FACIOMAXILLARY DISEASE DENTAL NOTES

CLEFT LIP AND PALATE

 

DEVELOPMENT OF FACE:

Face develops from
Median nasal process
Lateral nasal process
Maxillary process
Mandibular arch
Globular arch
Olfactory pit and eye

ETIOLOGY

  • Familial– more common in cleft lip
  • Protein and vitamin deficiency
  • Rubella infection
  • Radiation
  • Chromosomal abnormalities
  • Maternal epilepsy and drug intake during pregnancy ie steroids, eptoin or diazepam
  • Associated with syndromes like

Pierre-Robin syndrome

Stickler’s syndrome

Klippel-Feil syndrome

Down’s syndrome

Teacher-Collin’s syndrome

 

CLASSIFICATION

Cleft lip alone:

Unilateral

Bilateral

Median

Cleft of primary palate [infront of incisive foramen] only:

Complete– nasal septum and vomer are separated from palatine process

Incomplete

Submucous

Cleft of both primary and secondary palate

Cleft lip and palate together

 

CLEFT LIP CLASSIFICATION

  • CENTRAL– Rare in the upper lip, B/w two median nasal process [Hare's lip]
  • LATERAL– maxillary and median nasal process, commonest, U/l or B/l
  • INCOMPLETE– doesn’t extend into the nose
  • COMPLETE– extends into nasal floor
  • SIMPLE– an only cleft in the lip
  • COMPOUND– cleft lip with cleft of alveolus

 

PROBLEMS IN CLEFT DISORDER

  • Difficulty in suckling and swallowing
  • More common in cleft palate
  • Defective speech
  • Altered dentition
  • Recurrent URTI
  • Resp obstruction
  • Chronic otitis media, Middle ear problems
  • Hypoplasia of the maxilla

TREATMENT

  • MILLARD CRITERIA: rule of 10

10 pounds in weight

10 weeks old

10gm% Hb

  • Millard cleft lip repair
  • Tenninson’s Z plasty– triangular flap

 

CLEFT PALATE

  • Due to failure of fusion of two palatine process
  • Can be complete or incomplete cleft palate

PROBLEMS OF CLEFT PALATE

  • Small maxilla with crowded teeth
  • Poorly developed upper lateral incisors
  • URTI
  • Chronic otitis media
  • Deafness may occur
  • Swallowing difficulties
  • Speech difficulty

 

TREATMENT

  • CRITERIA: RULE OF 10

10kg weight

10 months of age [10-18 months]

10gm% haemoglobin

  • Both soft and hard palate repaired– Wardill-Kilner push back operation

Mucoperiosteum flap is raised

  • Regular examination of ear, nose, and throat
  • Postoperative speech therapy

 

EPULIS

  • UPON GUMS
  • Swelling arising from the Mucoperiosteum of gums
  • Types:

Congenital

Fibrous– M/c

Granulomatous

Pregnancy

Carcinomatous

Myelomatous

Fibrosarcomatous

 

Congenital Epulis

 

  • Benign
  • Newborns
  • Arising from gum pads
  • M/c in girls and upper jaw– canine or premolar area
  • C/f:

Firm

Bleeds on touch

  • Treatment:

Excision

 

Fibrous Epulis

  • Fibroma arising from periodontal membrane
  • Benign
  • Red, firm/ hard, sessile/ pedunculated
  • M/c type
  • C/f:

Painless

Well localized, hard

Nontender and bleeds on touch

 

  • INVG:

Xray Jaw

Orthopantomogram [OPG]

Bx

  • Rx:

Excision with the extraction of adjacent tooth with root

 

Pregnancy Epulis

  • Pregnant women due to inflammatory gingivitis
  • Usually in 3rd month of pregnancy
  • Resolves after delivery
  • If not excised

Myelomatous Epulis

  • Leukaemic patients
  • INVG:

Peripheral smear

BM Bx

  • Rx:

Treat leukaemia

 

AMELOBLASTOMA

  • Also called Adamantinoma or Eve’s Disease or Multilocular Cystic Disease of the Jaw
  • Arises from dental epithelium– Enamel/ Dental lamina
  • M/c in mandible or maxilla
  • Variant of Basal Cell Ca
  • Locally malignant tumor– neither spreads through LN nor through blood
  • Curable
  • U/L
  • Can occur in a pre-existing dentigerous cyst
  • Multilocular cystic space usually

CLINICAL FEATURES

  • Swelling of jaw– angle of mandible m/c and attains a large size
  • Egg shell crackling
  • Gradually progressive, painless swelling
  • Smooth and hard
  • LN not enlarged
  • Outer table expansion
  • M/c in males– 4th to 5th decade

 

INVG

  • OPG

Multiloculated lesion

Honeycomb app

  • Bx
  • CT scan

 

TREATMENT

  • Segmental resection of the mandible
  • Hemimandibulectomy with reconstruction of the mandible

DENTIGEROUS CYST

  • Also called FOLLICULAR ODONTOME
  • Defn:

ØUnilocular cystic swelling arising in relation to the dental epithelium from an UNERUPTED TOOTH

  • Common in lower jaw
  • Occurs over crown of unerupted tooth– relation to Premolars or Molars
  • Causes expansion of outer table
  • C/f:

Painless swelling

Smooth and hard

  • Complication:

Turn into adamantinoma

  • INVG:

OPG– tooth within the cyst

DENTAL CYST

  • Also called RADICULAR CYST or PERIAPICAL CYST
  • Occurs under the root of the chronically infected dead erupted tooth
  • Lined by squamous epithelium derived from epithelial debris of mallassez
  •  
  • C/f:

Smooth, tender swelling in relation to caries tooth

Causes expansion of jaw bone

  • Complication:

Osteomyelitis of the jaw

  •  
  • INVG:

OPG

  •  
  • Rx:

Antibiotics

Drainage or excision of the cyst with extraction of infected tooth

 

ALVEOLAR ABCESS [DENTAL ABCESS]

  • Spread of infection from root of the tooth into the periapical tissue
  • Forms peripheral abscess which later spreads through the cortical part of the bone into the soft tissues forming an alveolar abscess

Etiology

  • Disease begins in pulp of tooth -> Pulpitis -> spread to root -> localized osteitis-> abscess formation-> spread into soft tissue outside in cheek -> swelling in the jaw with redness and edema of gum
  • Bacteria:

Staphylococci, streptococci, anaerobic bacteria and gram negative organisms

Clinical Features

  • Deep, throbbing pain– jaw and adjacent oral cavity with diffuse swelling over the cheek
  • Tender soft tissue swelling– eventually bursts spontaneously leading to sinus formation
  • Oedema, pain and tenderness of floor of the mouth
  • Trismus and dysphagia
  • Fever and features of toxaemia
  • Tender palpable LN in the neck

INVG

  • XRAY- mandible or maxilla
  • Pus culture

TREATMENT

  • Antibiotics
  • I and D of abscess
  • Extraction of infected tooth
  • Excision of sinus if required

COMPLICATION

  • Septicaemia
  • Spread of infection into other spaces like parapharyngeal, sublingual and submandibular spaces– Ludwig’s Angina
  • Lower incisor abscessà abscess of chin and medial mental sinus
  • Chronic osteomyelitis of jaw with discharging sinuses

TREATMENT

Antibiotics

Sequestrectomy

Mandibulectomy

OSTEOMYELITIS OF JAW

  • Inflammatory process in jaw
  • Acute or chronic
  • Site:

Maxilla

Mandible

TYPES

  • ACUTE:
  • Common in children
  • Siteà maxilla or mandible
  • C/f:

Swelling, redness and fullness

Pus may tickle from nostril if maxilla involved

  • SUBACUTE:
  • Commonest type
  • Common in adult
  • Apical sepsis, endarteritis and bone necrosis
  • Siteà Mandible
  • C/f:

Pain, swelling, tenderness,

Irregularity and bone thickening

 

  • CHRONIC:
  • Common in mandible
  • Causes:

Apical abscess, alveolar abscess, trauma, radiation, TB, syphilis etc

  • C/f:

Pain, bone thickening, irregularity

Discharging sinus and sequestrum

  • INVG:

X-ray– features of osteomyelitis

 

INVG

  • X-RAY
  • CT scan
  • Pus culture
  • Bx

TREATMENT

  • Antibiotics
  • Sequestrectomy
  • Mandibulectomy if needed

 

BASAL CELL CARCINOMA

  • Also called RODENT ULCER
  • Low grade, locally invasive carcinoma arising from basal layer of skin or muco-cutaneous junction
  • Doesn’t arise from mucosa
  • Commonest malignant skin tumor
    • M/c in white skinned people and exposed to UV light
    • Common in middle aged and elderly men
    • Common site– Face

    ONGHREN’S LINE -> above the line drawn b/w angle of mouth and ear lobule

    • Erodes deeply into local tissue including cartilages, bone causing extensive local destruction– hence RODENT ULCER
    • Doesn’t spread through lymphatic or blood

TYPES

1)Nodular– common in face

2)Cystic/ nodulocystic– M/c

3)Ulcerative

4)Multiple

5)Pigmented BCC

6)Basi- squamous– behaves like squamous cell ca which spread into LN

C/F

  • Non tender, dry, slow growing, non mobile, with raised and beaded edge with central scab
  • Often with central depression or umbilication
  • Site of beading– area of active proliferation
  • No LN or blood spread
  • Can be low risk or high risk

Criteria

  • High risk BCC:
  • Size> 2cm
  • Near eye, nose, ear
  • Ill-defined margin
  • Recurrent tumor
  • Immunosupressed individuals

INVG

  • Wedge Bx
  • X-ray
  • CT scan

TREATMENT

  • Radiosensitive and if away from vital structures– curative radiotherapy
  • Not given once it erodes cartilage or bone
  • Surgery: Indication

Rodent ulcer eroding into cartilage or bone

BCC close to the eye

Recurrent BCC

Wide excision with skin grafting

Laser Sx

Cryosurgery

TEACHER- COLLINS SYNDROME

  • Mandibulofacial dysostosis
  • Hypoplasia of the zygomatic bone and mandible
  • Antimangoloid slant to the palperable fissure
  • Coloboma of lower eyelids
  • Low ear lobule with deficient middle ears
  • Familial– 3rd arch syndrome

 

 

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