lab + imaging

• Volume and contour modifications: Changes in the size and shape of a region.
• Color modifications: Alterations in normal pigmentation, either hyperpigmentation or depigmentation.
• Consistency modifications: Changes in the texture or firmness of tissues.
• Pathological mobility: Abnormal movement of teeth, mandible, tongue, etc.
• Functional alterations: Abnormalities in salivation, such as asyalia, hiposyalia, and hypersyalia.
• Temperature modifications: Inflammation or ischemia leading to changes in temperature.
• Pain: Spontaneous or stimulated discomfort.

EXTRA- & INTRA-oral exam

Dental abnormalities

• malposition
• fragile
• hyper/hypo calcificiation
• decays
• periodontal disease

direct

indirect (by antagonists teeth)

mastication (foreign body)

extraction

• subluxation - slightly mobile → observation
• luxation with intrusion → extraction / observation
• luxation with extrusion → extraction
• avulsion → leave it (Øreplantation)

• fissures of enamel or dentin without loss of substance → Ø treatment
• pentrating into pulp📷 (complicated) → dental treatment

1. Horizontal: cervical, median or apical 📷
• cervical + median → extraction
• apical → apicocectomy 📷
‣

💬

Apicocectomy is typically done under local anesthesia, and an incision is made in the gum to access the root. The damaged portion of the root is then carefully removed, and the area is thoroughly cleaned and sealed to prevent further infection. Finally, the gum is stitched back into place to promote healing. The goal of an apicoectomy is to save the tooth and alleviate any pain or discomfort caused by the root fracture.

2. Vertical 📷→ extraction

periodontal lesion (peridontal disease stage 3 or 4 📷) → no mobility + pain at percussion → Øtreatment

1. Subluxation 📷→ slight etrusion, slight mobility, pain → observation
2. Partial Luxation 📷→ lost anchor → reposition + immobilization📷
3. Avulsion = Total luxation (tooth out) 📷→ tooth replacement → 4weeks immobilization

analgesics

AB

Oral hygiene

HIV-Tetanus prophylaxis

1. Median (btw. central incisors)
2. Paramedian (betw. incisor + cainine)
3. Lateral (canine - third molar)
4. Angle (after thrid molar)
5. Ramus
6. Condylar apophysis
7. Coronoid apophysis

• non-specific fracture signs
• edema
• bruising/hematoma
• abrasion + wound
• deformations + discontinuity
• abnormal movement
• anesthesia
• crepitus
• trismus (occlusion on bite exam)
• ↓movement transmission to TMJ
• Le Bourg maneuvers
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💬
👉🏽
Lebourg maneuver: Palpation asc. rammus (of mandible) 📷→ pain felt in front (chin) Palpation chin → pain felt in asc. ramus
• intraoral damage: interdental spacing, mucosa bruise, hematoma, mobile teeth
• saliva w/ blood

1. Median → Harmonia movement betw. incisors → minimal secondary dysplacement (due to symetrical muscle force)
2. Paramedian → Fracture line, displacement: prox. segment goes down, distal sigments goes up
3. Lateral → displacement (distal↑, prox↓), hemorrhage (artery involvement), hematoma of the floor → pushing tongue back → dysphagia, cant close mouth properly (occlusion modification)
4. Angle → If in front of muscl insertion (displacement as above ⇒ occlusion modified), if in the area of muscle insertion →Ødisplacement
5. Ramus → swollen parotid, pain, trismus (cant open mouth), frontal disocclusion → prox segment goes up, distal goes medially (two step occlusion), ↓sensitivity (inf damage alveolar nerve (D’alger)
6. Condylar → TMJ pain, preauricular pain, ear bleeding, ear pain
7. Coronoid → concom. zygomatic fracture, cant open mouth (Trismus), no occlusion

all muscles pull back → tongue pulled back as well into pharynx → asphyxia

Transmission of force: condylar

CT

callus in 4weeks

immediate: shock, hemorrhage, nerve damage

secondary (later): ST infection, bone-infection (osteomyelitis, osteitis), sepsis

Late: delayed consolidation, ankylosis of TMJ📷, constriction of the mandible , pseuoarthrosis

reduction + fixation

surgical reduction + fixation

surgical osteosynthesis with micoplates + microscrews

Manual 📷 or orthopedic 📷reduction followed by → Emergency 📷 or Orthopedic 📷 fixation

odontogenic (tooth) + pharygeal abscess (latero-pharyngeal)

(any abcess can lead to septic mediastinits❗)

Staphilococcus

• Septic shock
• fever +Oligura + Tachycardia + diaphoresis +agitation
• Dysphagia + Dyspnea
• ASthenia
• Chest pain
• Trismus
• productive cough

Xray- enlarged mediastinum 📷

CT - enlarged + gas mediastinum + pleural collection ; also gas in abcess (origin) 📷

1. wide incision + drainage of all affected cervical region (open the whole fucking neck) 📷
2. Debridement of necrotic tissue (uni or bilateral)
3. AB (first broad spec (Meropenem, Vanco, Metronidazole) later accord antibiogram)
4. General correction

thoracotomy 📷

• Arrhythmia
• septic shock
• erosion of carotid artery

Inflammation of the mucosa lining the paranasal sinuses

→ due to viral, bacterial infections, or allergic reactions.

• Chronic rhino-sinus inflammation
• nasal polyps (obstructive)
• Sept diviation

• Molar + Premolar teeth pathologies near the sinus (periodonitis, pockets)
• Osteitis
• Tumors
• Treatments damage
• Foreign bodies + Dental implants

• Triad:
1. Dental pain → intraorbital pain → ↑↑in pain when bending over
2. Subjective cacosmia (abnormal sense of smell)
3. purulent rhinorrhea
• Others:
• Congested skin
• pain at palpation
• nasal obstruction + congestion
• tension infraorbital region
• fatigue + fever

1. Sinus endoscopy → drainage of pus 📷
2. Anterior rhinoscopy 📷
3. Xray 📷/ CT📷
4. Antibiogram + (culture)

• Sinusitis after URT infection

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💬

• chronic exacerbates maxillary sinusitis
• purulent rhinitis (Øsinus)
• maxilly cyst, intrasinusal cyst
• osteomyelitis (maxillary)
• dental tumor
• carcinoma

1. Odontogenic sinusitis + Øoral-antral communication → endoscopic drainage and extraction +extraction tooth

→ if endoscopic not sucessfull → Caldwell-Luc radical antrostomy (trans-os drainage)📷

2. Odontogenic sinusitis with oral-antral communication

• Antrostomy + closure of communication

• NSAID, AB
• Nasal decongestants + fluidifiers

T

directly or repeatend acute maxil. sinusitis

• Diffuse pain, headache
• Purulent rhinorrhea
• Subjective cacosmia (subjective perception of foul or unpleasant odors)

• nasal endoscopy 📷
• ant. rhinoscopy
• CT❗📷

• maxillary sinusitis (allergic fungal etc. ) → bilateral + atrophy + Øhyperthrophy
• maxilarry cyst 📷
• sinus mucocele (mucous cyst)📷
• tumors 📷

• NSAIDS
• decongestions + fluidfiers
• Removal of the causal factors
• Hyperplastic mucosa → endoscopic funtional surgery (partial removal of mucosa) 📺
• Last resort: Complete removal of mucoa (Caldwell-Luc sinus radical cure)📷

vestibulum 📷+ hard pallate 📷

• surgical dental extraction
• cyst or tumor surgery
• accidental injuries
• infections (nonspecific or more specific i.e. TBC)

• Endo-oral orifice → alveolar ridge, vestublar, invisible
• after 4-6w after extraction → might be invisble + epithelialized but maxillary polyp can protrude through it
• VALSALVA sign (compress nose + blow air → fluid leaking out the orifice
• fluid backflow thorugh nostril
• air from sinus into nose
• nasal voice

• spontanous healing
• chronic sinusitis +/- ac. sinusitis

• Protetic treatment: after maxillectomy or in relapsing communications
• Comunication orifice plasty (when clean + w/o secretion )
• Fibula flap 📷- in large communication - tumor exision, postraumatic
• Local flap 📷(1-2 suture planes) in small/medium communications + recent small defects(direct healing when flap over it)

• no hard blowing of nose
• AB + NSAIDs 7days
• decongestants

the skin

• #1 Traumatic (penetrating)
• abscess of partoid gland
• Sialolithiasis (complicated with abscess + fistula)
• TB
• Tumor
• Surgery

• small orifice with erythematous halo
• on path of main salivary duct or directly from parenchyma 📷
• salivary discharge

• catheterization fistula duct
• Sialography or Fistulography (contrast + xray)

when trauma in this area → prophylactic treatment: suture Stenon duct📷; drain tube

curative:

• Atropine → ↓in salivary secretion
• Restricting mastication
• Compressive bandage on gland
• Cauterization (of fistula tract)
• Surgical plasty of fistula

removal of entire gland

inflammation of the epithelium of the salivary glands

• bacteria from mouth (pneumococcus, staph)
• Virus: Mumps, Herpes, Cocsacki

1. Catarrhal
2. Suppurative
3. Gangrenous

1. Catarrhal → inflamm infiltrate, enlarged gland, painful, fibrous viscious saliva
2. Suppurative → microabscess, pus in gland + duct which is also excreted📷, enlarged, pain
3. Gangrenous → necrosis, parotid inflammation, skin congestion+necrosis+ulcer, facial n. damage, altered general condition

prophylactic: supression of etiology, hygiene, stimulation saliva secre: pilocarpine

curative:

• AB systemic + inject into gland(with proteoloytic enzymes)
• masage of gland
• if necessary: incision + drainage

F → most often in submandibular gland, but parotid also possible

1. Salivary Colic: migration calculus → distension (intense pain w eating) → "salivary phantom tumor" → disappears few hours postprandially
2. Salivary Abscess: usually after colic → pain, fever, mastication + swallow difficulties → Rooster's crest + purulent secretion Wharton's duct
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💬

3. Salivary "tumor" → repeated infection → fibrotic transformation → enlarged, harded, only slightly painful

• submandibular abcess,
• sublingual abscess
• submandibular adenitis

• Sialolithotomy📷 if at approachable area + AB
• if not: excision of gland 📷

lesion + perforation of accessory (minor) salivary gland

F → children + young

• Paramedian lower lip
• buccal

• usually taken out - because recurrance
• also can heal + evacuate spontaneously

chronic obstruction accessory gland → cystic dilation of excretory duct of

also often recurrance → take it out (surgical excision together with accessory gland)

Ranula 📷

• sublingual
• submandibular

(both =bisac)

surgical excision together with sublingual gland

• mixed tumor
• of major+minor salivary gland

higher than in major

T

• nodular
• painless
• well-demarcated
• mobile

• rapid growth
• accentuation of skin vessels
• facial nerve paresis
• positive lymphnodes
• pain
• altered general condition

• adenocarcinoma
• glandular cyst

• Surgical excision: Parotidectomy but ↑recurrance risk → take adequate margins
• Superficial paritoidectomy (if sup. parotid lobe)
• Deep Paritoidectomy (if deep lobe)
• preserve the facial nerve

Warthin tumor

• parotid gland
• submandibular gland
• palate

1. PLGA (Polymorphous low grade adenoca)
2. NOS (Not other specified; only adenocarcinoma can be specified)

T

F → can be of any grade

• nodular onset
• pain
• facial nerve paresis
• infiltratative growth
• rapid increase in size
• lymphadenopathy

F → 50% survival at 5y

radical surgery of primary tumor + lymph mets

• radiation when indicated
• superfiical parotidectomy when low grade + superficial lobe
• total parotidectomy when deep lobe
• neck dissection when LN mets, tumor >4cm, high grade, invading
• also resection of strucutre in continuity (skin, muscles, bones)

mucoepidermoid carcinoma

Uncertain cause

• bilateral parotid gland enlargement 📷
• soft + non-tender

• if mild → Ø treatment
• if gland disfigured → partial parotidectomy

Sjörgen syndrome

‣

💬

Sicca symptoms:

• dry eyes
• dry mouth
• parotid gland enlargement

extraglandular:

• atralgia + myalgia
• GI abnormalities
• neuronal abnormalities
• RTA (renal tubular acidosis), pericarditis, pulmonary HT

1. Ocular symptoms
2. Oral symtpoms
3. Ocular signs (Schirmer test 📷)
4. Oral signs → abnormal sialography
5. Histo → lymphocytic sialoadenitis
6. Auto-Antibodies (Anti-SSA or Anti-SSB)

symptomatic treatment (curative is Ø possible)

• topical therapy
• cyclosporing for dry eyes
• steroid
• rituximab (if primary Sjögren synd)

• parotid enlargement (uni-bilat)
• ↓salivary flow
• Øeye involvement (lacrimal gland)

1. Lymphoma
2. Adenocarcinoma

• symptomatic for salivary flow
• alpha interferon
• subtotal partidectomy in tumor-like appearance

lungs

0.5-15%

• parotid painless welling (uni or bilat)
• ↓salivary flow

• clinic
• radiology
• histology (non-caseating granuloma)

• steroids
• Immunosuppressiva (MTX, AZA)

• pre-exisitng problem will affect/is affected by treatment
• oral lesion might by due to systemic disease

• duration
• change in size
• change in appearance (i.e. lump → ulcer)
• Associated symptoms: pain, swelling, dysphagia, LN swelling etc.
• B-symptoms: nausea, fever, anorexia, weight loss
• History reason for lesion → trauma, tooth-pain etc.

ABCDE 📷

• location
• consistency
• borders
• color
• size + shape
• surface
• LN
• pulsation + fluctuation

• Ulceration
• ill-defined border, raised margins
• bleeding
• fixation
• LN enlargement, Øpain, firm, fixed

vascular endthelium prolif

1. Tuberous - irregular red surface 📷
2. immature - port-wine stain 📷
3. Arterio-venous - pink, red (pulsatile) 📷

• Bleeding and ulceration
• Ocular locations can lead to strabismus, amblyopia, and astigmatism.
• Cervical locations may cause airway obstruction.
• Multiple cutaneous and visceral hemangiomas can be observed.

• Tuberous → surveillance
• steroids
• Sclerosing agents injection
• Laser therapy
• Embolization
• Surgical excision (only in small, well defined - you can provoke severe hemorrhage ❗)
• (or embo + excision)

• congenital epithelial cyst - arise in child or young adult
• from failure of obiteration of second branchial cleft in embryonic development
• arise on lateral part of the neck (often submandibular, generall along SCM ant. border)

• solitary painless, non-tender 📷
• history of interemittend swelling + tenderness during URT infection (might be tender if secondary inflammation/infection)

→ evtl. mucoid purulent discharge into pharynx or skin (associated sinus tract)

‣

💬

MRI 📷

often cholesterol crystalls inside the tumor❗

• metastatic carcinoma → cystic degeneration
• lymphoma
• paraganglioma

• infection
• mass effect → dysphagia, dyspnea, pain
• cosmetic

• acute infection (treat prior)
• general contraindication for surgery

🔪Cyst removal (surgical excision)

→ horizontal incision

F it is the most common congenital cervical cysts

Anomalous development + migration of thyroid gland

average 6y

50% before 20

• asymptomatic palpable midline neck mass at the hyoid bone (or supra or infra-)📷
• moves with swallowing
• evtl. pain + dysphagia

clinically + US

normal thyroid tissue at usual location → thyroid scans + functional test

Sistrunk procedure: removal of cyst + central portion of hyoid bone (to ensure complete removal of tract)

benign ondotogenic tumor of jaws

solid, cystic, mixed

Angle of mandible

• locally destruction + spread into ST → treat like a maligant tumor
• can undergo malignant transformation

facial or jaw bone deformities

F does not do that

Xray → "soap bubbles" 📷

surgical

• curretage (scraping out) / enucleation (only tumor cells removed; other parts untouched)
• bone resection + reconstruction

• extensive surgical exision + LN dissection
• Interferon alpha
• Radiation +chemo

• waxy papules
• pearly appearance
• central depression + ulceration
• bleeding + crusting
• raised borders
• teleangiectasis
• slow growing

excision + plastic reconstruction (free skin graft, local + regional flaps)

→ if less predictive: chemo + radiotherapy

MOHS MICROGRAPHIC SURGERY 📷

‣

💬

• ulcer + elevated edges covered with plaque
• enlarged plaques and nodules → central areas of inflammation, necrosis +oozing
• cutaneous horn📷

• underlying bone
• perineural invasion
• reginal LN mets

• wide excision + reconstruction
• LN dissection (prophylactic or therapeutic)
• LONG TERM MONITORING❗ → ↑risk of recurrence + LN mets

erythoplakia + leuplakia (slightly raised)

(can also be spleckled leukoplaskia ) white patch on periphery of erythroplakia

Nerve+ear+tongue+tooth+pharynx+functional(trismus)+bleeding

• Nerve-damage: Paresthesia, Paresis, paralysis
• Otalgia (ear pain) → if tongue, floor, maxill. sinus lesion
• Odontalgia (tooth pain) → bone tumors
• Tooth mobility → bone tumors
• Glossodynia (burning mouth)→ tongue tumor
• Dysphagia → paryngeal tumor
• Spontaneous bleeding or when chewing
• Ankyloglossia (limited tongue movement)
• Trismus (limited mouth opening)

• clinic
• Toluidine-blue staining 📷
• Cytology
• Biopsy
• LN examination
• Imaging → MRI, CT, xray, US, scincti
• check tumor suppressor gene p53
• other tumor markers

• Ulcer or fissure (Øpain Ø healing)
• Nodular (later ulcerated)
• Proliferative - cauliflower

DESTRUCTION + INFILTRATION:

• Dental signs: pain, mobility, avulsion

• Eye signs: Orbital floor syndrome + post. orbital sydrome

‣

💬

• Extension infratemporal fossa: Trismus, pain, edema
• Nerve involvement: Pain, paresthesia, paresis, paralyis
• Functional impairment: Difficulties chewing, swallowing, moving tongue + jaw
• Adenopathy
• Distant mets + related symotoms
• B-symptoms

1. Partial cleft
1. Anterior: (involves primary plate)
1. Incomplete: lip + nasal floor
2. Complete: alveolus, lip + nasal floor
2. Posterior: (involves secondary plate)
1. Incomplete: soft pallate
2. Complete: soft + hard pallate
2. Total Cleft = ant + post. cleft

⇒ both can be unilateral or bilateral

combination betw.

ant, post, complete, incomplete, unilat, bilat

oblique facial cleft: 📷

syndromic kind of cleft: 📷

Cleft assoc. w/ macrostoma → 📷

syndromic patients

FUNCTIONAL DISORDERS:

• sucking, swallowing
• chewing
• phonation
• middle ear function

→ with indersiciplinary team

1. at 2 weeks: treatment planning, caries prevention, palatal plate📷 (to obturate the cleft)
2. 3-6m: lip plasty (uni- or bilat
3. 5-6m: auditory function test
4. 12-18m: Soft+hard palate plasty
5. 2y: surveillance of tooth eruption
6. 3-4y: logopedic treatment (breathing exercises + occlusive consonant pronunciation)
7. 5-6y: re-intervention lip, nasal floor, vestibular space, elongation columella📷
8. 8-12y: secondary osteoplasty (with autogenous illiac crest graft)
9. 8-14y: Intensification orthodontic treatment (calibration upper + lower arch, dental reposition) , speech therapy, osteodistraction
10. 15y: nasal cartilage + nasal bone surgical correction
11. 18y: Maxillary hypoplasia surgical correction
12. 20y: correct of unfinish + final prosthetic treatment