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    • 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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