Oral and Maxillofacial Surgery

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 Mid-face
Definition:
The area between
a superior plane
drawn through
the zygomatico-
frontal sutures
tangential to the
base of the skull
and inferior
plane at the level
of the maxillary
dental occlussal
surface.
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 Structures connection
(structures in relation)

 Orbit
 Maxillary sinus
 Nasal bone
 Naso-orbital
ethmoid (NOE)
complex
 Zygomatic
complex
 Frontal bone and
sinus 3
 Vertical and horizontal pillars

•Area of strength
•Vertical and horizontal pillars
•Muscular attachment
•Area of weakness
•Sutures
•Lining tissues and air-filled cavities 4
 Pattern of fractures
of mid-face skeleton
 Alveolar fracture and dental fracture

 Le Fort ‘s fracture ((french surgeon Rane Le Fort

1901)

 Naso-orbital ethmoid fracture

 Zygomatic complex and arch fracture

 Frontal sinus and bone fracture

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 Alveolar bone fracture
Involve block of
alveolar bone
with or without
 Intrusion of

teeth
 Extrusion of
teeth
 Luxation of teeth

 Fracture of teeth

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 Le Fort’s fractures
 Le Fort I (low
level or Guerian
fracture)
 Unilateral/ bilateral
Horizontal fracture
through the maxilla
above the level of
the nasasl floor and
alveolar
process(apertura piriforma,deasupra
apexurilor dentare,fosa canina,creasta zigomatico-
alveolara,tuberozitatea maxilara si 1/3 inferioara a
apofizelor pterigoide)

Piriform rims
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 Anterior maxilla
 Zygomatic buttresses
 Signs and symptoms
 Slight swelling of upper lip

 Ecchymosis in upper lip sulcus

 Hematoma intra-orally over zygoma and in palate

 Disturbed occlusion

 Mobility of teeth of the involved segment of maxilla

 Combination of soft tissue laceration

 Exposure of nares and the maxillary antra in case of

gross injury

 Impacted type of fracture is oftenly not mobile and

teeth cusps(varfuri) may be damaged

 Cracked-pot percussion of upper teeth 8

 Le Fort’s fractures

 Le Fort II
(pyramidal or subzygomatic)
Separation of NF suture,
medial orbital walls (lacrimal
bone), inferior orbital floor
and rim (adjacent to
infrorbital canal and
foramen), anterior maxilla
below zygomatic buttress
and ptrygoid laminae about
halfway up.(Linia de fractura are traiect oblic in
jos si inspoi prin: oase nazale,os lacrimal,apofiza ascendenta a
maxilarului,rebordul orbital la nivelul gaurii infraorbitale(podeaua
orbitei ramane integra),peretele antero-lateral al sinusului
maxilar,1/3 mijlocie a apofizelor pterigoide,peretele lateral al fosei
nazale,vomerul,septul nazal cartilaginos.)

Separation of the block from the base of skull is completed

via the nasal septum and may involve the floor of the
anterior cranial fossa 9
 LeFort’s fractures

 LeFort III
(cranifacial dysjunction, high
transverse, suprazygomatic)
Separation of NF suture, medial
orbital walls (involve the depth of
the ethmoid bone and cribriform
plate, pass below optic foramen
and cross the inferior orbital
fissur), inferior orbital floor,
lateral orbital wall, ZF suture,
zygomatic arch, suprazygomatic to
the root of ptrygoid plate.(Linia de fractura
are traiect oblic in jos si inapoi prin:oasele nazale la nivelul suturii
naso-frontale,os lacrimal,apofiza ascendenta a maxilarului,suprafata
orbitala a etmoidului,peretele inferior al orbitei(pana la sutura sfeno-
maxilara),peretele extern al orbitei(prin sutura fronto-malara),apofiza
pterigoida in 1/3 superioara,arcada temporo-zigomatica,lama
perpendiculara a etmoidului,vomerul. )

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Signs and symptoms
although it is possible to distinguish between le fort II and III, the
signs and symptoms are almost similar
 Gross edema of soft tissue
 Bilateral circumorbital
ecchymosis
 Bilateral subconjunctival
hemorrahge
 Obvious deformity of the
nose
 Nasal bleeding and
obstruction
 CSF leak rhinorrhea
 Dish-face deformity
 Limitation of ocular
movement
 Possible diplopia and
enophthalmous
 Retropostioning of the
maxilla with anterior open
bite
 Lengthening(alungirea)of
the face
 Difficulty in mouth opening
 Mobility of the upper jaw
 Occusional hematoma of
the palate
 Cracked-pot sound on
percussion
 Step deformity at infra-
orbiatal margin
 Anasthesia of midface
 Nasal bone moves with
mid-face as a whole
 Tenderness and sepration
at FZ suture
 Tenderness and deformity
of zygomatic arch
 Depression of occular level
and pseudoptosis
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 Bowerman classification of midface-fracture
(1994)
 Fracture not involving the occlusion
• Central region
 Nasal bone/ septum (lateral, anterior injuries)
 Frontal process of the maxilla

 Nasoethmoid
 Fronto-orbito-nasal dislocation

• Lateral region (zygomatic complex EX dento alveolar

frcature

 Fracture involving the occlusion

• Dento alveolar

• Subzygomatic:
 Le Fort’s (I, II)

• Supra zygomatic:
 Le Fort III

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These fractures may occur unilaterally or bilaterally, with separation
of maxillary midline and or extension to frontal or temporal bone
 Prevalence of mid-face fractures
Fracture Type Prevalence

Zygomaticomaxillary complex (tripod fracture) 40 %

I 15 %
LeFort II 10 %
III 10 %
Zygomatic arch 10 %
Alveolar process of maxilla 5%
Smash fractures 5%
Other 5%
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 Diagnosis
 Inspection
Extra-oral
(e.g. swelling, deformity, asymmetry
Leaks)
Intra-oral
(e.g. hematoma, occlusion)

 Palpation
Step deformity, criptation, cracked pot sound, mobility

 Radiographical investigations
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 Radiographical examination
Plain radiograph

 Occipitomental
(10 or 30 degree)

 Water’s view
Suitable for isolated orbital
fracture
Search line (Campbell’s line 1977)

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 Radiographical examination

 Lateral skull view

 OPG
 Occlusal view of the
maxilla
 Perapical views of
damaged teeth

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 Radiographical examination

 CT scan
 3-D CT imaging

• Coronal sections
• Axial sections

1. Whenever intracranial damage and

frontal sinus are suspected
2. Extensive fracture that involves
nasoethmoid complex or orbital
region
3. Orbital trauma to evaluate the
degree of orbital injury and
enophthalmos 17
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 Indications for treatment

 Physical signs of a fracture of the maxilla.

 Evidence of a fractured maxilla on imaging.

 Disruption of the occlusion of the teeth.

 Displacement of the maxilla.

 Post traumatic facial deformity.

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 Indications for treatment

 Fractured or displaced teeth.

 Cerebrospinal fluid leak.

 Abnormal eye movement or restriction of

eye movement.

 Occlusion of the nasolacrimal duct.

 Sensory or motor nerve deficit.

 Other evidence of loss of function

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 Aims of treatment
 Relieve pain

 Restore function.

 Restore bone anatomy.

 Prevent infection

 Restore the dental occlusion

 Restore jaw movement at the earliest

possible stage
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 Restore normal nerve function

 Factors affecting the risk

 Association with multiple injuries.

 Presence of uncontrolled haemorrhage

 Impairment of the airway.

 Presence of bone comminution

 Association with a dural tear.

 Association with a base of skull fracture.

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 Factors affecting the risk

 Presence of a pre-existing dentofacial

deformity.

 Time elapsed since the injury.

 Presence of a medical or surgical factor

which would delay general anesthesia

 Presence of any factor which would delay

healing. (eg nutritional deficiency or
alcoholism)

 Stage of dental development (deciduous,

mixed or permanent dentition)
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 Factors affecting the risk

 Presence of fractured teeth.

 Total absence of teeth (edentulous)

 Inability of the patient to co-operate with

treatment.

 Association with fractures of the mandible

especially bilateral fractures of the
condyles.

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 Principles of treatment
Closed reduction may be appropriate in
cases

 Simple uncomplicated fractures

 Complex or comminuted fractures

 Medical or surgical contraindications to

open reduction

 Maxillary fractures in children

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Open reduction may be appropriate
where

 Immediate or early jaw function is

desirable

 Difficulty is encountered in reducing the

fracture by a closed method

 The fracture is unstable 26

 Definitive treatment
 Reduction

Manual manipulation

Use of dis-impaction forceps

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 Fixation and immobilization

Extraoral fixation

Craniomandibular fixation
Box-frame (pin fixation)(cadru extern)
Halo-frame(coroana)
(ghips)Plaster of paries headcap

Craniomaxillary fixation
Supra-orbital pins
Zygomatic pins
Halo-frame
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Immobilization within the tissue
Direct fixation

 Transosseous wiring at
fracture sites
 Frontozygomatic sutures
 Infrorbital margin
 Midline of the palate

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 Immobilization within the tissue

Internal-wire suspension

Circumzygomatico-mandibular

Infraorbital border-mandibular

Frontomandibular

Pyriform fossa-mandibular

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 Immobilization within the tissue

Support via the maxillary sinus by

filling materials
• Ribbon gauze
• Balloon
• Folly catheter
• Polyethylene material

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Length of the hospital stay will depend
on a number of factors including:

• Presence of other injuries

• Age and medical status of the patient

• Severity of the injury

• Technique employed in the reduction and

fixation of the fracture

• Presence or absence of medical or

surgical complications

• Social circumstances of the patient

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Salivary Glands
 General Aspects

 There are three pairs of major salivary

glands consisting of the parotid,
submandibular, and sublingual glands.
In addition there are numerous minor
glands distributed throughout the oral
cavity within the mucosa and
submucosa.
 On average about 0.5 liters of saliva
are produced each day but the rate
varies throughout the day.
 The nature of the secretion also varies
from gland to gland. Parotid secretions
 The Parotid Gland
 The parotid is the largest of the major
salivary glands
 The gland is situated in the space
between the posterior border of the
mandibular ramus and the mastoid
process of the temporal bone
 The external acoustic meatus and the
glenoid fossa lie above together with
the zygomatic process of the temporal
bone.
 Inferiorly, the parotid frequently
overlaps the angle of the mandible and
its deep surface overlies the transverse
 The peripheral branches of the facial nerve and the parotid duct
lie within a loose cellular layer between these two sheets of fascia.
 The branches of the facial nerve emerge from the anterior border
of the gland. The parotid duct also emerges to run horizontally
across the masseter muscle, before piercing the buccinators
muscle anteriorly, to end at the parotid papilla .
 Submandibular glands

 Each submandibular gland consists of a large, superficial lobe

lying within the digastrics triangle in the neck, and a smaller,
deep lobe lying within the floor of the mouth posteriorly.
 The two lobes are continuous with one other around the posterior
border of the mylohyoid muscle.
 Superficial lobe-each submandibular superficial lobe lies within the digastrics triangle.
-Its anterior pole reaches the anterior belly of the digastric muscle, and the posterior
pole reaches the stylomandibular ligament.
-Superiorly, the superficial lobe lies medially to the body of the mandible
- Inferiorly, it often overlaps the intermediate tendon of the digastric muscles and the
insertion of the stylohyoid.
Deep Lobe-The deep lobe of the each submandibular gland arises from the superficial
lobe at the posterior free edge of the mylohyoid muscle and extends forwards to the
back of the sublingual gland
Each submandibular duct is about 5 cm long in an adult.The wall of the duct is thinner
than that of a parotid duct.
It opens into the floor of the mouth on the summit of the sublingual papilla at the side of
the lingual frenum, just below the tip of the tongue.
 Sublingual glands
 The sublingual glands are the smallest of the major salivary
glands. It is predominantly a mucous gland.
 The gland lies on the mylohyoid and is covered by the mucosa
of the floor of the mouth, which is raised as it overlies the
gland from the sublingual fold.
 Posteriorly, the sublingual gland is in contact with the deep
lobe of the submandibulargland.
Minor salivary glands-The minor salivary glands are distributed
widely in the submucosa of the head and neck region, most
frequently found in the roof of the oral cavity and oropharynx.
- They are grouped according to their anatomic location –
labial,buccal, palatoglossal, palatal, tonsillar, nasal cavity,
nasopharynx,larynx, trachea, etc.
-They have mixed functional secretions – the labial and buccal are
both serous and mucous secreting, whereas the palatoglossal are
mucous secreting.
 Functions of Saliva

Saliva has the following functions:

 Mechanical cleansing of food and
bacteria
• Lubrication of oral surfaces
• Protection of teeth and oral–
oesophageal mucosa
• Antimicrobial activity
• Dissolution of taste compounds
• Facilitation of speech, mastication
Abnormal function of the salivary glands affects thesecretion of the
saliva:
• The salivary secretion may be reduced.
• The salivary secretion may be increased.
• The composition of the saliva may be changed at a
reduced,increased or normal flow rate.
• The outflow of secretion may be abnormal.
Hyposalivation- Inadequate salivary function is often associated with
the sensation of a dry mouth, referred to as xerostomia
Hypersecretion-Increased secretion of saliva is called
hypersalivation,ptyalism, sialorrhoea or hypersialia
 Causes of Salivary Hypofunction
• Iatrogenic– Medications,
Radiotherapy,Chemotherapy,Surgical
trauma
• Chronic inflammatory/autoimmune
diseases– Sjogren’s syndrome
• Endocrine disorders– Diabetes
mellitus, Hyper- and hypothyroidism
• Neurological disorders–
Depression,Anxiety,Parkinson’s
disease
• Genetic disorders and congenital
 Swellings of the parotid, acute and
chronic, present in two fashions:
1. Swelling of the entire gland (such as
mumps)
2. Partial swelling of the gland (such
as tuberculosis, cat scratch disease,
benign and/or malignant neoplasms)
 In cases of submandibular swelling,
the entire gland is considered
swollen, and a swelling of part of the
Differential diagnosis of parotid
swellings
Differential diagnosis of
submandibular swellings
 Mumps
 Mumps is the most common viral infection of the salivary glands, presenting with unilateral
or bilateral swelling of the parotid glands
 In 85% of cases, it affects children under the age of 15 years.
 Stensen’s papilla may be irritated and swollen, but no pus is visible or expressible.
 Glandular symptoms are often preceded with 1–3 days of a prodromal period, where the
patient’s complaints might include malaise, discomfort,loss of appetite, chills, headache, fever
and sore throat
 Mumps is due to a paramyxovirus, an RNA virus related to influenza and parainfluenza virus.
 Acute bacterial

 The disorder is of acute onset, with tender,

painful swelling of the salivary gland
 Parotids are affected more frequently than
are submandibular glands. One of the
possible reasons is that the bacteriostatic
activity of the parotid saliva is inferior to
that of the submandibular saliva.
 Management consists of broad-spectrum
antibiotics(after determining the precise
bacterial aetiology of the infection) and
anti-inflammatories for reducing pain and
swelling.
 The contamination mode of the parotid
glands in cases of suppurative parotitis is
unknown.
 Recurrent parotitis in childhood is the most frequent non-viral affection of
salivary glands in children, which usually resolves around puberty
 Its precise origin remains unclear, and as a result, no specific treatment
exists.
 The disease is characterised by recurrent episodes of acute or subacute,
unilateral or bilateral, swelling of the parotid glands, and usually
associated with fever andpain.
 Mucopurulent saliva can be expressed from the papilla, which is often
erythematous.
 Episodes recur every several months, sometimes more often, but thechild
is usually free of symptoms between episodes.
 Sialolithiasis
 Sialolithiasis is the main cause of unilateral, diffuse parotid or submandibular
gland swelling.
 It results in a mechanical obstruction of the salivary duct, causing repetitive
swelling during meals, which can remain transitory or be complicated by
bacterial infections.
 Traditionally, recurring episodes of infections lead to open surgery
 Sjögren’s Syndrome
 Sjogren’s syndrome (SS) is a systemic autoimmune disease that presents
with sicca symptomatology of the main mucosa surfaces.
 Glandular Manifestations-Xerostomia, the subjective feeling of oral
dryness, is the key feature in the diagnosis of primary SS, occurring in
more than 95% of patients.
 Reduced salivary volume interferes with basic functions such as speaking
or eating, and the lack of salivary antimicrobial functions may accelerate
local infection (candidiasis), tooth decay, periodontal disease and angular
cheilitis.
-Chronic or episodic swelling of the
major salivary
 Sialosis
 Sialosis (sialoadenosis, or sialadenosis) is a form of
salivarygland swelling characterized by persistent,
asymptomatic, bilateral, diffuse, non-inflammatory,
non-neoplastic parotid swelling with occasional
involvement of the submandibular salivary gland and,
rarely, the minor salivary glands.
 Classification

Sialosis is related to four main conditions:

1. Idiopathic
2. Nutritional-a. Malnutrition b. Bulimia c.
Gastrointestinal disease d. Amylophagia e. Vitamin A
deficiency
3. Drug induced -a. Alcohol b. Antihypertensives c.
Naproxen d. Valproic acid
4. Endocrine/metabolic-a. Diabetes insipidus b. Diabetes
mellitus c.Hypothyroidism d. Cirrhosis of the liver e.
Uraemia
 BENIGN TUMORS
 The overwhelming majority (80–
85%) of parotid gland (PG) tumours
is benign, and the rate decreases for
the submandibular gland (SMG; 40–
55%), minor salivary glands (MSG;
20–50%) and sublingual gland
(SLG;15–30%).
 Among benign salivary gland
tumours, pleomorphic adenoma (PA)
is most frequently encountered,
accounting for about 60% of all
 Pleomorphic Adenoma
 The usual feature here is a painless lump in the preauricular or
retromandibular areas
 The tumour mass usually shows well-defined margins; at palpation, it
may appear mobile over superficial and deep planes, with firm or hard
consistency.
 Large tumours may appear as polylobulated lesions.
 Growth is generally slow, and the patient does not report any sudden
change in mass size and/or morphology in relation to meals
 Submandibular Gland
-The most common presentation is a slow-growing, usually
painless mass in the submandibular region
-No volume changes while eating are observed
-The lesion is mobile over superficial and deep planes.

 Sub-lingual Gland
-A submucosal mass in the anterior floor of the mouth,lateral
to the lingual caruncle is commonly observed.
- The lesion is slow growing, usually painless and may cause
discomfort in lingual movements and during speech.
SALIVARY GLANDS NEOPLASMS
 Primary Neoplasm-A primary neoplasm is a
malignant tumour of a major salivary gland:
parotid, submandibular, sublingual gland or
of the minor salivary glands (all mucus-
secreting glands in the lining membrane of
the upper aerodigestive tract).
 Secondary Neoplasm-Lymphatic metastases
to lymph nodes within the salivary gland of
a tumour of other origin, haematogenous
metastases from distant primary tumours or
direct invasion from cancers that lie
adjacent to the salivary glands are
considered secondary neoplasms
 Parotid Glands-In three of four cases, secondary
neoplasms are benign tumours for some time: a
painless, slowly increasing swelling in the region of a
salivary gland. Facial palsy – most probably
incomplete or of only a few peripheral nerve branches
– is present in only one of four cases of parotid gland
malignoma.
 Submandibular Glands-Both benign and malignant
tumours usually present as a painless, mobile mass in
the submandibular triangle.Again, pain, skin
infiltration and fixation to the mandible are signs of
local extension.
 Minor Salivary Glands-Presentation depends on the
site of the tumour and does not differ from other
malignant tumours such as squamous cell carcinoma.
The palate is the most common site, and the tumour
usually manifests as a submucosal mass or ulceration.