tearing of the gingival and alveolar mucosa.

3. Comminuted

A fracture in which the bone is splintered or crushed.

4. Green-stick

Greenstick fractures are incomplete fractures of flexible in which one cortex

of the bone is broken, the other cortex being bent and for this reason
typically occur only in children. This type of fracture generally has limited
mobility.

5. Complicated

A fracture of bone associated with injury to other vital structures such as

arteries, veins, or muscles.

6. Complex

Fracture of both mandible and maxilla.

7. Pathological

A pathologic fracture occurs when a bone breaks in an area that is weakened

by another disease process e.g. cystic lesion.

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 III- According to no. of fracture lines
1. Single

2. Multiple

IV- According to the side

1. Unilateral

2. Bilateral

V- According to the relation between traumatic object and

fracture.
1. Direct

It is the fracture that occurs at the site of impact and the associated soft
tissue damage is more because of the crushing effect.

2. Indirect

It is the fracture that occurs at a site which is situated at a distance from

where the force is applied. The associated soft tissue damage is less or
absent. Trauma to the parasymphyseal region cause direct ipsilateral
parasymphyseal fracture associated with indirect contra lateral subcondylar
fracture

VI- Presence or absence of teeth

1. Fracture in patient with full component of teeth

2. Fracture in a partially edentulous patient

3. Fracture in a completely edentulous patient

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 VII- According to the degree of the displacement
In fractures of the angle of the mandible, the muscles attached to the ramus
(masseter, temporal, and medial pterygoid) displace the proximal segment upward
and medially when the fractures are vertically and horizontally unfavorable.
Conversely, these same muscles tend to impact the bone, minimizing displacement
in horizontally and vertically favorable fractures.

The farther forward the fracture occurs in the body of the mandible, the
more the upward displacement of those muscles is counteracted by the downward
pull of the mylohyoid muscles. In bilateral fractures in the canine areas, the
symphysis of the mandible is displaced inferiorly and posteriorly by the pull of the
digastrics, geniohyoid, and genioglossus muscles

1. Vertical favorable fracture

2. Vertical unfavorable fracture

3. Horizontal favorable fracture the broken part moved horizontal it is called

vertical fracture
4. Horizontal unfavorable fracture

13
 any axial photo
vertical

displacing medially horiontally

Vertically un-favorable Vertically favorable

any lateral view

horizontal

displacement vertical by masseter muscle

Horizontally un-favorable Horizontally favorable

Factors affecting displacement of the fracture

1. Direction of the fracture lines

2. Direction of muscle pull

3. Presence or absence of teeth

4. Direction and magnitude of force

5. Type of traumatic object

6. Numbers of fracture lines

14
 Diagnosis of mandibular fracture
A. History

B. Clinical examination

C. Radiographic examination

History
1. Medical history (AMPLE)

• Allergies

• Medications

• Past illness

• Last meal

• Events preceding trauma

2. Mechanism of injury

3. Date of trauma

4. Site and cause of trauma

5. Loss of conscious

6. Tetanus immunization.

Clinical Examination
A. Extraoral inspection

1. Facial orifices: eyes, nares, ears, mouth

2. Facial deformities
3. Areas of laceration, bleeding, or edema

B. Extraoral palpation

1. Facial skeleton

15
 2. Areas of step deformity and tenderness
3. Bimanual manipulation of the fractured segments

C. Intraoral inspection

1. Occlusion
2. Presence of deviation during opening and closing
3. Areas of bleeding, hematoma, edema
4. Broken, avulsed, or chipped teeth

D. Intraoral palpation

1. In vestibule for step deformity or tenderness

2. Teeth mobility
3. Bimanual manipulation of the fractured segments

Radiographic Examination
A- Intraoral radiograph

1. Periapical radiograph

2. Occlusal radiograph

16
B- Extraoral radiograph

1. Panoramic radiograph

2. Poster anterior radiograph

3. Lateral oblique radiograph

4. Modified Town's view

5. Submentovertex

6. Sinus view

7. Computerized Tomography (C.T.)

17
 Aim of treatment of mandibular fractures
1. Restoration of function to the affected bone. For the mandible, this must
include:

• The ability to masticate food properly

• To speak normally
• To open the mouth as wide as before the trauma

2. Restoration of any defect that may arise as a result of injury (contour).

3. Prevention of infection at the fracture site.

Treatment of mandibular fracture

Basic principles:

1. Reduction.

2. Fixation.

3. Immobilization and rehabilitation.

I. Reduction
It is the reposition of the two fractured bony segments into the
preinjury normal anatomical position.

Types of reduction:

1. Closed reduction

• Done bimanual

• In recent fractures, with no or minimum displacement

• Guided by occlusion and alignment of inferior border

18
 2. Closed reduction by traction

• In recent fractures, with minimum displacement

3. Open reduction
Indication of open reduction
• In relation to fracture line
a. Non-union.
b. Mal-union.
c. Fibrous union.
d. Bone loss that needs bone grafting.
• In relation to the anatomy
a. Displaced angle: as all fracture angles are horizontally unfavorable.
b. Displaced body with loss of teeth in the proximal segment.
c. Parasymphyseal fracture.
i. OR with RIF if bilateral.
ii. Lingual splint (mono-fixation) if unilateral
d. Condylar fractures.
e. Multiple facial fractures

Contraindication
• Severe comminuted fracture.

19
 • Bone at fracture site involved with infection.
• Pathological abnormality of the bone.
Advantages

• Avoidance of debilitating weight loss.

• None interfere with speech.
• Convenient for patient with neurological seizures.
• Avoidance of TMJ disturbance especially in cases of condylar fractures.
• Immediate pain free mobilization.

Disadvantages

• Potentiality for soft tissue and bony infections.

• Susceptibility for mental and mandibular nerves injury
• High cost.
• High operative time with patient under G.A.
• Facial scarring in using transfacial approach.
• Possibility for damaging roots of related teeth.

ii. Fixation of Fracture Mandible

Fixation is the maintenance of the bony Segments in position after
reduction until healing occurs.
Methods of Fixation
Rigid internal fixation (RIF) (compression osteo-synthesis):
• Any form of internal fixation that is strong enough to prevent
inter-fragmentary mobility.
• Allow active use of the skeletal structures during healing.
• E.g. Dynamic compression plate (DCP)

20
Non-rigid internal fixation (NIF):
• Any form of internal fixation that is not strong enough to prevent
inter-fragmentary mobility.
• Not allow active use of the skeletal structures during healing.
• Needs supplementary jaw immobilization.

The main difference between RIF & NIF is Compression of the fragments.

21
 A- Non-Rigid Fixation
1. Dental Wiring
a. Direct Wiring:
Disadvantage

• When any wire i s broken during the healing period all the
procedures have to be repeated again.

b. Eyelet wiring (Ivy loops):

c. Multiple loop wiring (Stout's wiring)

22
d. Arch Bar
• Should never cross displaced fracture line.
• Fixed to the teeth by wires
• Each arch bar has hooks to which other wires are attached to tie both arch bar together ➔
closing the mouth and fixing the bar.
• Avoid to be used on anterior teeth.

1. Upper jaw → intact bar.

2. Fractured Jaw
• No displacement uses intact arch bar.
• Displaced fracture line split the arch bar at the fracture site.
3. During ORIF to maintain proper maxillomandibular relationship before surgery.

Advantage over wire

• The wire injury the teeth and may exfoliate it but the arch bar distributes the forces on all the
teeth.
• Wire is not suitable if there is no sufficient number of teeth.
• Stronger and distribution of forces.

E. Transmucosal 2.0 Cortical IMF (MMF) screws

• Placed between roots then wires are attached to both screws and tying them together.

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2. SPLINTS

Indications for The Use of Splints:

• When there is insufficient number of teeth.
• Preruption phase.
• Deciduous dentition.
• Edentulous patient.
• Some cases of alveolar fracture
Advantages
• Used as a definitive treatment.
• Allow movement of the mandible.
Disadvantages
• Need much lab work.
• Consume time.
Types
1. Split acrylic splint
• Used for Children → permanent Teeth (incomplete root) & deciduous
Teeth (root resorption).

24
2. Non-split acrylic splint
• Used for partially edentulous patients.

3. Gunning splint
• Used i n cases of completely edentulous patients.
• Fixed to the jaws by either circumandibular wiring or MMF screws.

iii. Immobilization (IMF Period)

• Adults → 4-6 weeks.
• Children → 3-4 weeks.
• Elder → 6-8 weeks.

25
 B. Rigid Fixation (Open Reduction and Internal Fixation)

Rigid fixation is any form of fixation that is s t r o n g e n o u g h t o p r e v e n t i n t e r

- f r a g m e n t a r y m o v e m e n t a c r o s s t h e fracture during the healing period.
Principles of rigid fixation
1. Anatomic reduction.
2. Stable internal f i x a t i on.
3. C a r e f u l t i s s u e h a n d l i n g w i t h preservation of the blood supply.

4. Early mobilization.
Advantages of rigid fixation
1. Maintain precise anatomic reduction of the reduced fractured segments.
2. Allows for primary bone healing which limits the risk of nonunion,

malunion and infection.

3. Early mobilization of the jaws.
4. Limit the use of intermaxillary fixation and its disadvantages .
Types of Plates
1. Titanium plate
• Should be removed after time as in case of implant placement or the
patient travelling a lot.
• Never used in children at growth stage as it makes a growth disturbance.
2. Resorbable plate.
• Used with children.

General principles for insertion of plates and screws

1. The plates available in different length according to thickness of the bone to
be fixed ➔ 6 mm, 8, 10 and 12mm.
2. Drilling and insertion of the screw are in the same direction which is
perpendicular to the bone surface.
3. Place at least 2 screws proximal and 2 distal to the fracture.
4. Minimum number of miniplates in any fracture is 2 plates.

26
Rigidity of fixation depend on:
1. Rigidity of the plate (Thickness of the plate).
2. Material of the plate (Titanium or stainless steel).
3. Number of screws.
4. Length of screws.
5. Bi or moncortical screws.

WE REMOVE THE METAL PLATE AND THE SCREW

• To avoid stress on the

• In case of children to avoid growth

disturbance.
•
If the patient will put implant in the site
•

1. Reconstruction Plates (Rigid Fixation)

• Available in variable lengths 6-24 holes.

• Straight or Pre-contoured.
• Placed on the inferior border of the mandible by bicortical screw.
• Minimum 3 screws on each side of the fracture.
Indications
1. Angular/Supra-angular fracture.
2. Continuity defects.
3. With condylar prosthesis.

4. Comminuted fracture.

27
2. Dynamic Compression Plates (Dcp) (Rigid Fixation)

• Used with Bicortical screws.

• Used when we have space between fracture part.
D i s a d v a n t a g e s:
 T r a u m a t i c b o n e loss.
 Extensive comminution and severe bone atrophy.

1. The mandible divided into area of compression and area of tension.

2. To overcome these forces during fracture repair, compression plates

should be applied to the area of tension in the mandible.

3. In the mandible, the alveolar portion is the tension zone and

therefore, it is the ideal location for a compression plate.

4. But the application of a compression plate with bicortical screws in

the alveolar region is impossible due to the presence of teeth root +

because mandibular canal.

5. So, the only place is the inferior border of the mandible with the use

of a tension band at the superior border to neutralize the force of

28
 tension in the alveolus.
6. The tension band also to avoid the displacement of the segment from

the superior border.

7. Methods of tension band are:
• Arch bars.
• Miniplates.
• Mini DCP
• EDCP.
8. Monocortical screws are used to secure tension band to avoid damaging the

nerve or roots.

3. Lag Screws (Rigid Fixation)

• It is placed from the outer cortex through the fracture line to engage
the inner cortex.
• Drilling must be 90 to the fracture line.
Indication:
 Ob l i q u e f ract u re of t h e mandible and zygoma.

 Symphysis and body fracture.

 Subcondylar fractures.

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4. Non-Compression Plates ( Rigid Fixation)
• Stabilize the reduced bony segments without applying any force
across the fracture line.

5. Locking Compression Plate (Rigid Fixation)

• Protect the bone from stress shielding (bone resorption + local
ischemia) and allow the action of the muscles over the bone.
• The holes of the screw in the plate have thread so when we drive the
screw inside the plate, the screw make the plate away from the
surface of the bone.

30
6. Miniplates (Semirigid-Fixation)

• Small malleable st. st. or titanium or vitalium plate + monocortical screw

fixation and it is placed transorally.
• Used with monocortical screws.
• Champy advised the ideal zone of osteosynthesis in the mandible is in the
juxta-alveolar area (between the mandiblar canal and the roots of the teeth).
• If we have two fracture line; one of them must be fixed by rigid fixation
while the other can be fixed by miniplates.

• Fractures of the body are secured with a miniplate placed just below the apices
of the teeth (zone of tension).
• Fractures of the angle are treated with a miniplate placed along the external oblique
ridge.

31
 • Advantages of miniplates
 Simple surgical approach without scarring.
 Easy to apply.
 Less time consuming.
 No MMF.
 Decreased possibility of the teeth damage and
inferior alveolar nerve involvement due to using monocortical screws.

7. Resorbable plates(Semirigid-Fixation)
Advantages:
 No foreign material left after treatment.
 Easy adaptation.

Disadvantages:
 Resorption requires inflammatory reaction.
 Rigidity is not comparable to metallic plates.

32
8. Skeletal pin fixation rigid-fixation)

Screws used in fracture

• They differ in length and thickness
• M a y b e r e s o r b l e o r t i t a n i u m.
• M a y b e u n i c o r t i c a l o r b i c o r t i c a l.
• All the screw used with the plate are drilled in the bone
90 degree to the bone s urface a nd p arallel t o f racture li
ne except the lag screwhich is drilled 90 to the fracture
line.
• The lag screw i s k nown a s compression screws while t
he screws used to fix the plate is known as positioning sc
rews.

33
 Condylar Facture
Classification of Condylar Fractures
1. Classification according to the fracture level

• Condylar head.
• Condylar Neck.
• Subcondylar.

2. Classification according to the relation of condyle to Mandible:

• Non – displaced.
• Deviated or angulated.
• Displaced.
• No bony contact.

3. Classification according to the relation of condyle to the Glenoid Fossa:

• None Displaced.
• Displaced-still related to fossa.
• Dislocation-completely out of fossa.

34
Etiology and Mechanism of Condylar Injuries
• Injuries to the condylar area are the result of indirect forces, where the
forces of impact are transmitted along the mandible from distant sites
such as the angle, body, symphysis to the condylar neck.
• In children, injury to the condyle leads to hemorrhage inside the capsule ➔
hemoarthorosis ➔ fibrous in & around the TMJ ➔ gradual bone formation
around thejoint ➔ ankylosis. bilateral fracture occurs often in case two movable
objects
Clinical signs of condylar fracture
I- Extraoral:

1. Swelling over the joint

2. Blood in the external auditory meatus

3. Deviation of chin in unilateral fracture

4. Tenderness on palpation and during mouth opening

5. Inability to palpate condylar movement

6. Limited range of motion

II- Intra-oral:

1. In unilateral fracture there is malocclusion (premature contact in the affected

side and open bite in the other side), and shift in the midline

2. In bilateral fracture there is anterior open bite with normal occlusion posterior

3. Teeth fracture: palatal cusps of upper and buccal cusps of lower teeth
35
 Radiographic Examination
1. Panoramic radiograph: showing empty fossa and increase in joint space

2. Modified Town's view: showing elongated condylar fracture

3. Coronal CT: important in sagittal fracture of the condyle

Goals of therapy
1. To get stable occlusion

2. Restoration of interincisal opening

3. Full range of mandibular excursive movement

4. Decrease deviation

5. No pain

6. Avoid internal derangement

7. Avoid growth disturbance

Treatment of the condylar fracture

1. Reduction

A. Closed reduction
Indications:
1. Correctable Malocclusion.
2. Deviation of the mandible with function.

Technique:

Short term immobilization (MMF) 7-10 days followed by muscle mobilization and
physiotherapy

B. Open reduction
 Absolute indications of ORIF:

A- Limitation of function secondary to:

1. Fractured in middle cranial fossa
36
 2. Foreign body in joint capsule
3. Lateral extracapsular dislocated condyle
4. Other dislocated fracture that produce mechanical stop during opening
B- Inability to bring the teeth into occlusion by closed reduction.
 Relative indications of ORIF:

1. Bilateral condylar fracture with comminuted midface fracture

2. Contraindication for MMF e.g. medical restricted
3. Bilateral condylar fracture
4. Dislocated condylar fracture
2. Methods of fixation
• Inter osseous wiring.
• Pin fixation.
• Eternal pin fixation.
• Lag screw.
• Miniplates
3. Management of condylar fractures in children
• The main danger of subcondylar fracture in children is the presence of bleeding in
the TMJ which is followed by ankyloses.

• Undisplaced/minimally displaced condylar fractures → conservative non-

immobilization with active function.

• Severely displaced with malocclusion ➔ 7-10 days immobilization followed up

by active function and physiotherapy to avoid ankyloses.
Postoperative care
1. Immediate postoperative care:
a. Postoperative vomiting
b. Respiration and signs of obstruction

37
 c. Patient position and wire cutter

2. Intermittent ice packs in area of surgery

3. Medications: antibiotic, analgesics, and sedative
4. Feeding
5. Oral hygiene measures
6. Follow-up

Complications of fracture
1. Plate exposure
2. Delayed union
3. Non-union
4. Malunion
5. Infection
6. Nerve injury
7. ankylosis

38
 FRACTURES OF THE MAXILLA

Midface Fracture
1. Zygomaticomaxillary complex (ZMC).
2. Zygomaticofrontal fracture.
3. Naso-orbital-ethmoidal fracture.
4. Lacrimal bone fracture.
5. Le fort I, II, III fractures.
6. Isolated orbital fracture.
7. Isolated zygoma fracture.
8. Dentoalveolar fracture.
9. Panfacial fracture.

Classification of Fractures of The Maxilla:

1. Le Forte I:
• Transverse fracture: Occurs transversely through the maxilla
above the level of the teeth.

39
2. Le Forte II:
• p y r a m i d a l fractures of the maxilla: Fractures involve the
nasoethmoid and maxillary bones with disruption of the inferior and
medial orbital walls.

3. Le Forte III:
• f r a c t u r e o r craniofacial disjunction: Fractures extend from
the nasoethmoid region across the orbit, involving the orbital
floor and the medial and lateral walls.

40
Diagnosis of Fracture Maxilla
• Bl eeding from the nose, periorbital edema and subcutaneous
hematoma are also suggestive of fractures of the maxillary and nasal
regions.
• Dish-face deformity results from fracture dislocation of the middle third
of the face.
• Malocclusion, open bite or premature c o n t a c t o f t h e p o s t e r i o r t e e t h.
• Absence of malocclusion.
• Cerebrospinal rhinorrhea.
• Bilateral bimanual palpation of:
1. The o r b i t a l m a r g i n s .
2. T h e n a s a l b o n y p ro ce s ses .
3. Th e p ro min en c es of t h e zygoma.
4. The intra-oral prominences of the maxilla may indicate

irregularities from fractures.

• The following views are
helpful.
1. Water's view.
2. Panoramic views.
3. C. T. S c a n p r e f e r a b l y w i t h 3 D reconstruction.

41
 Zygomatic Fractures

Diagnosis of Zygomatic Fracture

• Flatness of the face or a dimple over the middle of the arch.

• Depression of the g lobe of the eye.
• Ecchymosis of the lids, conjunctiva and sclera with unilateral
epistaxis.
• Pain on mandibular motion or truisms.
• Anesthesia in the distribution of the infra-orbital nerve (the
upper lip, lower eyelid and the lateral nasal area).
• Diplopia
• Bi-manipulation around the orbital rim, zygomatic arch as well
as intra-orally at the junction of the zygomatic process
with the maxilla to detect irregularity or indentation.
• The most useful radiographic views for diagnosis of
zygomatic fractures are:
a. Water’s view.
b. Submental vertex projection for the zygomatic arches.
c. C.T. Scan.

Treatment of Zygomatic Fracture

The surgical approach to the fractured zygomaticomaxillary complex

includes:
1. Gillies' approach ( temporal approach)
this incision is located 2.5 cm above and anterior to the helix of
the ear approximately at the hair line.

42
 2 . Buccal sulcus approach ( intra- oral approach):
Vestibular incision is made through which exposure of the maxilla, t h
e r oo t o f t h e z y g o m a a n d m e d i al surface of the zygomatic arch.

43
 CHAPTER TWO
ORAL TUMORS

44
 Diagnosis is the determination of the nature of a disease or pathologic condition.
An accurate diagnosis is obviously important so that the most appropriate
treatment can be initiated as soon as possible.
• Occasionally the diagnosis is relatively straightforward. Usually, however, a
variety of conditions with similar clinical features need to be considered, and a
differential diagnosis is prepared.
• This progression from information to differential diagnoses to final diagnosis is
known as the diagnostic process or method. The diagnostic process should pass
through a systematic approach that involves the following steps
o A comprehensive health history
o History of the identified lesion
o Clinical and radiographic examinations.
o Relevant laboratory testing and biopsy, if indicated.

A comprehensive Health History

The medical history is essential because

o Patients with certain medical conditions (e.g. hypertension or certain cardiac
conditions) may require special management precautions when invasivedental
surgery is required.
o surgical intervention may complicate a poorly controlled condition.
o The lesion under investigation may be the oral manifestation of a significant
systemic disease.
• Agranulocytosis may be associated with gingival recession, oral ulceration
and infectious pharyngitis.
• Leukemia may be associated with gingival enlargement, bleeding & oral
infection.

45
 History of the specific disease

1. Lesion duration and size.

• By combining information on the growth rate with findings regarding the duration of
presence, one can make a more accurate assessment of the nature of the lesion.
• Aggressively enlarging lesion in short time indicates a malignant lesionand vice versa.

2. Change in character or features

• Noting changes in the physical characteristics of a lesion can often assist inthe diagnosis.
• A lump becoming an ulcer may suggest a malignant process
• An ulcer start as a vesicle may suggest a localized or systemic vesiculobullous or viral
disease.

3. Associated symptoms
• Pain & tenderness are often signs of an inflammatory or infectious process.
• Cancers, erroneously thought by many to be painful, actually are often painless unless
secondarily infected.
• Dysphagia can suggest changes in the floor of the mouth or in Para-pharyngeal tissues.
• Paresthesia or numbness may be related to pressure on nerves caused by a cystic lesion
or tumor mass.

4. Presence or absence of systemic symptoms

• Presence of systemic symptoms (fever, malaise) should draw the dentist’sattention to the
possibility of a systemic condition. e.g. viral conditions

5. Presence or absence of historical event associated with the

onset of the lesions.
• Oral lesions can be caused by Para-functional habits, hard or hot foods, application of
medications not intended for topical use, recent trauma or conditions involving the
dentition.

46
CLINICAL EXAMINATION.

• An examination is classically described as a process that includes inspection, palpation,

percussion, and auscultation.
• In the head & neck region, inspection & palpation are more commonly used as diagnostic
modalities, with inspection always preceding palpation.
• Some lesions are so fragile that manipulation of any kind may result in hemorrhage or
rupture of a fluid-filled lesion or loss of loosely attached surface tissues, which would
compromise any subsequent examinations.
• Percussion is reserved for examination of the dentition.
• Auscultation is infrequently used but is important when examining suspected vascular
lesions.
• The following are some important additional points to be considered during the inspection
of a lesion.

1. Anatomic location
• Certain lesions have a predilection for certain anatomic areas.
• The dentist should attempt to ascertain, as much as possible, which tissues are
contributing to the lesion based on its anatomic location.
• For example, a mass on the inner aspect of the lower lip would prompt the dentist to
include a minor salivary gland origin in the differential diagnosis, along with connective
tissue origin & other possibilities.

2. Single versus multiple lesions.

• To find multiple or bilateral neoplasms in the mouth is unusual, while it may be common
with vesiculobullous, bacterial, &viral diseases.
• Similarly, an infectious process may exhibit outward spread, as one lesion infects the
adjacent tissues with which it has had contact.

3. Size & shape of the lesion.

o The diameter of the lesion is recorded using a ruler that can be disinfected.
o Oral lesion varies greatly in their growth presentation as it may be
o flat or slightly elevated
o endophytic or exophytic
47
 o Sessile (broad based) or pedunculated (on a stalk).

4 The surface appearance of the lesion.

• The epithelial surface of a lesion may be smooth, lobulated or irregular.
• If ulceration is present, the characteristics of the ulcer base andmargins should be
recorded.
• Margins of an ulcer may be flat, rolled, raised, or everted.
• The base of the ulcer may be smooth; granulated; or covered withfibrin membrane,
slough, or hemorrhagic crust (scab).

Features of Malignant ulcer

1. Painless unless infected or involve a nerve.

2. Raised, everted and rolled margins.

3. Non-healing ulcer that persist for more than 2 weeks

4. Necrotic floor and indurated base.

5. Fixed to deep structures

6. Bad odor.

5. Lesion coloration.
• Keratinized white lesions may represent potentially premalignant changes.
• An erythematous (or mixed red-and white) lesion may represent an evenmore ominous
prognosis for dysplastic changes than a white lesion.

6. Sharpness of lesion borders and mobility.

• Determining the boundaries of the surface lesion will aid in determiningwhether it is fixed
to the surrounding deep tissues or freely movable.

7. Consistency of the lesion to palpation.

• Soft: in case of Lipoma
• Firm: Fibroma
• Hard: Osteoma
• Fluctuant: fluid filled cavity.
48
 8. Presence of pulsation.
• Palpation of a mass may reveal a rhythmic pulsation that is suggestive ofa significant
vascular component.
• Auscultation of the area with a stethoscope may reveal an audiblemurmur in the area.
• Invasive procedures on lesions should be avoided.
• Such patients should be referred to specialists for treatment because life-endangering
hemorrhage can result if intervention (biopsy) is attempted.

9. Examination of regional lymph nodes.

• This should be accomplished before any biopsy procedure.
• If lymph node is detected, the following 5 points should be noted.
1. Size
o Nodes are considered to be normal if they are up to 1 cm indiameter.
o Any lymph node larger than 1 cm for 4-6 weeks in absenceof infection should be
evaluated histologically.
2. Pain/tenderness
o Pain is usually the result of an inflammatory process or suppuration, but pain may also
result from hemorrhage intothe necrotic center of a malignant node.
o The presence or absence of tenderness doesn’t reliablydifferentiate benign from
malignant nodes
3. Consistency
o Stony-hard nodes are typically a sign of cancer
o Very firm, rubbery nodes suggest lymphoma.
o Softer nodes are the result of infections or inflammation.
4. Matting.
o A group of nodes that feels connected and seems to move asa unit is said to be “matted.”
o Nodes that are matted can be either benign (e.g.,tuberculosis,) or malignant.
5. Degree of fixation:
o fixation indicates malignancy.

N.B: characteristics of malignant lymph nodes: large (more than 1 cm), stonyhard,
fixed, matted and painful lymph nodes.

49
 RADIOGRAPHIC EXAMINATION

Aim: To fully delineate the exact nature and location of intra-bony lesions.
o Plain radiography
o CT and MRI

LABORATORY INVESTIGATION.

In certain instances, supplementary laboratory tests can assist in lesion identification. Certain oral
lesions may be manifestations of a systemic disease process such as hyperparathyroidism and
leukemia.

BIOPSY OR REFERRAL

Some dentists may feel comfortable performing many biopsy procedures on their patients, whereas
others may refer their patients to other specialists. This is a personal choice and should take several
points into consideration.

1. Health of the patient

• Patients can be referred to specialists who are trained to deal withpatients with
special medical needs.

2. Surgical difficulty.
• Each dentist should use judgment when deciding whether the biopsy iswithin his surgical
abilities or not.

3. Malignant potentials
• Refer the patient before biopsy to a specialist who is able to providedefinitive treatment if
the lesion is shown to be malignant.
• It is better for the referral specialist to evaluate the lesion before anysurgical intervention
has compromised its clinical features.
• Biopsy can also produce reactive lymph nodes that are possiblyunrelated to the original
lesion.

50
Biopsy is the removal of tissue from a living body for microscopic diagnostic examination.It is

the most accurate of all diagnostic tissue procedures & should be performed whenever a definitive
diagnosis cannot be obtained using less invasive procedures.

Indications for biopsy

• Lesions with no identifiable cause that persist for more than 10 to 14 days despitelocal
therapy
• Intra-bony lesions that appear to be enlarging
• Any lesion that is felt to have malignant or premalignant characteristics
1. Bleeding: lesion bleeds on gentle manipulation
2. Duration: lesion has persisted more than 2 weeks
3. Leukoplakia or erythroplakia
4. Fixation: lesion feels attached to adjacent structures
5. Growth rate: lesion exhibits rapid growth
6. Induration: lesion & surrounding tissues are firm to the touch.
7. Ulceration: lesion is ulcerated or presents as an ulcer
• Confirmation of clinical diagnostic suspicions
• Any lesion that is the basis of extreme concern to the patient (cancerphobia)

When will oral biopsy be contraindicated?

• when the general health condition of the patient is very poor

• when acute, virulent, pyogenic infection is present
• pulsating lesions (those of vascular nature)

PRINCIPLES OF BIOPSY

In clinically suspicious lesions, biopsy must be carried out as soon as possible.

The choice of the biopsy technique is determined by the indications of each case.
Direct injection of the local anesthetic solution inside the lesion is to be avoided,
because there is a possibility of causing distortion to the tissues.

51
 The use of the electrosurgical blade is to be avoided, due to the resulting high temperature,
which causes coagulation and destruction of tissues.
Avoid unnecessary trauma, pressure, manipulation. On grasping the biopsy, the normal part
of the removed tissue should be grasped.
Make sure all surfaces of specimen are recognizable.
Immediately after its removal, the tissue specimen should be placed in a container with
fixative. Keeping the tissue specimen outside of the container for a prolonged period dries the
specimen, while there is a risk of it falling or being misplaced.
The fixative solution to be used is 10% formalin, and not water, alcohol, or other liquids that
destroy the tissues.
Specimen must be totally immersed in the preservative solution at all times, even if the
container is tilted sideways during transport.
It is recommended that the container to be sent to the laboratory is plastic to avoid risk of
breakage during its transfer and subsequent loss of the specimen.
Biopsy data sheet should be submitted with the biopsy including patient’s personal data,
history, clinical and radio graphical findings)
The label with the patient’s date should be placed on the side of the container, & not on the
lid to avoid the possibility of mix-up at the laboratory after opening .
A negative (benign) pathology report should never be taken as a final assessment. If the
clinical behavior of a lesion suggests that it is not benign, a 2nd biopsy of the area should be
considered or a 2nd pathology opinion from an oral-maxillofacial pathologist.
In case of incisional biopsy
o Include the most representative area.
o Avoid areas of necrosis.
o Include both normal and pathological tissue.
o Include the basement membrane( deep specimen is better than wide shallow one)
o Multiple specimens are indicated in case of large lesion (more than 3 cm)showing
different features.

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TYPES OF BIOPSY

1. Brush cytology
It is a valuable noninvasive tool for monitoring patients with chronic mucosal changes (e.g.,
leukoplakia, lichen planus, & irradiation damage)
A small circular brush is used in a rotary fashion to collect a transepithelial specimen. The
brush is continually rotated against lesional tissue until pinpoint bleeding is detected clinically,
ensuring the likelihood of a full thickness (transepithelial) sample.
The instrument is then unloaded by rotating the brush against a glass slide to deposit and
disperse the disaggregated epithelial cells.
The sample is fixed with a solution provided by the company.
Results of brush cytology specimens are classified into 1 of 4 categories:
o Inadequate: incomplete transepithelial specimen
o Negative: no epithelial abnormality
o Atypical: abnormal epithelial changes of uncertain diagnostic significance
o Positive: definitive cellular evidence of epithelial dysplasia or carcinoma
For atypical or positive results, the patients should receive a scalpel biopsy.
This reflects the fact that the brush result is limited to reporting evidence of cellular
abnormalities; it does not provide a final diagnosis.

2. Aspiration biopsy

Type Indication
Fine needle In cases where lesions are not accessible for
aspiration biopsy
histopathological examination, e.g., tumors of the
parotid gland, deep neck masses, lymph nodes.

Aspiration biopsy In intraosseous radiolucent lesions. before entering into

the bony defect to rule out the potential of the lesionbeing

vascular in origin

53
 3. Excisional biopsy
An excisional biopsy implies removal of a lesion in its entirety.
Excisional biopsy is most often reserved for clinically benign or, at worst, precancerous
mucosal lesions that are less than 2 cm in diameter.

4. Incisional biopsy
Incisional biopsy involves removal of only a portion of a relatively more extensive lesion, so
that histopathological examination may be performed and a diagnosis made.
It is indicated in cases where the lesion is larger 2 cm and when there is suspicion that the
lesion is malignant.
N.B: -

• In the case of intra-osseous lesions, Precautionary Aspiration should be performed using

16-18-gauge needle connected to a 5- or 10-mL syringe.
• If the cortical plate cannot be penetrated by pressing the needle firmly through the
mucoperiosteum with a twisting movement, a flap is reflected and a large round bur,
under constant irrigation, is used cautiously to penetrate the cortical plate
Differential Diagnosis of the aspirate:
o Negative aspiration suggests that the bony mass is probably a solid tumor
o Aspiration of straw-colored fluid suggests a cyst
o Aspiration of pus, suggests an inflammatory or infectious process
o Aspiration of air is suggestive of a traumatic bone cavity
o Aspiration of blood suggests vascularized intra-osseous lesions.

PATHOLOGIC LESIONS CAN BE CLASSIFIED TOTHE

FOLLOWING MAJOR CATEGORIES:

• Cysts and cyst-like lesions of the jaws

• Benign odontogenic and non-odontogenic tumors of the jaws
• Malignant odontogenic and non –odontogenic tumors of the jaws
• Benign or malignant lesions of oral soft tissues.

I. Odontogenic Tumors

• A group of neoplasm arising from cells of the ectoderm and mesenchymal

54
 embryonic components of the odontogenic apparatus or their remnants.
• They show a wide range of clinical behavior that range from totally benign to
benign with local invasive properties and finally they can be malignant.

Classification of odontogenic tumors

Epithelial Odontogenic Tumors Mesenchymal Mixed

odontogenic tumor
• Simple Ameloblastoma. • Odontogenic fibroma • Ameloblastic Fibroma

• Calcifying Epithelial • Odontogenic myxoma • Ameloblastic fibro

Odontogenic Tumor Odontoma
(Pindborg's Tumor). • Cementoblastoma
• Ameloblastic
• Squamous Odontogenic Tumor. • Granular cell fibrosarcoma
odontogenic tumor
• Adenomatoid odontogenic • Odontoameloblastoma
tumor (AOT)
• Odontoma
• Clear cell Odontogenic carcinoma

• Malignant ameloblastoma.

Principles Of Surgical Management Of Jaw Tumors

o Eradication of the lesion with the least morbidity possible.

o Preservation of normal tissue as much as possible.
o Restoration of tissue loss, form and function.
o Long term follow up for recurrence.

Factors To Be Evaluated Before Surgery

1. Aggressiveness of Lesion
 Non aggressive benign lesion: conservative treatment via enucleation andcurettage
(e.g Odontoma, adenoameloblastoma)
 Locally invasive benign tumor: treated via resection with safety margin(
Ameloblastoma, myxoma, CEOT)
 Malignant tumor: needs more radical treatment with wider safety margin & removal

55
 adjacent soft tissue & neck dissection. Radiotherapy &chemotherapymay be used.

2. Anatomic Location of Lesion

i. Accessibility of the lesion
• Accessible lesion can be easily treated surgically
• Inaccessible lesion within the mouth may severely complicate surgical excision and,
therefore, jeopardize the prognosis. Other treatment modalitiescan be used such as
radiotherapy.
ii. Maxilla versus Mandible.
• The adjacent maxillary sinuses & nasopharynx allow maxillary tumors to grow
asymptomatically to large sizes thus requiring wide resection with poorprognosis. On the
other hand, mandibular lesions have a better prognosis.
iii. Proximity to adjacent vital structures.
• During tumor excision, the apices of related teeth roots will be completelyuncovered & the
dental pulps are stripped of their blood supply.
• Thus these teeth should be considered for endodontic treatment prior excision
iv. Size of tumor.
• When eve possible, the inferior border of the mandible is left intact to maintain continuity.
This can be accomplished by en bloc marginal resection.
• However, if the tumor extends through the entire thickness of the involvedjaw, a partial resection
becomes mandatory.
v. Intraosseous versus Extraosseous location.
• Lesions confined to the jaw bones have better prognosis than lesions that perforate the
cortical bone & invade adjacent tissue as the latter lesions will need a more aggressive
treatment including the excision of related soft tissue.

3. Duration of Lesion
• Static and slowly growing lesion indicates a benign lesion that needs aconservative
treatment.
• Rapidly growing lesion indicates an aggressive lesion that needs a moreradical treatment.

4. Possibility of recurrence.
• A wide safety margins is indicated in lesions with high rate of recurrence.

56
Surgical Treatment Of Jaw Tumors

First: ENUCLEATION AND CURETTAGE.

• It is the Local removal of tumor by instrumentation in direct contact with the lesion; used
for excision of the cystic lesions and many small benign tumors thattends to grow by
expansion, rather than by infiltration of the surrounding tissues e.g. Odontoma,
Cementoblastoma, or Ameloblastic fibro-odontoma. .

Second: RESECTION
• Removal of a tumor by incising through uninvolved tissues around the tumor,thus
delivering the tumor without direct contact during instrumentation.

Jaw resection is classified into the following:

1. Marginal resection
• Also named “Enbloc resection” or Resection without continuity defect. This
procedure allows complete excision of the tumor, while preserving the continuity of
the jaw bone and thus deformity, disfigurement & the need for secondary cosmetic
surgery and prosthetic rehabilitation are avoided
• Indications:
a. Benign lesions with a known propensity for recurrence.
b. Those lesions that are incompletely encapsulated or tend to grow beyond
their surgically apparent capsule.
c. Lesions previously treated by enucleation alone.
d. Examples include Ameloblastoma, Myxoma, CEOT , ameloblastic
odontoma and squamaous odontogenic tumor.
• Principles:
a. The resected specimen should include the lesion and 1-cm bony margins
around the radiographic boundaries of the lesion.

b. A frozen section biopsy should be done to confirm complete lesion excision.

• Surgical approach: mainly intra-oral

57
2. Partial resection
• Also named Segmental Resection or Resection with continuity defect.
• Resection of a tumor by removing a full-thickness portion of the jaw i.e.
resection of the inferior border of the mandible.
• This can vary from a small continuity defect to a hemi-mandibulectomy
• Hemi-mandibulectomy may be with or without Disarticulation based on whether the
condylar head is included or not in the resected part.
• Indications
a. For treatment of lesions that are infiltrative or have a tendency to recur and
extending close to the inferior or posterior border of the mandible.
b. Lesions close to the borders of the jaw, with the possibility of postoperative
pathologic fracture.
• Surgical approach

Intra-oral approach Extra-oral approach

Advantages 1. Easy access for application of 1. Easy access for posterior

archbars, extraction of involved
teeth.
2. An external scar is avoided.
3. Extraoral tissues are preserved for
alater reconstruction procedure
partof the mandible
2. Avoid contamination of the
surgical wound by oral flora.
3. Better prognosis for
immediate grafting.

Disadvantages 1. Contamination of the surgical wound 1. External scar.

by the oral flora. 2. Risk of induce injury to the
2. Difficult access to the most marginal mandibular nerve.
posteriorportions of the mandible.
3. Immediate bone graft by oral route
has a higher rate of infection and
results
in loss of the bone graft (30%)

3. Total resection
• Eradication of a tumor by the removal of the involved jaw (e.g., maxillectomyand
mandibulectomy)

58
 4. Composite resection
• It is a radical intervention, in which there is resection of a tumor within the bone,
adjacent soft tissues, and dissection of contiguous lymph node channels.

Reconstruction of Jaw after Removal of Oral Tumors

After surgical resection with continuity defect, reconstruction should take place to avoid;

 Facial disfigurement,
 Deviation of the mandible
 Altered occlusion

Criteria for a successful mandibular bone reconstruction

▶ Restoration of mandibular continuity and movements.

▶ Restoration of alveolar bone height: allow use of implants or dentures

▶ Restoration of osseous bulk: prevent fracture

▶ Restoration of acceptable facial form.

▶ Recoverable, non-debilitating donor site surgery.

Timing of Reconstruction
i. Immediate Reconstruction

Advantages Disadvantages

• Single stage surgery. • Recurrence in grafted bone.

• Early return of function. • Loss of graft from infection.

• Minimal compromise of aesthetics.

59
ii. Delayed Reconstruction: It is delaying the bone graft six months later

Advantages Disadvantages

• Guard against recurrence in grafted • Double stage surgery

bone.
• Late return of function
• guard Loss of graft from infection

AMELOBLASTOMA

It as a true neoplasm of enamel organ type tissue. It is categorized as a locally invasive benign
epithelial odontogenic neoplasm, with strong tendency to recur.

Demographic data:

• Incidence it represents 1% of all oral tumors and 18% of all odontogenic tumors.
• Age – peak between 20 and 35 however may occur at any age.
• No sex predilection – Can occur equally in men and women.
• Site:
o The ratio of ameloblastoma of the mandible to maxilla is 5:1.

o The sites of predilection are the posterior maxilla and the posterior molar-
ramus region of the mandible (60%).

Classification

• Central or intraosseous ameloblastoma

• Peripheral or extra osseous Ameloblastoma

Sign & Symptoms

• Usually asymptomatic (discovered during routine radiographic examination)

60
 • Lesion growth will result in Intra-oral swelling & Dental occlusion disturbance

• Paresthesia is uncommon, however may occur in late stage.

• Pain is rare, unless it cause root resorption or tooth mobility or become infected

• No facial disfigurement is noticed except when the tumor attains a large size.

• Large persistent lesion may exhibit egg-shell crackling.

Radiographically
• At most suggestive & not pathognomonic
• May be unilocular (less common) or Multilocular

• Lesion edges may be distinct or indistinct

• May contain impacted tooth (give the appearance of dentigerous cyst)

• Tooth displacement & root resorption may present
• The lesion may cause displacement of inferior alveolar canal & sinus membrane

Behavior and Local Spread

• The absence of capsule gives the tumor its locally invasive nature.
• The lesion grows slowly by invasion of medullary space and resorption of cancellous
and compact bone

• The often called "impenetrable barrier" of the compact inferior border of the
mandible is mythical. The inferior border is resorbed by the tumor sooner or later.
• When the tumor attains large size with bone erosion, then there is escape into
periosteum and mucosa and muscles of the adjoining region.
Management of ameloblastoma
• Complete removal of the lesion is equivalent to prevent recurrence
• Curettage as a primary surgical treatment is condemned as it disperses the tumor
into uninvolved areas resulting in a high recurrence rate.
• The characteristic feature of this tumor is that it microscopically infiltrates bone
beyond the tumor-bone interface seen in imaging.
• Thus, a 1.5 mm safe margin of uninvolved bone is a must
• Intra-osseous lesions are treated via mandibular resection with or without continuity

61
 defect based of the size of the lesion and its relation with the inferior border.
• Resection should be exterior to the tumor-involved tissue plane

 If cortical bone is penetrated → the Periosteal layer should be resected

 If periosteum is infiltrated → overlying muscle & mucosa should be resected
• In case of certainty of complete excision of the tumor, immediate reconstruction can
be done, otherwise reconstruction should be delayed until permanent tissue section
are studied.

• If the locally available un-involved soft tissue is sufficient to cover the resection bed,
reconstruction can be performed using free bone graft
• If insufficient to cover the resection bed, Vascularized composite pedicle graft of bone
& myocutanous tissue may be used for immediate reconstruction OR Delayed
reconstruction may be employed by application of reconstruction plate.

II. Malignant Tumors of the Oral Cavity

Cancer is a generic term for a large group of diseases. One defining feature of cancer is the
rapid uncoordinated and uncontrolled tissue growth -that continues even after the removal of
the initiating factor- which can then invade adjoining parts of the body & spread to other
organs; the latter process is referred to as metastasis.

TYPES OF INTRA-ORAL CANCERS

• Tumors originate from surface epithelium: e.g Squamous cell carcinoma.

• Tumors originate from glandular tissues: e.g. Adenocystic carcinoma.

• Tumors originate from mesenchyme tissues: e.g Osteosarcoma, Lymphoma.

PREVALENCE:

• Worldwide, oral cancer is the 12th most common cancer

• Oral cancer is more common in males by a ratio of 2:1 and it is most common in the
5th to 6th decades of life.
• The most common sub-site is tongue (mainly its lateral border), followed by floor of
62
 mouth & buccal mucosa are next in frequency.
• Oral cavity squamous cell carcinoma (SCC) accounts for 90 – 94% of oral
cancers, followed by lymphomas.

RISK FACTORS:

1. Tobacco: Smoking increases the risk of SCC by 5 to 9 times

2. Alcohol: if used with tobacco some studies showing a 100-fold increased risk.
3. Presence of premalignant lesions: e.g. leukoplakia and erythroplakia
4. Radiation: X-ray, sun rays
5. Viral infection: HPV is a major cause of oropharyngeal cancer
6. Chronic irritation and trauma.
7. Nutritional deficiency: iron deficiency causes mucosal atrophy.

CHARACTERISTIC FEATURES THAT RISESUSPICIOUS OF CANCER:

1. Chronic ulcer/lesion that persists for 2 weeks. (without apparent cause and/or fails to
respond to treatment)
2. Lesion easily bleed on gentle manipulation
3. Rapid growth lesion
4. Induration and fixation.
5. Enlarged stony hard matted cervical lymph nodes
6. Unexplained weakness, weight loss, anemia associated with dysphagia and
excessive salivation
7. Presence of premalignant lesion such as leukoplakia or erythroplakia
8. A sore throat or a feeling that something is caught in your throat that doesn’t go away
associated with prolonged voice changes
9. Tongue deviation on protrusion toward the affected side
10. Epiphora
11. Numbness of the tongue, lip, or other area of the mouth
12. Dentures that start to fit poorly or become uncomfortable
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 13. Unexplained loosening of the teeth or pain around the teeth
14. Non-healing extraction socket

Late complications of cancer includes

 Starvation
 Bronchopneumonia
 Distatant metastasis

CANCER STAGING

TNM staging
Tumor Node Metastases (TNM) is a clinical staging system for oral cancer.
First: Timing of TNM staging.
 Before biopsy as biopsy itself and potential scaring or infection may distort the
lesion and confuse later staging.

 Biopsy may also induce regional lymph node inflammation.

Second: Value of TNM staging.

 Select proper line of treatment
 Determine prognosis
 Evaluate and compare treatment results in relation to each other.
Limitation of staging
 Actual lesion size may be underestimated.
 Does not include factors of prognostic values such as comorbidity.
 Does not include morphological variables of prognostic value such as extra capsular
spread.

The TNM staging system based on

 T: Tumor size
 N: Lymph nodes metastasis
 Distant metastasis

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Treatment Modalities for Malignancies

1. Surgery

• Indication: small, superficial and accessible lesions.

• Advantages of surgical treatment.
A. Complete removal and pathological examination of the entire lesion
B. Oral cavity is readily accessible surgically.
C. Improvements in reconstruction surgery facilitate the early return of cancer
patients to their normal life.
D. Avoid complications of radiotherapy. e.g. osteoradionecrosis.
• Disadvantages:
A. Inability to eradicate foci of microscopic lesion.
B. Relative high incidence of complications such as wound infection.
• Aim of surgical treatment
1- Curative: via removal of primary tumor & metastatic cervical lymph nodes.
2- Palliative: in the case of end stage cancer
3- Reconstructive: Reconstructive surgery should be performed to ensure an
acceptable quality of life for the patient.
1. Radiation
• It is the use of penetrating ionizing radiation to treat cancer.
• Normal host cells are also affected by radiation and must be protected as
much aspossible during treatment.
• Indications:
1- Small or medium sized radiosensitive lesions with ill-defined margins.
2- Surgically inaccessible area.
3- Patient requires organ preservation approach &/or poor surgical risk patient.
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 4- Decrease lesion size to be resected (before surgery).
5- If surgical margins were histologically positive (after surgery).

• Advantages of radiotherapy
1- Minimal functional and esthetic alteration.
2. Ability to eradicate microscopic tumor cells

• Disadvantages of radiotherapy
1. Ineffective to ablate large tumor volume.
2. Acute and chronic morbidity.
3. Prolonged treatment.
4. Cannot be used in areas near bone.
• Methods of delivering Radiotherapy

1. External beam source.

2. Brachytherapy

How to decrease the dose of radiation on the normal tissues?

a. Fractionation
Instead of giving the maximal amount of radiation at one time, smaller
increments of radiation (i.e., fractions) are given over several weeks, which
allows the healthier normal tissues time to recover between doses. The tumor
cells, however, are less able to recover between doses.

b. Multiple ports
Instead of delivering the entire dose through one beam (port), multiple beams
are used. All beams are focused on the tumor but from different angles. Thus,
the tumor is exposed to the entire dose of radiation. However, because different
beams are used, the normal tissues in the path of the x-ray beams are spared
maximal exposure &, instead, receive only a fraction of the tumor dose.
3. Chemotherapy
• Cytotoxic drugs used in treating cancer.
• Most of these agents are given intravenously; however, recently injections into the
arteries feeding the tumor have been used.

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 • These drugs cause bone marrow suppression resulting in anemia, neutropenia and
thrombocytopenia with subsequent increased risk of bleeding and infection.
• To reduce these side effects, multiple-agent therapy-3 to 5 agents- is frequently
administered at the same time. Each may work at a different point in the life cycle of
the tumor cell, thus increasing effectiveness with less toxicity to the host.
• Indication
 If widespread systemic metastasis is detected or
 If a tumor is especially chemo sensitive as lymphoma.
4. A combination of these modalities.

FACTORS AFFECTING SELECTION OF TREATMENT MODALITY

Factors related to the patient: Patient’s well, age and general condition.

Factors related to the surgeon: Skill, Knowledge and available resources

Factors related to the tumor

1- Site of the lesion: accessible vs. inaccessible.
2- Histo-pathological differentiation: metastatic potential is more in less
differentiated lesion.
3- TNM staging (lymph node and distant metastasis)
 Single modulated treatment can be used in the absence of lymph node
metastasis
 Combined modulated treatment is indicated if there is lymph nodemetastasis
 Presence of distant metastasis &/or involvement of skull base : onlypalliative
treatment is indicated

4- Radio and chemo sensitivity of the lesion

FOLLOW-UP

• Oral cancer patients require close follow-up after they have completed treatment
for their malignancy.
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 • This follow-up should include regular head and neck exams, supplemented by
direct laryngoscopy and appropriate imaging studies.
• Typical follow-up protocol calls for monthly follow-up for the first 2 years, with
increasing intervals through 5 years.

PROGNOSIS:

• Oral cancer has one of the lowest five-year survival rates among the major typesof
cancers, with survival rates of 50% or less.
• Early diagnosis is crucial for improving the survival rate.

• If the detected lesions are small localized and treated efficiently; survival rates of70 to
90% can be achieved.
• The presence of cervical lymph node metastasis decrease 5-year survival by 50%.

• Survival time after distant metastasis is typically less than 6 months.

Prognosis of oral cancer depends on thefollowing

1- Timing of disease detection: patient’s and professional delay lead to a delayed

discovery of oral malignancies.

2- Presence or absence of cervical lymph node metastasis: most important factor.

3- Presence or absence of extracapsular spread

4- Presence or absence of distant metastasis.

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 CHAPTER THREE

SALIVARY GLAND DISORDERS

69
 SALIVARY GLAND DISORDERS
Definition: exocrine glands secreting saliva.
Classifications:
According to size:
Major SG Minor SG
Parotid gland. • 600-1000 minor SG.
Submandibular SG • 1- 5 mm in diameter.
Sublingual SG • Each gland has a single duct.
• Present all over the oral cavity and oropharynx except:
1. Ant 1/3 of the palate.
2. Ant 1/3 of the dorsum of the tongue.
3. Attached gingiva.

SALIVA
• Saliva contain electrolytes as Na+, K+, Cl, Bicarbonate, Ca + , Phosphate,
magnesium, urea, ammonia, uric acid, glucose and cholesterol.
• The electrolytes composition/ concentration in saliva secreted from the
parotid G. is higher than that of the submandibular G. except Ca+.
• Calcium concentration in the submandibular G is double that of the parotid
G → an important factor considering the salivary stone.
Functions:
• Digestion - Serous - Ptyalin (a-amylase- hydrolysis of starch)
• Lubrication › Mucus secretions (mucin = glycoprotein) - lubricant.
• Antimicrobial.

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 ANATOMY

PAROTID GLAND SUBMANDIBULAR GLAND SUBLINGUAL GLAND

Size Largest intermediate Smallest major SG

Parts • Superficial part. • Superficial part:
• Deep part. Superficial to mylohyoid
• Accessory part (20% of Hilum: behind
individuals): above mylohyoid ms
stensen's duct and • Deep part: deep to
opens into it. mylohyoid ms Just
beneath the floor of the
mouth
Location Retromandibular fossa • Superficial part: Sublingual space
(between ramus and submandibular
sternomastoid (digastric) triangle
muscle) Deep part: sublingual
space.
Duct Stensen's duct opens Wharton's duct opens Ducts of rivinus (8- 20
in parotid papillae in S.L caruncle. ducts) opens
opposite to upper 7. Into:
a. Bartholin's duct
b. plica sublingualis
Bartholin's duct: opens
into wharton's duct or
in the floor of the
Secretions Serous Mucus Mixed
Structures External carotid A
within Retromandibular
Vein
Blood • Arterial • Arteries • Arterial from sublingual
supply Branches of Ext. Branches of facial and and submental arteries
Carotid A lingual arteries • Venous drainage
• Ve ous • Veins corresponds to the
Into Ext. Jugular Drains to the arteries
Vein corresponding veins
Lymphatic Upper Deep cervical Lymphatics Deep
Drainage nodes via Parotid Cervical Nodes via
nodes submandibular nodes

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Boundaries • Superiorly:
Zygomatic arch
• Inferiorly: Inferior
border of the Md.
• Anteriorly: Masseter
Ms.
• Posteriorly: External
ear and
sternomastoid Ms.
Nerve in • Marginal mandibular Lingual N.
close N.
relation • Hypoglossal N.
• Lingual N.
Nerve • Parasympathetic N Parasympathetic fibers Similar to that of
Supply Secretomotor via from chorda tympani submandibular glands
auriculotemporal N (via lingual nerve,
Sensory fibers from chorda tympani and
lingual branch of sympathetic fibers)
• Sympathetic N
Vasomotor mandibular nerve
Delivered from
plexus around the Sympathetic fibers from
external carotid plexus on facial A
artery

• Sensory N
Reach through the
Great auricular and
auriculotemporal N

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 DIAGNOSTIC AIDS
Clinical history
A. PAST AND PRESENT MEDICAL HISTORY
• To determine any medical conditions or medications that is known to be associated
with salivary gland dysfunction.
• Examples: patient who received radiotherapy for a head and neck malignancy or
patient who taking a tricyclic antidepressant.
• These two examples associated with salivary hypofunction.
B. SWELLING
Intermittent swelling
• If associated with eating, it suggests an obstruction and the swelling will subside
between meals if the gland is not infected.
Persistent swelling
• Caused by tumors or a generalized process such as sjeogren’s syndrome, diabetes,
alcoholism…. etc.
Unilateral swelling
• Results from localized processes such as infections, tumors or mechanical obstruction.
Bilateral swelling
• Associated with a systemic condition such as mumps or an endocrine dysfunction.
C. PAIN
• Pain and fullness of the gland, related only to eating suggest obstruction.
• Infection and inflammation produce a more persistent pain not related to eating.
D. SALIVARY FLOW
• Decreased or increased.
Xerostomia
• Commonly caused by:
1. Drugs.
2. Systemic diseases (Sjeogren’s syndrome).
3. Secondary to radiation therapy.

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Sialorrhea (increased salivation)
• Commonly caused by:
1. Increase in flow rate
2. Secondary to an inability to swallow normal secretions.
3. Emotional or psychogenic factors.
4. Chronic neurological disorders (Parkinson’s disease, cerebral palsy, mental
retardation ... etc.)

Physical examination
A. INSPECTION
1) Size
• Diffuse enlargement of a single gland suggests inflammatory process or a tumor.
• Enlargement of multiple glands suggests:
1. Sjeogren’s syndrome.
2. Metabolic disorder (alcoholic cirrhosis).
2) Site.
• In the preauricular and Submandibular regions parenchymal glandular involvement
must be distinguished from regional lymph node involvement.
• Intra-oral minor salivary gland lesions usually appear on the posterior palate.
3) Shape.
4) Symmetry.
5) Overlying skin / mucosa.
6) Surrounding edge → well/ ill defined.
7) Inspection of the duct orifices for pus or calculus.
B. PALPATIONS
Palpation of the gland
• Parotid gland: E.0 Bidigital palpation.
• Submandibular S. G: bimanual palpation I.0 and E. 0 (submd L.N felt E.0 only while
S.Md S. G swelling felt E0 and I0)
• Sublingual S.G: I.O only.

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1) Palpation for:
1. Gland
• Consistency.
• Massaging the gland and looking at the duct orifice → duct purulence &
flow of saliva.
2. Duct
• Palpable stone, Site, size.
2) Tenderness.
3) Temperature.
4) Fluctuance.
5) Mobility of the swelling relative to the under & overlying tissues.
1. Movable → benign or fixed → malignant.
6) Regional L.N status.
1. Palpable.
2. Tenderness.
3. Consistency.
4. Mobility.
7) Check the integrity of the nerves:
1. Facial nerve assessment (suspicious malignancy in parotid)
• Temporal branch → ask the patient to elevate his eyebrows.
• Zygomatic branch→ ask the patient to close his eye tightly.
• Buccal branch → ask the patient to whistle.
• Marginal mandibular branch-ask patient to smile and show his teeth
2. Lingual nerve assessment → test sensation of ant 2/3 of tongue.
3. Hypoglossal nerve assessment → check tongue movement.
4. Any defect of nerve function → malignant infiltration of the nerve.

Preoperative diagnostic screening

1. PLAIN RADIOGRAPHS:
Advantages:
1- Used to demonstrate the presence of calculi.
2- Used as comparative documentation after removal of the stone.
Disadvantages:

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 o No information about ductal system and soft tissue.
1- Occlusal view
o It is used for detection of calculi in the floor of mouth (Wharton’s duct).
2- Periapical film
o Detect a stone in the parotid duct by placement against the inside of the cheek.
3- Puffed cheek view
o For calculi of the parotid duct.
2. COMPUTERIZED TOMOGRAPHY (CT) SCANNING:
Indication
1. The best choice for examination of masses of the salivary glands.
2. Study the diffuse non-inflammatory enlargement of the salivary glands.
3. MAGNETIC RESONANCE IMAGING (MRI):
Equal or better than CT in:
1. No contrast medium.
2. Less radiation.
3. No need for ductal cannulation.
4. Can be used in acute inflammation.
5. Detection of a lesion or mass.
6. Can be performes with Sialography → MRI Sialography.
4. RADIONUCLIDE SCANS (SCINTIGRAPHY):
• Radioactive isotope as technetium 99 is injected and traced by gamma camera.
• Uptake of the isotope by the gland increase in case of acute inflammation and
decrease in case of chronic inflammation.
Indication:
1. Determination of space occupying lesions
2. Evaluate the salivary function of the glands.
3. Evaluation of patients when sialography is contraindicated or cannot be
performed (such as in cases of acute gland infection or iodine allergy).
5. ULTRASONOGRAPHY:
Advantages:
1. Fast.
2. Economical.
3. Non-invasive.

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 4. Simple.
Indication:
1. Detect stone ≥ 2mm.
2. Detecting space occupying lesions.
3. Differentiate a cystic lesion from a solid mass.
4. Differentiate intrinsic lesion from extrinsic mass.
6. BIOPSY
1. Helpful in the diagnosis of Sjeogren’s syndrome.
2. The most common suggested procedures are:
a. Excision biopsy → should be done if the diagnosis remains inconclusive after
the investigation → from the intra-oral minor salivary gland (lower lip).
b. Incisional biopsy → should not be done because it will seed tumor cells into
the surrounding tissues.
c. Fine needle aspiration biopsy (FNAB).
7. LABORATORY INVESTIGATION:
• Laboratory blood studies are helpful in the evaluation of dry mouth, particularly in
suspected cases of Sjögren’s syndrome.
• The presence of nonspecific markers of autoimmunity, such as antinuclear
antibodies, rheumatoid factors, elevated immunoglobulins, and erythrocyte
sedimentation rate → the definitive diagnosis of Sjögren’s syndrome.
• ↑ Serum amylase → salivary gland inflammation.

8. SIALOGRAPHY:
Definition:
Sialography is the radiographic visualization of the salivary gland following retrograde
instillation of soluble contrast material into the ducts.
Contrast medium: (both contains high percentage of iodine)
Oil based Water soluble
• High viscosity. • Low viscosity.
• Difficult to inject  discomfort. • Easy to inject  discomfort
• Long time for elimination. • Shorter elimination time.
• E.g. lipiadol. • E.g. (Hypaque and renografin).

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Appearance
1. The normal ductal architecture has a “leafless tree” appearance.
2. Non-opaque sialoliths appear as voids.
3. Sialectasis is the appearance of focal collections of contrast medium within the
gland, seen in cases of sialadenitis and Sjögren’s syndrome.
Indications:
1. Detection of ductal obstruction, stenosis &stricture
2. The presence and the size of the tumors
3. Detection of salivary fistula
Therapeutics uses:
1. CM contains Iodine (bacteriostatic effect).
2. Drainage of ductal debris & mucus plug.
Contraindications:
1. Sensitivity of iodine.
2. Acute infection (ruptures the already inflamed gland + the injection of contrast
material might force bacteria throughout the ductal structure and worsen the
infection).
3. Thyro-toxic patient.
Advantages
1. Detection of radiolucent sialoliths.
2. Functional evaluation of the gland.
3. Detection of the position and size of a neoplasm.
4. Fistulae and abscess cavities can be displayed.
Disadvantages:
1. Invasive.
2. Requires iodine dye.
9. SIALOENDOSCOPE
Indications:
• Diagnosis of S.G pathosis either in duct or parenchyma.
• Used to dilate small stricture.
Limitations:
• Acute infection (Painful and may perforate the duct lumen).
• Too narrow duct.

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10. SIALOCHEMISTRY:
• Saliva can be collected from the parotid and Submandibular glands by cannulation of
their ducts.
• If ↑ Na+ and ↓K+ ➔ Sialadenitis.
The saliva can be analyzed for:
1. Electrolytes (Sodium, potassium, chloride, phosphate).
2. Flow rate.
3. Total salivary proteins (Amylase, glycoprotein, and albumin).
4. Immunoglobulin.

CLASSIFICATION OF THE SALIVARY GLANDS

DISEASES
DEVELOPMENTAL
• Aplasia (agenesis), atresia.
• Aberrancy (Latent bone cyst).
INFLAMMATORY
Viral (Viral sialdenitis)
• Mumps.
• Coxachie A.
Bacterial
• Non-specific
1. Acute bacterial sialdenitis.
2. Chronic bacterial sialdenitis.
3. Necrotizing sialometaplasia.
4. Radiation sialadenitis
• Specific
1. Tuberculosis.
2. Actinomycosis.
3. Sarcodosis.
CYSTIC
• Retention cyst.
• Extravasation cyst.
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 • Ranula.
• Latent bone cyst
OBSTRUCTION
• Sialolithiasis.
• Stenosis & stricture.
AUTOIMMUNE
• Sjeogren’s syndrome.
FUNCTIONAL DISORDERS:
• xerostomia
• sialorrhea (ptyalism)
METABOLIC
• Malnutrition (kwashiorkor).
• Alcoholic cirrhosis.
• Endocrine (Diabetes mellitus.)
NEOPLASTIC
• Benign
1. Mixed tumor (pleomorphic adenoma).
2. Monomorphic adenoma.
3. warthin's tumor (cystadenolymphoma, papillary cystaenoma lymphatosum).
• Malignant
1. Mucoepidermoid carcinoma.
2. Adenocystic carcinoma.
3. Polymorphous low –grade Adenocarcinoma.

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 CYSTIC CONDITIONS
MINOR SALIVARY GLANDS
THE MUCOCELE
Swelling caused by the accumulation of saliva at the site of a traumatized or obstructed minor
salivary gland duct.
Classified into:
1. Extravasation Mucocele: traumatic injury → salivary leakage into the surrounding
tissue → granulation tissue “encapsulation”
2. Retention Mucocele: Represents dilatation of salivary excretory duct due to
obstruction by a mucous plug or sialolith formation (FOM, palate)
The site: the lower lip in young people, buccal mucosa.
Etiology: minor trauma.
Clinically:
1. Superficial lesion: small bluish translucent, smooth, fluctuant vesicle.
2. Deep lesion: a firmer vesicle with the same color of normal mucosa.
Diagnosis
1. History of painless swelling
2. Clinical examination: fluctuant swelling mainly in lower lip
3. X-ray –ve.
4. A spi rat i on → muc us .
Treatment:
1. Simple removal of the “cyst” leads to recurrence of the mucocele 15-30%.
2. A vertical incision over the lesion with removal of the underlying minor salivary gland.
3. In recurrent cases, a CO2 laser is used.

SUBLINGUAL GLAND
THE RANULA
It’s the accumulation of saliva beneath the thin mucous membrane of the floor of the mouth
due to obliteration of sublingual gland duct.
Clinically:
1. Soft, compressible, painless bluish mass enlarge slowly.
2. May raise the tongue and interfere with the speech.

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Etiology: Extravasations of saliva secondary to trauma.
“Plunging” ranula:
The mylohyoid muscle does not always form a complete diaphragm for the floor of the
mouth, and leakage of saliva below the mylohyoid can allow the lesion to present in the
upper neck.
Diagnosis
1. History of painless swelling
2. Clinical examination: fluctuant swelling at one side of floor of mouth or cervical
ranula
3. X-ray –ve.
4. A spi rat i on → muc us .
Treatment
A- Marsupialization.
B- The excision of the sublingual gland.

INFLAMMATORY/REACTIVE CONDITIONS
The parotid gland is most often affected by these conditions.

NON-SPECIFIC
1. ACUTE BACTERIAL (SUPPURATIVE) SIALADENITIS (POSTSURGICAL PAROTITIS)
• A suppurative process affecting the major glands more often than the minor glands.
• More common in parotid
Predilection for Parotid:
1. The parotid is more prone to bacterial infection due to its secretions are serous and
thus lack the protective constituents (IgA, lysozomes) seen in mucinous secretions of
the other salivary glands.
2. The submandibular glands may be protected by the high level of mucin in the saliva,
which has potent antimicrobial activity.
Etiology
1. Salivary stasis → retrograde contamination of the salivary ducto-acinar units by oral
flora (Bacterial ascending infection).
2. Causes of salivary stasis include postsurgical setting, dehydration, medical illness,
radiation, aging and sialolithiasis.
3. Postoperative sialadenitis is due to decrease in salivary flow during anesthesia +
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 administration of anticholinergic drugs.
Clinical presentation
1. General symptoms; fever….
2. Sudden onset of unilateral or bilateral salivary gland enlargement.
3. The involved gland is painful, indurated, and tender to palpation.
4. The overlying skin may be erythematous.
5. Purulent discharge from Stensen’s duct
Diagnosis:
1. History: swelling and pain
2. Clinical examination
• E.0 examination → Redness, hotness, tenderness, and swelling. Fistulous
tract.
• IO examination → Pus oozing through duct on milking the gland.
3. Imaging: CT, MRI, Ultrasound and scintigraphy
4. Needle aspiration → pus.
Treatment of Acute Sialadenitis/Parotitis
1. Culture and sensitivity testing (for appropriate antibiotics).
2. Supportive measures
 Fluid replacement.
 Empirical antibiotic and analgesics.
 Improved oral hygiene.
 Massage of the gland.
 Warm compresses.
 Sialogogues (salivary stimulants).
3. Failure to respond → incision and drainage.
4. Incisions should be placed parallel to facial nerve branches to avoid injury.
Complications of Acute Parotitis
1. Direct extension.
 Into external auditory canal and TMJ.
 Into the parapharyngeal space → airway obstruction, mediastinitis, internal
jugular thrombosis and carotid artery erosion.
2. Hematogenous spread
3. Dysfunction of one or more branches of the facial nerve.

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2- NECROTIZING SIALOMETAPLASIA
• Benign self-limiting condition of the oral cavity.
• It originates from the minor salivary glands of the hard palate, buccal mucosa, lip or
retro molar area.
• Clinical picture:
1. Presents as an ulcer.
2. It is usually painless.
3. The ulcer may be unilateral or bilateral and appears large, deep and sharply
demarcated.
• Etiology: Local ischemia (trauma, L.A injury, smoking).
• Treatment: Self-limiting & heals by secondary intention in 6-8 weeks.

SPECIFIC INFLAMMATION
Mumps (epidemic parotitis)
• Non-suppurative bilateral acute sialadenitis of viral origin.
• It is a contagious disease (Droplet infection).
• Its incubation period is 2-3 weeks.
• It affects mostly children at 6-8 years old.
The causative virus
1. Mumps paramyxovirus.
2. Coxsackie virus A.
3. Echo virus.
Clinical picture:
1. Painful parotid swelling may last 2 weeks.
2. Usually one gland is affected first then the other.
3. The symptoms subside in 3-7 days and recovery occurs within 2-3 weeks.
Complications of mumps:
1. Other organs (e.g., testes, ovaries, breasts, and pancreas) may be affected.
2. In adults, orchitis may lead to sterility.
Diagnosis:
1. Leucocytopenia with relative lymphcytosis.
2. Increase in serum amylase (normal by 2-3w of disease).
3. Serology reveals:

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 • Complement fixing antibodies.
• S or soluble antibodies.
Prevention: MMR (Mumps-Measles- Rubella) vaccine
Treatment
1. It resolves spontaneously in 5-10 days.
2. Symptomatic relief of pain and fever (analgesic antipyretic).
3. Prevention of dehydration is essential by increase fluid uptake.

IMMUNOLOGIC DISORDERS
SJEOGREN’S SYNDROME
Definition
Sjögren’s syndrome is an autoimmune disease characterized primarily by decreased lacrimal
and salivary gland secretions.
Clinical features:
Triad of:
1. Xerostomia (mouth).
2. Keratoconunctivitis sicca (eyes).
3. A connective tissue disease (usually rheumatoid arthritis).
• Salivary, mucous and lacrimal glands replacement by a lymphocytic infiltrate causes
the classic symptoms of dry eyes, dry mouth and parotid swelling.
Two forms:
• Primary: involves the exocrine glands only
• Secondary: associated with a definable autoimmune disease, usually rheumatoid
arthritis.
Diagnosis
Diagnostic tests include:
1. Schirmer’s tear function
Using two strips of red litmus papers placed at the inner side of the lower eyelid (area
of lacrimal glands). A positive finding is lacrimation of 5 mm.
2. Sialography will give “the apple-tree in blossom” appearance.
3. Salivary biopsy (either from the lower lip or the tail of the parotid gland.
4. Immunologic and hematologic laboratory studies.

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Treatment
1. Dry foods, smoking and alcohol consumption should be avoided.
2. Treatment is directed to:
a. Supportive care with sialogauges to stimulate salivation and salivary replacement
by means of methylcellulose.
b. Supportive care with artificial tears.
c. Treatment of the autoimmune connective tissue diseases.

OBSTRUCTIVE DISORDERS
A. SIALOLITHIASIS
Definition
The formation of calcific masses (stones) within the ductal system of a major or minor salivary
gland.
Causes of obstruction include
1. Salivary calculi (Sialolithiasis).
2. Pressure on the duct due to an adjacent mass.
3. Invasion of the duct by a malignant neoplasm.
4. Mucous retention/extravasation.
Clinical features
1. It occurs in men twice as often as in women.
2. The Submandibular gland is the most common site of involvement (80%), followed
by the parotid (19%).
3. The stones are single, but it may be multiple (more in the parotid in this case).
Etiology
The exact nature of stone formation is not known, but may be due to:
1. The calculi are believed to arise from the deposition of ca ++ salt around a nidus of
debris within the duct lumen, these debris include bacteria, ductal epith cells, or
foreign bodies.
Formation of calculi is also facilitated by several secondary factors:
1. The mucous content of the submandibular gland makes its secretions more
viscous than the parotid.
2. The duct of the submandibular gland is longer than that of the parotid gland and

86
 runs against gravity in a tortous.
3. The submandibular duct is situated at a lower level than its orifice.
Signs and symptoms:
1. Absence of subjective symptoms (discovered accidental).
2. Eating initiates intermittent transient swelling accompanied by moderate
discomfort.
3. The involved gland is enlarged and tender.
4. Stasis of the saliva → infection, ductal stricture, and ductal dilatation fibrosis, and
gland atrophy.
5. No salivary flow or purulent discharge.
6. If the treatment is not beginning: Swelling, redness and tenderness are present
along the course of Wharton’s duct & pus may exude from the duct orifice.
Diagnosis:
1. History of swelling at mealtime which subside between meals.
2. Palpation along the course of the duct.
3. Occlusal view.
4. C.T, MRI, Ultrasound.
5. Sialography.
Treatment
Treatment Modalities
 Removal of the stone:
 Conservative management by:
 Milking the gland.
 Shock-wave Lithotripsy (external and intraductal).
 Electrohydraulic Lithotripsy.
 Interventional sialendoscopy
 Surgical removal (Sialolithotomy).
 Gland excision (Sialadenectomy).
I. Conservative Management
1. Milking the gland.
Stone may be removed by spontaneous exfoliation on stimulation of salivation to flush the
stone out of the duct:
1. Indication:

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 • Small, mobile stone at or just behind the duct orifice.
• Stone causing partial obstruction.
2. Procedures
• Hydration.
• Application of moist warm heat.
• Gland massage.
• The use of sialogogues.
2. Shock-wave Lithotripsy (external and intraductal).
3. Electrohydraulic Lithotripsy.
4. Interventional sialendoscopy
II.Surgical treatment
1. Extraglandular → removal of the stone (sialolithotomy) → intraoral approach.
2. Intraglandular → removal of the gland → intraoral approach (sublingual gl) or
Extraoral approach (Parotid, submand. gl).
1. Stone removal
• Surgical removal of submandibular duct sialoliths (sialolithiotomy, sialodochplasty,
marsupialization or 2nd duct orifice):
• Surgical removal of parotid duct sialoliths (sialolithiotomy)

2. Gland removal (sialadenectomy):

Indication
• Very posterior stones.
• Intra-glandular stones.
• Irreversible parenchymal damage.

SALIVARY GLANDS TUMORS

A. Benign tumors

1- MIXED TUMOR (PLEOMORPHIC ADENOMA)

Incidence and location
1. Most common salivary gland tumors.
2. The majority arise in the parotid (84%).
3. Mixed tumors account for more than 50% all intra-oral minor salivary gland tumors.

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 4. Male to female is 3:2.
5. 5% malignant transformation.
Clinical features
1. In the parotid gland, these neoplasms are slow growing and usually occur in the
posterior inferior aspect of the superficial lobe.
2. In the submandibular glands, these neoplasms are well-defined palpable masses.
3. Intraorally, the mixed tumor most often occurs on the palate, followed by the upper
lip and buccal mucosa.
4. Mobile, except when they occur in the hard palate, where they are adhering firmly to
the underlying tissue.
Treatment
1. Complete excision with 1 cm margins of clinically uninvolved normal tissue.
2. For the parotid gland, superficial parotidectomy with preservation of the facial nerve.
3. For the Submandibular gland, complete excision of the gland is indicated.
4. For intraoral tumors, extracapsular excision is indicated including the overlying
mucosa and saucerization of any bony margins of resection.

2- MONOMORPHIC ADENOMA
Benign salivary gland tumors composed predominantly of epithelium with no evidence of
mesenchymal tissue.
Incidence and location
1. Rare tumor the parotid and minor salivary glands.
Clinical features
1. A submucosal nodular mass.
2. Freely mobile firm to slightly compressible.
3. Normal color of overlying mucosa.
Treatment
• Extracapsular surgical excision

3-WARTHIN'S TUMOR (CYSTADENOLYMPHOMA,

PAPILLARY CYSTAENOMA LYMPHATOSUM)
Incidence and location
1. 6% of epithelial tumors of the salivary glands.

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 2. Almost in the parotid gland.
3. 3-4% of all minor salivary gland tumors
4. Intraorally, most commonly in the palate and buccal mucosa.
Clinical features
1. Soft to firm.
2. Asymptomatic mass in the parotid.
3. It grows slowly.
4. Arise from salivary gland tissue sequestered in lymph nodes.
Treatment
• Surgical excision with safety margins and superficial parotidectomy.

B) MALIGNANT TUMORS

1- MUCOEPIDERMOID CARCINOMA
Incidence and location:
1. 70 % in the parotid.
2. 20 % minor salivary glands.
3. 10 % submandibular gland.
Radiographic features: Multilocular radiolucency.
Clinical features:
1. The low-grade tumor in the palate
• Grow very slowly
• Not ulcerated until after very long time
• Appear bluish in color
• Don't invade the bone
2. The low-grade tumor in parotid
• Freely movable
• Firm
• Circumscribed mass
3. The high-grade tumor in the palate
• Faster growing
• Diffuse
• Ulcerate early
• Destruct underlying bone

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 • Painful
4. The high-grade tumor in parotid
• Diffuse mass
• Fixed
• Facial nerve affection
Treatment
1. The low-grade tumor in the palate
• Tumor excision with 1 cm of soft tissues margin.
2. The high-grade tumor in the palate
• Hemimaxillectomy + postoperative radiotherapy.
• Bilateral neck dissection.
3. The low-grade tumor in parotid
• Involve superficial lobe and without facial nerve involvement→ superficial
parotidectomy + nerve preservation.
• If it extends to deep lobe or involve facial nerve → total parotidectomy + nerve
resection, then nerve grafting.
4. The high-grade tumor in parotid
• Total parotidectomy + nerve resection.
• Ispilateral neck dissection + radiotherapy postoperative.

2- ADENOCYSTIC CARCINOMA
Incidence and location
1. Most common in the palate.
2. Most common malignant tumor of Submandibular S.G and parotid G.
3. Age: 53 years.
4. Male to female 3:2.
Clinical features:
1. Slowly growing, non-ulcerated mass.
2. Firm on palpation.
3. Bone invasion occurs.
4. Unilocular mass.
5. Lung metastasis.
6. Chronic dull pain.
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Treatment
Because of the ability of this lesion to spread along the nerve sheaths, radical surgical
excision of the lesion is the treatment.
1. For palate:
• Hemi-maxillectomy with 3 cm safely margin
• Complete extirpation of pterygomaxillary space till skull base
• Extirpation of greater palatine nervous bundle to skull base
2. For Parotid G:
• Total parotidectomy + nerve preservation if facial nerve not involved
• If it involves facial nerve → total parotidectomy + nerve resection, then nerve
grafting.
3. For Sumandibular S.G and Tongue:
• Radical excision & post-surgical radiotherapy and chemotherapy.

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 CHAPTER FOUR

FUNCTIONAL DISORDERS OF TMJ

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Definition
the TMJ is a diarthrodial joint, which is a discontinuous articulation of two bones permitting
freedom of movement that is dictated by associated muscles and limited by ligaments.

FUNCTIONAL ANATOMY OF TMJ

The temporomandibular joint (TMJ) is composed of:
1. The temporal bone and the mandible.
2. The articular disk.
3. Ligaments.
4. Muscles.

Therefore, the joint has four articulating surfaces:

1. The articular facets of the temporal bone (glenoid fossa).
2. The mandibular condyle.
3. The superior surface of the disc.
4. The inferior surface of the disc.

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BONY STRUCTURE OF TMJ
The articular portion of the temporal bone is composed of three parts:
1. The articular or mandibular fossa.
 A concave structure extending from the posterior slope of the articular
eminence to the postglenoid process, which is a ridge between the fossa
and the external acoustic meatus.
 The surface of the articular fossa is thin and separated the TMJ from cranial
cavity.
2. The articular eminence.
3. The pre-glenoid plane, a flattened area anterior to the eminence.

• The joint lined on its inner surface by a synovial membrane which secretes the
synovial fluid.
• Functions of the synovial fluid include lubrication of the joint, phagocytosis of particulate
debris, and nourishment of the articular cartilage.
The mandibular condyle:
1. the condyle tends to be rounded mediolaterally and convex anteroposteriorly.
2. On its medial aspect, just below its articular surface is a prominent depression, the
pterygoid fovea, which is the site of attachments of the lateral pterygoid muscle.

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THE ARTICULAR DISK OF TMJ
• The articular disk (pear shaped) is composed of dense fibrous connective tissue and is
non-vascularized and non-innervated.
• Anatomically the disk can be divided into three general regions as viewed from the lateral
perspective: the anterior band, the central intermediate zone, and the posterior band.
• The anterior and posterior band are thick while the intermediate zone is thin because it
is the area of function between the mandibular condyle and the temporal bone.
• The anterior band of the disc articulate with the articular eminence while the posterior
band of the disc is localized over the condyle.
• The intermediate zone is thinnest dense avascular hard area. It is generally the area of
function between the mandibular condyle and the temporal bone.
• During jaw movement, the speed of movement of the disc is half the speed of the condyle
because the disc performs rotation movement over the articular surface of the condyle.
• The articular disc divides the joint cavity into two compartments (upper
compartment & lower compartment).
• The TMJ is a close room. The lower compartment permits Hinge (Rotation)
movement during the initial mouth opening. The upper compartment permits
sliding (translatory movement) during the maximum mouth opening.

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RETRODISKAL TISSUE OF TMJ
• Posteriorly the articular disk blends with a highly vascular, highly innervated structure ➔
the bilaminar zone, which is involved in the production of synovial fluid.
• The superior aspect of the retrodiskal tissue is termed the superior retrodiskal lamina.
• The inferior aspect of the retrodiskal tissue is termed the inferior retrodiskal lamina.

LIGAMENTS OF TMJ
1. FUNCTIONAL LIGAMENTS:
 The collateral l igament.
 TM l i gament.
 The capsular ligament.
These are composed of collagen and act as restraints to motion of condyle and disc

2. ACCESSORY LIGAMENTS:
 Sphenomandibular Ligament.
 Stylomandibular l igament.
Acts as pressure restraints to the joint (passive restriction of joint)

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THE COLLATERAL OR DISCAL LIGAMENTS:
• They are short paired structures attaching the disc to the lateral and medial poles
of the condyle.
• Its function is to restrict the movement of the disc away from the condyle and
allowing smooth motion of the disk-condyle complex.
THE CAPSULAR LIGAMENT:
• It is attached superiorly to temporal bone (articular eminence) and inferiorly to the
neck of the condyle.
• Its function is:
 restrict medial, lateral & inferior forces and holding the joint together.
 Offers resistance to extreme range of motion.
 Contains synovial fluid within the superior and inferior joint spaces.

THE TM LIGAMENTS:
• They are part of capsular ligament.
• They are located on the lateral aspect of each condyle.
• Each temporomandibular ligament can be separated into two distinct portions.
1. The outer (lateral) oblique portion.
2. The inner (medial) horizontal portion.

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 • The function of the outer (lateral) oblique portion of the temporomandibular ligament is
to limits the amount of inferior distraction that the condyle in the translatory and the
rotational movements.
• The function of the inner (medial) horizontal portion of the temporomandibular ligament
is to limit posterior movement of the condyle. This restriction of posterior movement
serves to protect the retrodiskal tissue.

THE SPHENOMANDULAR LIGAMENT

• It arises from the spine of sphenoid bone to the lingula as well as medial side of
condylar neck.
• Act as a point of rotation during activation of the lateral pterygoid muscle, thereby
contributing to translation of the mandible.
STYLOMANDIBULAR LIGAMENT
• It descends from styloid process to the posterior border of the angle of mandible.
• It functions similarly to the sphenomandibular ligament.

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NERVE SUPPLY
1. . Au ri cu lot emp oral ne r ve .
2. Deep temporal nerve.
3. Masseteric nerve.
BLOOD SUPPLY
1. Superficial temporal artery.
2. M asset er i c artery.
3. M axi ll ar y artery.
The retrodiscal tissues contains the venous drainage of the TMJ and is responsible for
production of synovial fluid.

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MUSCULATURE OF THE TMJ

Musculature of the
TMJ

Infra mandibular Supra mandibular

Supra hyoid Infrahyoid temporalis

masseter
M. Pterygoid
Diagstric sternohyoid L Pterygoid
Geniohyoid sternothyroid
Mylohyoid Thyrohyoid
Stylohyoid omohyoid

1. Supra-mandibular muscles: functions as elevators for the mandible.

2. The inframandibular muscles: functions as depressors for the mandible.
• The suprahyoid muscles: functions as depressors for the mandible when the hyoid
bone is fixed in place. They also elevate the hyoid bone when the mandible is fixed
in place.
• The infrahyoid muscles: serve to fix the hyoid bone during depressive movements
of the mandible.

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 EVALUATION AND DIAGNOSIS OF
TEMPOROMANDIBULAR JOINT DISORDERS (TMD)

TMD IS A COLLECTIVE TERM, WHICH DESCRIBES CLINICAL PROBLEMS THAT INVOLVE THE
FUNCTION OF THE MASTICATORY MUSCLES AND THE JAW JOINT.

1. HISTORY

• Chief complaint.
• History of present illness including accurate description of pt's symptoms type — location —
duration.
• Stimulus of pain and assessment of patient threshold of pain.
• The threshold of pain is the point at which pain begins to be left ➔subjective phenomen.
• Use of any drug by the patient e.g. tranquilizers physical.
• The presence of any pernicious habits (Nail biting, pen biting), bruxism or
clenching.
• Previous treatment procedures.

2. CLINICAL EXAMINATION INCLUDE THE FOLLOWING

1. The head and neck should be inspected for soft tissue asymmetry or evidence of muscular
hypertrophy.
2. The muscles should be palpated for the presence of tenderness, fasciculations, spasm, or
trigger points.
3. Masticatory system: muscular hypertrophy or asymmetry:
• For temporalis:
 Tested while the patient clenching on his teeth.
 By finger intraorally at anterior margin of coronoid down to retromolar area.
 Extraorally for the rest part of the muscle at temporal region.

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 • For masseter:
 Tested while the patient clenching on his teeth.
 Extraorally for superficial part and deep part below zygomatic arch.
• For lateral pterygoid:
 Superior head: ask the patient to bite on tongue blade bilaterally ➔Pain.
 Inferior head: ask the patient to open and protrude his mouth against resistance
➔ Pain.
• For Medial pterygoid:
 Same method of examination as superior head of lateral pterygoid.
 How to differentiate ➔Medial pterygoid is active at maximal mouth opening ➔
ask the patient after biting on the tongue blade to open his mouth widely ➔ Pain
➔ medial pterygoid and if pain is relieved ➔ superior head of lateral pterygoid.
4. TMJ:
• The TMJs are examined for tenderness and noise by palpation on external auditory
meatus or inside the ear.
• The location of the joint tenderness (e.g., lateral, posterior) should be noted.
• The most common forms of joint noise are clicking (a distinct sound) and crepitus (i.e.,
multiple scraping or grating: sounds).
• Many joint sounds can be easily heard without special instrumentation but in some
cases auscultation with a stethoscope may be used.
• Range of motion (Inter-incisinal distance) ➔Mouth opening, 35-45 mm vertically
and 10 mm protrusively and laterally.
• Maximum inter-incisinal opening:
 Voluntary ➔the maximum opening attained by the patient.
 Assisted opening ➔by the help of the operator hand.
• Check movement at maximum inter-incisinal opening ➔ vertical or S shape.

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 5. Examination of occlusion to evaluate:
• To rule out dental origin of chief complain.
• Loss of teeth and posterior dental support.
• Malocclusion or presence of inclined teeth.
• Presence of occlusal facets, wears, exposed dentine or erosions.

3. RADIOGRAPHIC EXAMINATION

 Adv:
• Excellent evaluation of the lateral pole of the condyle, glenoid
fossa and temporal bone.
• Helpful in diagnosing bony internal joint pathology.
 Disadv:
Transcranial • Not allow detailed examination of all aspects of the TMJ.
radiographs (
Reverse -
towne; s view or
Transorbial
view)

 Adv:
• Relation of TMJ with other components of mandible & teeth.
• Helpful in evaluation of condylar fractures.
 Disadv:
• The relationship between condyle and glenoid fossa cannot be
evaluated.
• All Soft tissue including the disc can’t be evaluated.
Panoramic
radiograph

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  Adv:
• The best in determine the position of the condyle in the glenoid
fossa.
• Allows radiographic sectioning of the joint at different levels of
the condyle and fossa complex ➔ visualizing the joint in "slices"
from the medial to the lateral pole.
• Eliminate bony superimposition and overlap and provide a
relatively clear picture of the bony anatomy of the joint
 Disadv:
• All Soft tissue including the disc can’t be evaluated.

Tomography

Arthrography involves the injection of contrast material into the inferior or superior
spaces of a joint, after which the joint is radiographed to view:
 Perforation or adhesion of disc.
 Rupture of capsule.
Disadv: severely uncomfortable for patients.

Arthrography

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 Coronal, axial and sagittal cut show:
 TMJ ankylosis.
Computed  Condylar fracture.
tomography  O s s e ou s c h a n g e .
 Disc displacement.
Disadv: increased expense, inadequate image of soft tissues.
Cone beam CT As computer tomography
 Adv:
• Shows disc morphology, position and displacement
• Shows joint effusion.
MRI
• Pathological conditions related to the joint
 Diadv: increased expense, inadequate image of bony tissues.
 Called radionucleotide imaging
 Evaluating degeneration and remodeling in T M J.
Bone scanning
 Used to determine active areas of bone metabolism.
 Diadv: this technique is extremely sensitive.
Arthroscopy Useful in detecting adhesions, disc perforations and disc displacement.

4. LABORATORY INVESTIGATIONS

• Complete blood count (C.B.C).

• Erythrocyte sedimentation rate (E.S.R.).
• Increase in rheumatoid arthritis, vascular and collagen diseases, infections, malignancy.
• Synovial fluid analysis differentiates between osteoarthritis and gout (Podagra when it
involves the big toe).
• Podagra is a medical condition characterized by recurrent attacks of acute inflammatory
arthritis ➔red, hot and swollen joint.

5. PSYCHOLOGICAL EVALUATION

• Most of the patients with signs and symptoms of chronic pain syndrome are suffering from
depression and anxiety.

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 CLASSIFICATION OF TEMPOROMANDIBULAR
DISORDERS

I. NON-ARTICULAR TEMPOROMANDIBULAR DISORDERS

(MASTICATORY MUSCLES DIORDERS)

1 . M yof a s c i a l p a i n ( M P D S ) .
2 . M yof i b rot i c c on t rac t i o n .
3 . L o cal m ya l g i a . P a i n & D y s f u n c t i on
4 . M u sc l e s t r a i n ( M yos p a sm ) .
5 . M yo s i t i s .
6 . N e op l a s i a .

II. ARTICULAR TEMPOROMANDIBULAR DISORDERS (TMJ

DISORDERS)

1. Congenital.
2. Disc derangement.
3. Dislocation.
4. Inflammatory.
5. Osteoarthritis.
6. Ankylosis.
7. Fracture.

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 I. MYOFACIAL PAIN AND DYSFUNCTION
SYNDROME (MPD)

DEFINITION
• It is not a disease entity rather than a set of etiologic related disorder.
• It is a functional disorder characterized by discomfort in the oral and paraoral regions
induced by movement of the jaw, and independent of local disease involving teeth or
mouth.
• MPD is usually a combination of facial pain and mandibular dysfunction.
• MPD is a stress-related psychological disease.

PSYCHOPHYSIOLOGIC THEORY OF MPD

PSYCHOLOGICAL STRESS

MUSCLE HYPERACTIVITY

MUSCLE FATIGUE

MYOSPASM

MPD

CAUSES

• Muscle stress or overload, emotional stress & deep pain ➔ trigger points.

CLINICAL SYMPTOMS
• Trigger point ➔ constant deep pain.

RADIOGRAPHIC
• No radiographic TMJ findings.
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GENERAL CHARACTERISTICS OF MPD PATIENTS
• Predominately females.
• 20-40-year age group.
• History of other psychophysiological Diseases.
• Often suffer from chronic depression.
• Seeking multiple care providers.
• Having difficulty accepting a psychophysiological etiology for their Problem.

DIAGNOSIS
1. Clinical Examination:
• General condition of teeth and tissues, any pulpal or periodontal disease or exposed
cementum may cause muscle spasm and pain.
• Bite relationship any inability to find comfortable rest position or over-closure due to loss
of posterior teeth.
• Previous dental treatment e.g. restorations, extractions which may alter the occlusion.
• Oral habits: e.g. clenching, lip licking, lateral jaw thrust or playing with certain teeth. These
habits will cause eccentric occlusal relationship that may lead to MPD.
2. Tenderness of the masticatory muscles.
• Muscles of mastication are primarily involved in MPDS then sternomastoid & trapezius
muscles.
• Pain referrals of temporal muscle → refer pain to the entire maxillary dentition +
responsible for common temporal headache.
• Pain referrals of masseter muscle → superficial layer refer pain to posterior dentition of
both maxilla & mandible while deep layer refer pain to the region of the ear.
• Pain referrals of medial pterygoid → pain refer from this muscle is vague, refer pain to
the floor of the nose, throat, condylar area & ear.
• Pain referrals of lateral pterygoid → refer pain to the TMJ.
• Lateral pterygoid → unilateral spasm of this muscle causes mandibular deviation to the
contralateral side.

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 • Lateral pterygoid → bilateral spasm initiates protrusive movement; chronic spasm of this
muscle causes the symptom of tinnitus.
• Sternomastoid → refer pain to chin, ear and preauricular area.
• Trapezius → refer pain to the angle of mandible.
3. Determine range of mouth opening:
• Normal opening for 4-5 cm.
• Normal opening for male is 3.5 — 4.5 cm.
• The patient is asked to open his jaw up to the point of pain, and measure with caliber or
ruler the distance between midline of upper and lower central incisors.
4. Direction and degree of deviation of the mandible
• Patients with MPD show incoordination of mandibular muscles e.g. spasm of one lateral
pterygoid muscle will produce mandibular deviation on opening.
5. Examination of TMJ
• Palpation of the joint by placing finger tips lightly over T.M.J area condylar head felt to
move out of the glenoid fossa, any soreness or dissimilar morphology should be noted.
• Auscultation of clicking noises of T.M.J region.

TREATMENT
Objectives of treatment of MPD dysfunction are:
1. Control of pain and discomfort.
2. Decrease muscle inflammation.
3. Improve jaw function.
4. Elimination of occlusal disharmony.
5. Lowering of psychological stress or tension.
1. MEDICATIONS FOR MPD PATIENTS
• Mild analgesics for pain.
• Muscle relaxants" for anxiety.
• Hypnotic for sleep (diazepam).
2. HOME THERAPY
• Check for clenching habits.
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 • Limitation of jaw movement.
• Soft non-chewy diet.
• Moist heat and massage of the jaw muscles.
3. OCCLUSAL ADJASTEMENT
• By selective grinding of teeth or high restorations to maintain occlusal stability.
4. THERMOTHERAPY
• Sustained muscle contraction leads to ischemia and accumulation of noxious products
within muscle that may lead to pain. (physically harmful or destructive products to living
beings.).
• So, application of heat therapy as hot compresses, electric pad, ultrasound machines
activate the local circulation of muscle produce vasodilatation and washing noxious
metabolites so it leads to relaxation of muscle fibers.
5. BITE APPLIANCE
• THE PURPOSE OF A BITE APPLIANCE IN MPD PATIENTS IS TO ELIMINATE CHRONIC TOOTH
GRINDING AND CLENCHING HABITS.
• Requirements of splint:
 Minimal in bulk 2 mm.
 Occlusal surface of the appliance should be flat.
 Worn at night and sometimes during day.

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 II. TMJ ANKYLOSIS

DEFINITION
• It is a Greek word meaning stiff joint.
• Meaning chronic limitation, consolidation or immobilization of the mandibular condyle.
• An organizing hematoma under the influence of osteogenic periosteum may result in
fibrous or bony ankylosis.
• This is when the body begins to break down the clot and fibroblasts start to organize
creating a matrix of fibrous tissue.

TYPES OF ANKYLOSIS
1. TRUE ANKYLOSIS (INTRA ARTICULAR)

• It is the result of formation of fibrous or bony adhesions between articular surfaces of

mandibular condyle.
a) Bony Ankylosis b) Fibrous ankylosis
2. FALSE ANKYLOSIS (EXTRA - ARTICULAR):

• Results from pathologic condition outside the joint i.e. the pathology is not involving the
articular surfaces of the ternporomandibular joint.
• It rather involves the joint capsule, ligament, tendons, muscles, oral mucosa, adjacent
bones.

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 1. PSEUDO ANKYLOSIS (FALSE ANKYLOSIS, EXTRA
ARTICULAR ANKYLOSIS)

DEFINITION:
Limitation of movement between two bones that is not due to osseous fusion of the articular
surfaces, but is secondary to a pathologic change in the tissue outside the joint capsule.

CAUSES:
1. Fibrosis of the tissues:
• Near or around the joint due to traumatic incident.
• Fibrosis of muscles & facial layers as in therapeutic irradiation.
2. Bone impingement
• Overdevelopment and/or elongation of the coronoid process:
• Depressed fracture of the zygomatic complex or arch impinging on the coronoid
process.
• Tumors of the condyles or coronoid process.
• Fracture & dislocation of the condyles.
3. Neurogenic disorders
• Due to flaccid paralysis of the muscles.
• This dysfunction includes epilepsy, brain tumor.
4. Hysterical trismus
5. Myositis ossificans:
• It is unusual pathologic entity, it is of two types:
 Localized type: involved single muscle which is usually the masseter.
 Generalized type: More than one muscle of mastication, buccinators may
be involved.
• It starts by single severe trauma or repeated minor trauma, leads to hematoma
formation, then calcified and ossified.

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6. Muscle trismus:
• Due to infection of adjacent elevator muscles of the jaw resulting from
pericoronal infection of lower 3rd molars, or submasseteric abscess.
7. Myofascial pain dysfunction syndrome.
8.Temporomandibular joint dysfunction:
• Prolonged limitation of opening due to meniscus mal-relation.
9. Scleroderma:
• It is a collagen disease of unknown etiology characterized by fibrosis,
hardening and rigidity of the skin, subcutaneous tissues and muscles.
• When the face is involved there may be constriction of buccal orifice which in
itself limit mandibular movements.
10- Tetany:

• Is a medical sign, characterized by lack of calcium and excess of phosphate (high

phosphate-to calcium ratio) can also trigger the involuntary contraction of
muscles.
• Milk-and-alkali Tetany is an example of this imbalance.
• The muscle cramps caused by the disease tetanus are not classified as tetany;
rather, they are due to a blocking of the inhibition to the neurons that supply
muscles.
11- Tetanus:

• An acute, often fatal disease characterized by spasmodic contraction of

voluntary muscles, especially those of the neck and jaw.
• caused by the toxin of the bacillus Clostridium tetani; which typically infects
the body through a deep wound.
• Also, called lockjaw

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 2. TRUE ANKYLOSIS "Intra-articular ankylosis "

MORE COMMON THAN FALSE ANKYLOSIS.

DEFINITION:

Chronic limitation or immobilization of mandibular condyle, caused by fibrous or bony fusion

between articular surfaces of TMJ.

TYPES
• May be bony union or fibrous union.
• May be unilateral or bilateral.

ETIOLOGY
1. Trauma:
• Blows to the chin pushing condyle against glenoid fossa with intra articular
hemorrhage.
• Birth trauma (forceps delivery).
• Prolonged immobilization of TMJ.
2. Infection
• Otitis media.
• Mastoiditis.
• 0steomyelitis of the ascending ramus.
• Abscess of the surrounding soft ➔parotid, temporal, peritonsillar, or
dental infections.
• Blood-born infections (septicemia) are common in children may lead to
septic arthritis and Ankylosis.
• Rheumatoid arthritis.

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CLASSIFICATION:
1. According to type of adherence:
• Fibrous ankylosis.
• Bony ankylosis.
2. According to degree of fusion between the ramus & the base of the skull:
• Class I: condyle is fused with glenoid fossa.
• Class II: condyle is fused with glenoid fossa + coronoid process is fused with zygomatic
arch.
• Class I I I : ramu s i s fu sed w i th b ase of th e sku l l (sigmoid notch cannot be
identified).

CLINICAL PICTURE (DIAGNOSIS OF ANKYLOSIS):

In unilateral TMJ bony ankylosis
1. Facial Asymmetry.
2. Shift of the mandible midline to the affected side.
3. Inability to deviate the jaw towards the normal side.
4. Prominent angle of the mandible (accentuated antigonial notch).
5. Under developed body & ramus (vertically & horizontally) of the affected side.

6. Teeth on the affected side are usually in distal occlusion.

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In Bilateral TMJ Bony Ankylosis
1. Bird face or Andy Gump (Prominent
maxilla + under developed mandible).
2. Vertical rami and the body of the mandible are
short due to failure of the mandible to develop
in all directions.
3. Crowding of permanent teeth.
4. Open bite.
5. Retrognathia.
6. Antigonial notches bilaterally are prominent.
7. Inability to open mouth.

RADIOGRAPHIC EXAMINATION:
1. In fibrous ankylosis:
• Narrowing of the joint space.
• Destructive & proliferative changes may be present in bony components.
2. In bony ankylosis:
• Dense sclerotic mass of bone between the condyle and the glenoid fossa.
• May extend to involve the coronoid process, sigmoid notch and zygomatic arch.
3. Accentuation of antigonial notch.
4. Short and wide ramus of the mandible.

TREATMENT:
• The most used techniques are condylectomy, gap arthroplasty, and interposition arthroplasty.
• These are performed through preauricular or submandibular approaches, or a
combination of both.
1. Condylectomy:
1. Surgical removal of the condyles.
2. Indication:

• When the anatomy of the condyle is not totally disrupted.

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 • Fibrous ankylosis.
2. Gap arthroblasty
1. When the joint is massively fused no attempt is made to remove the condyle, as it will lead to

fracture of the thin roof of the glenoid fossa and perforation into the middle cranial fossa.
2. A section of bone (1.5-2 cm) is removed between the fused joint and the condylar
neck.
3. Optimum width of gap is 1.0 cm to 2.0 cm is recommended.

3. Interposition arthroplasty:
1. After completion of gap arthroplasty, a substance can be interposed between the
cut surfaces.
2. This allows:

• Reconstruction of the joint.

• Prevents recurrence.
• Obliteration of dead space.
3. Examples of interposing materials:
• Biogenic material:
 Muscle graft.
 Fat.
 Skin.
 Costochondral joint.
 Stemoclavicular cartilage.
• Alloplastic materials:

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  Silastic.
 Teflon.
 Stainless steel.

III. SUBLAXATION AND DISLOCATION OF THE TMJ

1. SUBLUXATION (HYPERMOBILITY)
• Is defined as self-reducing incomplete dislocation of the mandibular condyle where it passes
anterior to the articular eminence on wide opening of the mouth, without locking of the jaw.
• This type of condylar derangement is generally known as "loose joint" which considered as
hypermobility of the condyle.

2. DISLOCATION
• Displacement of the condyle out of the glenoid fossa where it is held anterior and
superior to the summit of the articular eminence by spasm of the muscles of mastication.

CAUSES OF DISLOCATION:
1. External trauma especially with the mouth opens.
2. Sudden wide opening of the mouth as with yawning or during epilepticseizures.
3. Prolonged wide opening of the mouth during dental or pharyngeal procedure.
4. Excessive manipulation of the jaw during dental extraction.
5. Chronic degenerative changes of osteoarthritis.
6. Muscular discoordination from drugs e.g., antiemetic drugs.
7. Excessive capsular laxity.

TYPES OF DISLOCATION:
1- Unilateral or bilateral dislocation
• In unilateral dislocation only one condyle is locked anterior and superior to the
eminence.
• In bilateral dislocation both condoyle appear anterior and superior to the crest of the
eminences.

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2 . Acute , chronic and habi t ual disloc at ion
• Acute (initial) dislocation is dislocation which occurs for the first time. It is difficult to be
reduced by the patient.
• Chronic (recurrent) dislocation: In this type the dislocation occurs repeatedly on periodic
basis. Generally, it cannot be reduced by the patient.
• Habitual dislocation: Dislocation occurs daily or several times each day which usually can be
reduced by the patient.
3. Anterior or lateral dislocation
• Anterior: Generally, the dislocation is forward and is limited to an anterior direction.
• Superior and posterior dislocation are rare & have to be associated with severe force to
fracture of temporal bone.
• Lateral dislocation of the condyle is associated with contralateral subcondylar fracture.

SIGNS AND SYMPTOMS:

• In bilateral dislocation, the mandible is locked in the open position with only the posterior
molars contacting. The patient has a prognathic appearance with prominence of the chin.
• In unilateral dislocation, the midline of the mandibular incisor teeth deviates toward the
normal side, and the molar teeth on the affected side are in contact with open bite.
• A noticeable depression is observed anterior to the auditory canal indicating an empty
glenoid fossa.
• Marked limitation of mobility of the mandible.
• Pain in the T.M.J. region, Localized or radiate toward the angle of the mandible, mastoid
process or medially to the tonsillar area.
• Edema and tenderness in the TMJ area.
PATHOGENESIS:
1. Excessive laxity and flaccidity of the temporomandibular joint capsule and ligaments.
2. Uncoordinatedaction of muscles:
• Lateral pterygoid muscle.
• Masseter muscle.
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TREATMENT:
The treatment of dislocation may be divided into immediate, conservative and definitive (Surgical).
1. Immediate treatment:
• Indication: when the dislocation cannot be reduced by the patient.
• Anesthesia → without, or L.A or G.A.
• Technique:
1. The operator stands behind or in front of the patient and forces the posterior part of the
mandible downward by application of pressure to the occlusal surfaces of the molars with
the thumb to stretch the spastic elevator muscles.
2. At the same time, he raises the chin with his fingers, after which he forces the mandible
backwards.
3. Relaxation of the muscles before reducing the dislocated condyles by:
• Prolonged digital pressure on molar teeth.
• Administration of muscle relaxant e.g. Curare succinylcholine, if the patient is going
to be treated under G.A.
• Periarticular & intra articular injection of L.A.
4. Following manual reduction, it is preferred to immobilize the mandible for several days (4-
5 days) either bybandages, maxillomandibular fixation.

2. Conservative treatment:
• Injection of sclerosing solution into the joint capsule or joint space.
 The injection of sclerosing solution in the capsule initiates inflammation and
stimulates the formation of an increased amount of fibrous tissue in the capsule,
which resists excessive movement of the condyle.
 Indication: in cases of chronic dislocation.
• Immobilizations the jaw by MMF or bandages.
 The aim:
 Keep the temporomandibular joint at rest for a considerable length of time.
 Avoid extensive movements.
 Methods: Bandage and MMF.
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 • Occlusal adjustment.
• Muscle relaxants, sedatives and short-wave diathermy of the temporomandibular
joint regions are other modalities for treatment of chronic dislocation.
3. Surgical treatment:
A. Tightening of the capsule (Capsulorrhaphy)
• Capsular plication.
• Reinforcements of the capsule with temporal fascia

B. Creation of a mechanical obstacle

This method involves the creation of an obstacle in the condylar path sufficient to block excessive anterior
excursion of the condyle.
• Raising the height of the articular eminence by insertion of a silastic implant, bone graft or vitallium
mesh implant.
• Raising the height of the articular emince by down fracture of the zygomatic bone
(DAUTERY PROCEDURE).
C. Removal of mechanical obstacles
Elimination of the mechanical obstacles, which prevent the condyle from returning to its normal
positions.
• Menisectomy.
• Eminectomy or Emineplasty.
• High condylectomies.

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D. Creation of new muscle balance:
Reducing the muscle power which pulls the disc and condyle forward by:
• Myotomy of the lateral pterygoid muscles.
• Sacrificing the tendon of the temporalis.

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 QUIZ SHEET 521
Student name…………………………………………………………….……………….……...………………...
Section……................ Academic year…….…………..…..…………ID……...........…….…….……

1
2
3
4
5
6
7
8
9
10
 Assignment 521
Student name…………………………………………………………….……………….……...………………...
Section……................ Academic year…….…………..…..…………ID……...........…….…….……
 PRACTICAL EXAM SHEET 521
Student name:………………………………………………………………………

ID:……………………. Sec: ……………….. Academic Year:……..……….……

Tooth Number: …………………………………………………………………….

PROCESS GRADES GRADES

Infection control 2
Chair position 2
Operator position 2
Tissues preparation 2
Role of the opposite hand 2
Dental syringe grasping 2
Point of needle insertion 2
Local anesthesia technique 5
Forceps handling 2
Retraction and Support 2
Extraction movements 5
Delivery of the tooth 1
Postoperative instruction 1
Total 30

Doctor signature Date

……………………..……. …….……….…………