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 CLINICAL REVIEW
of ORAL
and MAXILLOFACIAL
SURGERY
A CASE-BASED APPROACH

SHAHROKH C. BAGHERI, DMD, MD, FACS, FICD

Chief, Division of Oral and Maxillofacial Surgery
Department of Surgery, Northside Hospital
Georgia Oral and Facial Surgery, and Eastern Surgical
Associates and Consultants
Atlanta, Georgia
Clinical Associate Professor
Department of Oral and Maxillofacial Surgery
Georgia Health Sciences University
Augusta, Georgia
Clinical Assistant Professor
Department of Surgery, School of Medicine
Emory University
Atlanta, Georgia
Adjunct Assistant Professor of Surgery
School of Medicine, University of Miami
Miami, Florida

SECOND EDITION
3251 Riverport Lane
St. Louis, Missouri 63043

CLINICAL REVIEW OF ORAL AND MAXILLOFACIAL SURGERY: ISBN: 978-0-323-17126-7

A CASE-BASED APPROACH SECOND EDITION

Copyright © 2014 by Mosby, Inc., an affiliate of Elsevier Inc.

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(other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treatment may
become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others, including
parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge
of their patients, to make diagnoses, to determine dosages and the best treatment for each individual
patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

Previous edition copyrighted 2008

ISBN: 978-0-323-17126-7

Vice President and Publisher: Linda Duncan

Executive Content Strategist: Kathy Falk
Senior Content Development Specialist: Courtney Sprehe
Publishing Services Manager: Julie Eddy
Senior Project Manager: Richard Barber
Design Direction: Paula Catalano

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

This book is dedicated to…

….all students, residents, and fellows in oral and maxillofa-

cial surgery in all corners of the world, and a tribute to their
commitment to improve upon the lives of others despite the
many challenges that lie ahead.

….my wife, Nooshin, and to my children, Shaheen and Bijan,

whose future is the spark behind this work. My parents, Parviz
and Ladan, and my brother, Homayoun, all of whom brighten
and bring joy to my day. It is because of them that I was able
to complete this project.

….to my prior mentors and friends who have influenced

and molded my surgical career. Dr. Robert A. Bays,
Dr. Sam E. Farish, Dr. Eric J. Dierks, Dr. Bryce E. Potter,
Dr. R. Bryan Bell, Dr. Leon Assael, and Dr. Roger A. Meyer.
And to my great friend, Dr. Husain Ali Khan.
Acknowledgments

This book would not have been possible without the support
and hard work of the many contributors that gave their time
and expertise. It is them who make this book possible.

Special thanks to Dr. Chris Jo, whose help as co-editor and

author was instrumental in completion of the first and second
editions of this text.

The production of this book would not have been possible

without the efficient and enthusiastic team at Elsevier. Special
thanks to Ms. Courtney Sprehe, Ms. Kathy Falk, and Mr. Rich
Barber.
CHAPTER E D I T O R S A N D C O N T R I B U T O R S

CHAPTER EDITORS Neil Agnihotri, DMD, MD

Private Practice
Deepak Kademani, DMD, MD, FACS
Virginia Oral and Facial Surgery
Associate Professor and Fellowship Director
Richmond, Virginia
Department of Oral and Maxillofacial Surgery
University of Minnesota
Saif Al-Bustani, MD, DMD
Chief of Oral and Maxillofacial Surgery
Resident
North Memorial Medical Center
Division of Plastic and Reconstructive Surgery, School of
Minneapolis, Minnesota
Medicine
University of North Carolina at Chapel Hill
Martin B. Steed, DDS
Chapel Hill, North Carolina
Associate Professor and Residency Program Director
Division of Oral and Maxillofacial Surgery, Department of
John M. Allen, DMD
Surgery
Private Practice, Pomona Valley Oral and Maxillofacial
Emory University
Surgery
Atlanta, Georgia
Pomona, California
Medical Attending Staff, OMS USC University Hospital
Husain Ali Khan, DMD, MD
Clinical Attending Staff, Los Angeles County/USC Medical
Georgia Oral and Facial Surgery, and Eastern Surgical
Center
Associates and Consultants
Clinical Attending Staff, USC School of Dentistry
Attending Surgeon
Los Angeles, California
Division of Oral and Maxillofacial Surgery, Department of
Surgery
Bruce W. Anderson, DDS
Northside Hospital
Private Practice, South OMS
Atlanta, Georgia
Peachtree City, Georgia
Clinical Associate Professor
Department of Oral and Maxillofacial Surgery
Leon A. Assael, DMD
Medical College of Georgia
Dean, School of Dentistry
Augusta, Georgia
University of Minnesota
Minneapolis, Minnesota
Roger A. Meyer, MD, DDS, MS, FACS
Director,Maxillofacial Consultations, Ltd.
Robert S. Attia, DMD
Greensboro, Georgia
Division of Oral and Maxillofacial Surgery, Department of
Department of Surgery, Northside Hospital
Surgery
Atlanta, Georgia
School of Medicine
Clinical Assistant Professor
Emory University
Department of Oral and Maxillofacial Surgery
Atlanta, Georgia
Georgia Health Science University
Augusta, Georgia
Shahid R. Aziz, MD, DMD, FACS
Private Practice, Georgia Oral and Facial Surgery
Associate Professor
Marietta, Georgia
Department of Oral and Maxillofacial Surgery
New Jersey Dental School
CONTRIBUTORS Division of Plastic Surgery, Department of Surgery
New Jersey Medical School
Nathan G. Adams, DMD, MD
University of Medicine and Dentistry of New Jersey
Private Practice, Oral and Facial Reconstructive Surgeons
Newark, New Jersey
of Utah
Salt Lake City, Utah

vi
 Chapter Editors and Contributors vii

Shahrokh C. Bagheri, DMD, MD, FACS, FICD Tuan G. Bui, MD, DMD
Chief, Division of Oral and Maxillofacial Surgery Private Practice, Head and Neck Surgical Associates
Department of Surgery, Northside Hospital Attending Surgeon, Oral, Head, and Neck Cancer Program
Georgia Oral and Facial Surgery, and Eastern Surgical Providence Cancer Center
Associates and Consultants Attending Surgeon, Trauma Service/Oral and Maxillofacial
Atlanta, Georgia Surgery Service
Clinical Associate Professor Legacy Emanuel Medical Center
Department of Oral and Maxillofacial Surgery Affiliate Assistant Professor
Georgia Health Sciences University Department of Oral and Maxillofacial Surgery
Augusta, Georgia Oregon Health and Science University
Clinical Assistant Professor Portland, Oregon
Department of Surgery, School of Medicine
Emory University Allen Cheng, DDS, MD
Atlanta, Georgia Fellow, Head and Neck Oncology and Microvascular
Adjunct Assistant Professor of Surgery Reconstructive Surgery
School of Medicine, University of Miami Legacy Emanuel Medical Center and Providence Cancer
Miami, Florida Center
Portland, Oregon
Michael L. Beckley, DDS
Clinical Assistant Professor Sung Hee Cho, MD, DDS
Department of Oral and Maxillofacial Surgery Head and Neck Oncologic Fellow
School of Dentistry Department of Otolaryngology
University of the Pacific School of Medicine
San Francisco, California Emory University
Atlanta, Georgia
R. Bryan Bell, MD, DDS, FACS
Medical Director, Oral, Head, and Neck Cancer Program Danielle M. Cunningham, DDS
and Clinic Clinical Attending, St. Joseph’s Hospital and Health Center
Providence Cancer Center/Providence Portland Medical Syracuse, New York
Center Private Practice
Attending Surgeon, Trauma Service/Oral and Maxillofacial Camillus, New York
Surgery Service
Legacy Emanuel Medical Center Eric Dierks, MD, DMD
Affiliate Professor Affiliate Professor
Oregon Health and Science University Department of Oral and Maxillofacial Surgery
Head and Neck Surgical Associates Oregon Health and Science University
Portland, Oregon Portland, Oregon

Samuel Bobek, DMD, MD Abdulrahman Doughan, MD, FACC

Private Practice, Head and Neck Surgical Associates Atlanta Heart Associates, PC
Associate Professor Stockbridge, Georgia
Oregon Health and Science University
Portland, Oregon Fariba Farhidvash, MD, MPH
Neurologist
Gary F. Bouloux, MD, DDS, MDSc, FRACDS (OMS) Atlanta, Georgia
Associate Professor
Division of Oral and Maxillofacial Surgery, Department of Sam E. Farish, DMD
Surgery J. David and Beverly Allen Family Professor of Oral and
School of Medicine Maxillofacial Surgery
Emory University Division of Oral and Maxillofacial Surgery, Department of
Atlanta, Georgia Surgery
School of Medicine
Shenan Bradshaw, DDS Emory University
Resident, Division of Oral and Maxillofacial Surgery Chief, Department of Oral and Maxillofacial Surgery
School of Medicine VA Medical Center
Emory University Atlanta, Georgia
Atlanta, Georgia
viii Chapter Editors and Contributors

Jaspal Girn, DMD, FRCD(C) Deepak Kademani, DMD MD FACS

Private Practice, Centrepoint Oral and Facial Surgery Associate Professor and Fellowship Director
Burnaby, British Columbia Department of Oral and Maxillofacial Surgery
Part-Time Clinical Assistant Professor University of Minnesota
Department of Oral Surgery, Faculty of Dentistry Chief of Oral and Maxillofacial Surgery
University of British Columbia North Memorial Medical Center
Vancouver, British Columbia Minneapolis, Minnesota

Ibrahim M. Haron, DDS Solon Kao, DDS, FICD

Resident, Division of Oral and Maxillofacial Surgery Assistant Professor of Oral and Maxillofacial Surgery
School of Medicine Deputy Program Director of OMS Training Program
Emory University Department of Oral and Maxillofacial Surgery
Atlanta, Georgia School of Dental Medicine
Georgia Regents University
Eric P. Holmgren, DMD, MD, FACS Augusta, Georgia
Private Practice, Oral and Facial Surgery Associates
Pittsfield, Massachusetts Husain Ali Khan, DMD, MD, FACS
Georgia Oral and Facial Surgery, and Eastern Surgical
Bradford Huffman, DMD Associates and Consultants
Resident, Department of Oral and Maxillofacial Surgery Attending Surgeon
College of Dental Medicine Division of Oral and Maxillofacial Surgery, Department of
Georgia Regents University Surgery
Augusta, Georgia Northside Hospital
Atlanta, Georgia
Jason A. Jamali, DDS, MD Clinical Associate Professor
Clinical Assistant Professor Department of Oral and Maxillofacial Surgery
Department of Oral and Maxillofacial Surgery Medical College of Georgia
University of Illinois at Chicago Augusta, Georgia
Chicago, Illinois
Brian E. Kinard, DMD
Damian R. Jimenez, DMD Resident, Division of Oral and Maxillofacial Surgery
Chief Resident, Division of Oral and Maxillofacial Surgery School of Medicine
School of Medicine Emory University
Emory University Atlanta, Georgia
Atlanta, Georgia
Antonia Kolokythas, DDS, MSc
Chris Jo, DMD Department of Oral and Maxillofacial Surgery
Atlanta Oral and Facial Surgery, LLC University of Illinois at Chicago Cancer Center
Atlanta, Georgia Chicago, Illinois

Jenny Jo, MD Deepak G. Krishnan, BDS

Peachtree Women’s Clinic Assistant Professor of Surgery and Residency Program
Atlanta Women’s Health Group Director
Atlanta, Georgia Department of Oral and Maxillofacial Surgery
University of Cincinnati Medical Center
Jeremiah O. Johnson, DDS, MD Cincinnati, Ohio
Former Chief Resident of Oral and Maxillofacial Surgery
Oregon Health and Science University
Portland, Oregon
Fellow, Royal Melbourne Hospital
Australia
 Chapter Editors and Contributors ix

Joyce T. Lee, DDS, MD, FACS Kambiz Mohammadzadeh, MD

Division of Oral and Maxillofacial Surgery, Department of Research Fellow
Surgery Georgia Oral and Facial Surgery
School of Medicine Atlanta, Georgia
Emory University
Atlanta, Georgia Anthony B.P. Morlandt, MD, DDS
Fellow, Head and Neck Microvascular Reconstruction
Patrick J. Louis, DDS, MD Department of Oral and Maxillofacial Surgery, Section of
Professor and Residency Program Director Head and Neck Surgery
Department of Oral and Maxillofacial Surgery University of Florida at Jacksonville
University of Alabama at Birmingham Jacksonville, Florida
Birmingham, Alabama
Timothy M. Osborn, MD, DDS
Michael R. Markiewicz, DDS, MD, MPH Assistant Professor
Resident, Division of Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery
School of Medicine Henry M. Goldman School of Dental Medicine
Emory University Boston University
Atlanta, Georgia Boston, Massachusetts

Robert E. Marx, DDS Rebecca Paquin, DMD, BS

Miller School of Medicine Resident, Department of Oral and Maxillofacial Surgery
University of Miami College of Dental Medicine
Miami, Florida Georgia Regents University
Augusta, Georgia
Wm. Stuart McKenzie, DMD, MD
Resident, Department of Oral and Maxillofacial Surgery Etern S. Park, MD, DDS
University of Alabama at Birmingham Fellow, Head and Neck Oncologic and Microvascular
Birmingham, Alabama Reconstructive Surgery
Legacy Emanuel Medical Center and Providence Portland
Mehran Mehrabi, DMD, MD Cancer Center
Private Practice, Advanced Dental Specialists Portland, Oregon
Glen Dale, Wisconsin
Ketan Patel, DDS, PhD
Roger A. Meyer, MD, DDS, MS, FACS Fellow, Oral/Head and Neck Oncologic Surgery
Director, Maxillofacial Consultations, Ltd. University of Minnesota
Greensboro, Georgia Minneapolis, Minnesota
Department of Surgery, Northside Hospital
Atlanta, Georgia Kumar J. Patel, BDS, LDSRCS, DMD, MS, FICD
Clinical Assistant Professor Private Practice
Department of Oral and Maxillofacial Surgery Marietta, Georgia
Georgia Health Science University
Augusta, Georgia Mayoor Patel, DDS, MS
Private Practice, Georgia Oral and Facial Surgery Adjunct Clinical Instructor, Craniofacial Pain Center
Marietta, Georgia Tufts University
Boston, Massachusetts
Michael Miloro, DMD, MD, FACS Adjunct Clinical Instructor
Professor and Head Department of Oral Health and Diagnostic Sciences
Department of Oral and Maxillofacial Surgery Georgia Regents University
University of Illinois at Chicago Augusta, Georgia
Chicago, Illinois Private Practice, Craniofacial Pain Center of Georgia
Atlanta, Georgia
Justine Moe, DDS
Resident, Division of Oral and Maxillofacial Surgery Piyushkumar P. Patel, DDS
School of Medicine Private Practice
Emory University Atlanta, Georgia
Atlanta, Georgia
x Chapter Editors and Contributors

Sandeep V. Pathak, DMD, MD Jonathan Shum, MD, DDS

Private Practice, Oral and Facial Surgery Associates Fellow, Head and Neck Oncology and Microvascular
Lawrenceville, Georgia Reconstructive Surgery
Legacy Emanuel Medical Center and Providence Cancer
Vincent J. Perciaccante, DDS Center
Adjunct Associate Professor of Surgery Portland, Oregon
Division of Oral and Maxillofacial Surgery University of Maryland Medical Center
School of Medicine Baltimore, Maryland
Emory University
Atlanta, Georgia Somsak Sittitavornwong, DDS, DMD, MS
Department of Oral and Maxillofacial Surgery
Ali R. Rahimi, MD, MPH, FACC School of Dentistry
Director, Cardiovascular Quality University of Alabama at Birmingham
Kaiser Permanente Georgia/The Southeast Permanente Birmingham, Alabama
Medical Group
Adjunct Assistant Professor A. Michael Sodeifi, DMD, MD, MPH
Department of Health Policy and Management Private Practice, Silicon Valley Surgical Arts
Emory University Cupertino, California
Atlanta, Georgia Private Practice, San Francisco Surgical Arts
Adjunct Assistant Professor of Oral and Maxillofacial
Kevin L. Rieck, DDS, MD Surgery
Assistant Professor of Surgery University of the Pacific
Division of Oral and Maxillofacial Surgery, Department of San Francisco, California
Surgery
Mayo Clinic Martin B. Steed, DDS
Rochester, Minnesota Associate Professor and Residency Program Director
Division of Oral and Maxillofacial Surgery, Department of
Ma’Ann C. Sabino, DDS, PhD Surgery
Parkside Oral and Maxillofacial Surgery Clinic Emory University
Hennepin County Medical Center Atlanta, Georgia
Minneapolis, Minnesota
Brett A. Ueeck, DMD, MD
Martin Salgueiro, DDS Assistant Professor
Department of Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery
Georgia Regents University Oregon Health and Science University
Augusta, Georgia Attending Surgeon, Cleft Lip and Palate Team
Shriners Hospital for Crippled Children
Edward R. Schlissel, DDS, MS Portland, Oregon
Professor Emeritus of General Dentistry
School of Dental Medicine David Verschueren, DMD, MD
Stony Brook University Private Practice, Northwest Oral and Facial Surgery
Stony Brook, New York Vancouver, Washington
Assistant Clinical Professor Clinical Associate and Assistant Professor
Division of Oral and Maxillofacial Surgery, Department of Department of Oral and Maxillofacial Surgery
Surgery Oregon Health and Sciences University
School of Medicine Portland, Oregon
Emory University
Atlanta, Georgia Lee M. Whitesides, DMD, MMSC
Private Practice
Abtin Shahriari, DMD, MPH Dunwoody, Georgia
Private Practice, Greater Atlanta Oral Facial Surgery
Cumming, Georgia Michael Wilkinson, DMD, MD
Private Practice, Gwinnett Medical Center Private Practice, Cache Valley Oral and Facial Surgery
Lawrenceville, Georgia Logan, Utah
Attending Surgeon, Northside Hospital and Saint Joseph’s
Hospital
Atlanta, Georgia
 F O R EWORD

A Purpose for our Knowledge

physical findings, imaging, and laboratory values. These are
Clinical knowledge is like no other. The entire purpose of all collated into patient assessment, which is combined with bio-
the clinical knowledge we retain or access is to help in making medical knowledge to choose the best treatments. Even the
a clinical decision. What should I do for this patient? How best evidence is often controversial. Where the limits of con-
should I advocate for treatment, select treatment from a temporary knowledge and the parameters that define the
variety of options, provide informed consent, sequence patient decision-making environment are not clear, the remaining
care, prioritize care, perform it, and evaluate patient care controversies over treatment are discussed. Finally, key to the
outcomes? All those tasks begin with didactic knowledge. Not success of such an effort, the clinical education presented in
didactic knowledge in the abstract, but knowledge that is Clinical Review of Oral and Maxillofacial Surgery details the
patient-based (e.g., clinical knowledge). Only knowledge that complications of treatment, such as infection and idiosyn-
is applicable to the care of a patient can be deemed clinical cratic drug reactions.
knowledge. The traditional surgical textbooks present bio- All this can and must be done in an efficient way that uses
medical knowledge in the abstract. They are a collection of the precious time of the practicing surgeon wisely. As Shake-
facts and concepts that are left to the reader to determine how speare said, “Brevity is the soul of wit.” Clinicians today must
to apply in the clinical setting. Although these texts can make dozens of daily decisions using the tenets of evidence-
provide foundational knowledge, their study cannot directly based medicine. To do so requires knowledge that, as in man-
improve patient care. ufacturing, is accessed “just in time” to care for an individual
This text differs fundamentally from that common para- patient. The large inventory of knowledge that has been tra-
digm in that it strives to impart true clinical knowledge. It is ditionally used to make clinical decisions has been supplanted
the goal of Clinical Review of Oral and Maxillofacial Surgery by the rapid increase of new information that must guide
to bring knowledge directly into the realm of patient care. In clinical decisions. To achieve that goal in a practical way,
this text, Dr. Bagheri and his expert clinician contributors take knowledge must be contemporary, easy to access, easy to read
103 clinical situations in patient care and apply the appropri- and understand, and of course it must be brief. Clinical Review
ate didactic knowledge to making a clinical decision. This text of Oral and Maxillofacial Surgery seeks to allow the reader
simulates real practice by addressing common clinical situa- to find clinically relevant knowledge efficiently.
tions that for the experienced clinicians will resonate in their In the era of a society and specialty that measures the
daily practice, and for the residents will set the landscape for continued competence of surgeons, certification/licensure and
their eventual clinical decision needs. credentialing are ongoing processes that must be concurrently
Evidence-based medicine is the application of didactic achieved and regularly enforced. Although clinical measure-
knowledge combined with clinical experience personalized to ments can be obtained by examining clinical outcomes, a
the needs of an individual patient. Evidence-based medicine continuous monitoring of contemporary knowledge to under-
is thus the most straightforward, practical, and effective way lie effective practice is becoming the norm. Clinical Review
to practice oral and maxillofacial surgery. Thus, the best evi- of Oral and Maxillofacial Surgery is particularly suited to this
dence-based practice is delivered by experienced clinicians, emerging environment of being able to apply contemporary
with a wealth of didactic knowledge, who also access the knowledge into clinical practice.
latest information and who address the needs of their patients The only purpose of clinical knowledge, as can be read
through careful listening and knowledge of each patient. How and enjoyed in Clinical Review of Oral and Maxillofacial
can the tenets of this method be taught to the surgeon who Surgery, is to make a decision that has a positive effect on
has not yet gained sufficient experience to allow didactics, patient care. The cases presented here resemble an objective-
skill, and patient/doctor communication to flow seamlessly simulated clinical encounter (OSCE). The case-based format
into great care? Clinical Review of Oral and Maxillofacial allows readers to calibrate their own opinions about a clinical
Surgery seeks to do so by simulating the clinical environment problem in a virtual, live patient setting and to customize it
by presenting common clinical problems addressed by true to the needs of their patients in real practice. Using these
experts in each area. The resident in oral and maxillofacial clinical presentations in real time to evaluate one’s own think-
surgery can particularly benefit from this text in that the key ing on a clinical problem can result in more effective care
elements of the clinical care of each problem are presented. influenced by the wealth of clinical evidence underlying the
As actual care unfolds, the questions to be asked on rounds, decision as well as the opinion of experts supplied with the
the queries and concerns of the patient, the needs of the health latest knowledge. Here in the pages of Clinical Review of Oral
care team, and the verification of one’s own clinical thinking and Maxillofacial Surgery we can help the sick to be well and
are confirmed in the text as each case setting is discussed. achieve our highest purpose.
Actual patient care is simulated in the Clinical Review by Dr. Leon Assael, Dean, University of Minnesota
demonstrating common clinical presentation, anamnestic and
xi
PREFACE

It is clear now, almost 10 decades after the formation of the ability. As the repertoire of procedures increases, so does
specialty in 1918, that the demand for and subsequently the the risk of unwanted complications of treatment that may
scope of oral and maxillofacial surgery have rapidly expanded require further surgical interventions, and these areas are
far beyond what anyone could have envisioned in the begin- addressed as well.
ning. As the world’s population ages, and with development Similar to the first edition, the purpose of this edition is to
of new diagnostic modalities, treatment and surgical proce- provide its readers with a systematic and comprehensive
dures to prolong a useful life span even further, there will be approach to the management of patients presenting with a
a sustained and consistent increase in the need for the services wide array of surgical or pathological conditions seen in this
of the modern oral and maxillofacial surgeon. specialty. Contrary to traditional textbooks of surgery (which
The traditional array of oral and maxillofacial operations present material in a fashion not directly related to a given
was mostly related to the surgical treatment of conditions patient, but rather list “classical” findings, pathophysiology,
such as infections, diseased teeth and associated pathology, and stereotypical treatment modalities), in this publication we
or repair of traumatic injuries or developmental deformities emphasize a case-based approach to learning that is suitable
limited to the oral region. However, as explained in this text- for readers of oral and maxillofacial surgery at all levels of
book, there has been considerable expansion of the recog- training or practice. Case-based learning is a proven and
nized scope of the specialty to include the cranium and the effective method of teaching. Some of the most common (as
neck, and not only to address the eradication of pathology. well as complex) cases are selected to illustrate individual
With the dawn of the twenty-first century, the long-antici- examples of the typical history, physical exam findings, labo-
pated goal of “expanded scope” of oral and maxillofacial ratory and imaging studies, analysis of treatment options,
surgery has ceased to be a “buzz word” and has become a complications, and discussion of other relevant information.
reality. Fueled by the energy, imagination, and skill of many Learning is enhanced by incorporating teaching around real-
young surgeons with post-residency fellowship training, and patient scenarios. However, each chapter is more than a
a realization that mere ‘ “familiarity” about an area of surgi- patient scenario, but rather a carefully written teaching
cal interest does not create true clinical competence that case that outlines essential information pertinent to funda-
can be transferred to quality surgical care,1,2 the specialty mental aspects of the condition as they present in the practice
has moved forward with confidence based on training and of oral and maxillofacial surgery. In this manner, the reader
documented clinical experience. It has become heavily com- is actively engaged in assessing the case, raising the interest,
mitted to research, teaching, and patient care in the addi- and therefore enhancing the understanding and retention of
tional areas of pediatric craniomaxillofacial surgery, information.
oncologic and reconstructive surgery, facial cosmetic surgery, In the past decades, the specialty of oral and maxillofacial
care of nerve injuries, surgery for temporomandibular joint surgery has seen numerous dramatic changes in training,
disorders (both open and arthroscopic), endoscopic mini- scope, and style of practice. Additional changes in the near
mally invasive operations, and dental and craniofacial future are undoubtedly in the offing. For example, traditional
implantology. None of this would have been possible without ways of conducting single or small-group private practice in
the opportunities given to those trainees who wished to offices may be replaced by a new model,3 in which groups of
expand their knowledge and skills beyond residency by com- subspecialists practice together in a university or large hospi-
pleting fellowship training or seeking further education tal setting and are fully staffed to see patients around the
beyond formal training in one of the areas just mentioned. clock. A single area of surgical expertise for a large metro-
Not only has the scope of diseases and conditions expanded politan area of several million people may be provided by a
but also additional efforts have been designed to change the group of surgeons practicing together in a large hospital or
patients’ quality of life by improving upon oral and facial university medical center setting. These surgeons focus solely
anatomic defects that affect both function and aesthetics. In on their area of expertise (for example, pediatric craniofacial
addition to surgical skills, supportive technology in the form surgery, maxillofacial trauma, or head and neck oncologic
of instrumentation, internal fixation and implant systems, and surgery and reconstruction) to the exclusion of other aspects
imaging modalities have allowed the evaluation and treat- of their specialty. All major surgery with a high demand for
ment planning for surgical corrections of complex head and technical expertise and experience in patient hospital manage-
neck pathology, congenital or development craniofacial ment is handled in such a fashion. These surgeons may be the
deformities, loss of teeth and supporting bone, or maxillofa- new oral and maxillofacial hospitalists of the twenty-first
cial injuries to be done with increased accuracy and predict- century! Only the more routine procedures or aspects of
xii
 Preface xiii

practice, which comprise the majority of work in today’s oral It is with great excitement and anticipation of the future
surgery private practices (tooth extractions, biopsies, routine development of our specialty that we publish this second
infections, and perhaps dental implants) might continue to be edition with new cases and updated information. It is hoped
managed by future oral surgeons who choose to practice in that all readers, in all corners of the world, will find within its
an office-based environment. What is contained in this new contents the information and inspiration that helps them
edition will give the reader a good overview of all areas of improve the care of their patients.
the specialty of oral and maxillofacial surgery as it faces the Shahrokh C. Bagheri
challenges of the twenty-first century. Atlanta, Georgia

1
Hupp JR: Surgical training: Is dabbling enough? J Oral Maxillofac Surg
69:1535, 2011.
2
Meyer RA, Bagheri SC: Familiarity does not breed competence, J Oral
Maxillofac Surg 69:2483, 2011.
3
Hupp JR: Integrated service-line care—lessons from China, J Oral Maxil-
lofac Surg 71:653, 2013.
 C H A PTER 1
Oral and Maxillofacial Radiology

This chapter addresses:

• Multilocular Radiolucent Lesion in the Pericoronal Region
(Keratocystic Odontogenic Tumor [Odontogenic Keratocyst])
• Unilocular Radiolucent Lesion of the Mandible
• Multilocular Radiolucent Lesion in the Periapical Region
(Ameloblastoma)
• Unilocular Radiolucent Lesion in a Periapical Region
(Periapical Cyst)
• Mixed Radiolucent-Radiopaque Lesion (Ossifying Fibroma)
• Cone-Beam Computed Tomography (CBCT)

Interpretation of radiographs is a routine part of the daily Despite clinicians’ ability to read and interpret many dif-
practice of oral and maxillofacial surgery. Commonly obtained ferent imaging studies, the oral and maxillofacial radiologist
radiographs at the office include the periapical, occlusal, pan- will play an increasingly greater role in the practice of oral
oramic, and lateral cephalometric radiographs. Cone beam and maxillofacial surgeons.
computed tomography (CBCT) scans are becoming more This section includes the radiographic presentation of five
readily available in many offices. Although this technology is important and representative pathologic processes, in addition
extremely useful, its indications, liabilities, and advantages to a new case demonstrating the use of CBCT. Included in
have to be clearly recognized. As the future unfolds, the each case is the differential diagnosis of associated conditions,
advancing technology will improve upon office imaging to guide further study.
modalities that will facilitate diagnosis and treatment. There- Figure 1-1 shows the most common location of several
fore, a knowledge of normal radiographic anatomy and clini- radiographically detectable maxillofacial pathologic pro-
cal skill in recognizing pathologic conditions become even cesses.
more essential.

Posterior maxilla Anterior maxilla

• Pagets disease of bone • Adenomatoid odontogenic
tumor (AOT)
• Nasopalatine duct cyst
Posterior mandible • Lateral periodontal cyst
• Dentigerous cyst (botryoid type)
• Keratocytic odontogenic tumor • Odontoma
• Ameloblastoma • Paget’s disease of bone
• Intraosseous
mucoepidermoid carcinoma
• Stafne bone defect (below canal) Anterior mandible
• Idiopathic bone marrow defect • Periapical cemento osseous
• Calcifying epithelial dysplasia
odontogenic tumor (CEOT) • Central giant cell granuloma
• Odontoma

Figure 1-1 The most common location of several radiographically detectable maxillofacial pathologic processes.

1
 Multilocular Radiolucent Lesion in the Pericoronal Region
(Keratocystic Odontogenic Tumor [Odontogenic Keratocyst])

Piyushkumar P. Patel, Chris Jo, and Shahrokh C. Bagheri

involving the area below the inferior border. The mass is hard,
CC
nonfluctuant, and nontender to palpation (large cysts may
A 20-year-old man is referred for evaluation of a swelling on rupture and leak keratin into the surrounding tissue, provok-
his right mandible. ing an intense inflammatory reaction that causes pain and
swelling). There are no facial or trigeminal nerve deficits
Keratocystic Odontogenic Tumor (KCOT) (paresthesia of the inferior alveolar nerve would be more
Keratocystic odontogenic tumors (KCOTs) show a slight pre- indicative of a malignant process). The intercanthal distance
dilection for males and are predominantly found in individu- is 33 mm (normal), and there is no evidence of frontal bossing.
als of Northern European descent. The peak incidence is seen His occipitofrontal circumference is normal (an intercanthal
between 11 and 40 years of age. Patients with larger lesions distance [the distance between the two medial canthi of the
may present with pain secondary to infection of the cystic palpebral fissures] of greater than 36 mm is indicative of
cavity. Smaller lesions are usually asymptomatic and are fre- hypertelorism, and an occipitofrontal circumference greater
quently diagnosed during routine radiographic examination. than 55 cm is indicative of frontal bossing; both can be seen
The World Health Organization (WHO) has recommended with NBCCS).
the use of the term keratocystic odontogenic tumor (KCOT), Neck. There are no palpable masses and no cervical or
rather than odontogenic keratocyst (OKC), because the former submandibular lymphadenopathy. Positive lymph nodes
name better reflects the neoplastic behavior of the lesion. would be indicative of an infectious or a neoplastic process.
Genetically, the lesion shows a repeatable chromosomal A careful neck examination is paramount in the evaluation of
abnormality (PTCH gene on chromosome 9q22.3-q31). any head and neck pathology.

HPI
The patient complains of a 2-month history of progressive, Box 1-1 Diagnostic Criteria for Nevoid Basal Cell
nonpainful swelling of his right posterior mandible. (About Carcinoma Syndrome
65% to 83% of KCOTs occur in the mandible, most often in
the posterior body and ramus region. KCOTs account for A diagnosis can be made when 2 major criteria (or 1 major and
approximately 3% to 14% of all oral cystic lesions.) The 2 minor criteria) are met.
patient denies any history of pain in his right lower jaw, fever, Major Criteria
purulence, or trismus. He does not report any neurosensory 1. Multiple (>2) basal cell carcinomas, or one in a patient under
changes (which are generally not seen with KCOTs). age 30, or >10 basal cell nevi
2. Any odontogenic keratocyst (confirmed on histology) or
polyostotic bone cyst
MHX/PDHX/MEDICATIONS/ALLERGIES/SH/FH 3. Palmar or plantar pits (3 or more)
4. Ectopic calcification: lamellar or early (< age 20) falx
Noncontributory. There is no family history of similar calcification
presentations. 5. Family history of NBCCS
Nevoid basal cell carcinoma syndrome (NBCCS) is an Minor Criteria
autosomal dominant inherited condition with features that can 1. Congenital skeletal anomaly: bifid, fused, splayed, or missing
include multiple basal cell carcinomas of the skin, multiple rib; or bifid, wedged, or fused vertebra
KCOTs, intracranial calcifications, and rib and vertebral 2. Occipitofrontal circumference (OFC) > 97th percentile, with
anomalies. Many other anomalies have been reported with frontal bossing
3. Cardiac or ovarian fibroma
this syndrome (Box 1-1). The prevalence of NBCCS is esti-
4. Medulloblastoma
mated to be 1 in 57,000 to 1 in 164,000 persons. 5. Lymphomesenteric cysts
6. Congenital malformation: cleft lip and/or palate, polydactyly,
eye anomaly (cataract, coloboma, microphthalmia)
EXAMINATION
From Evans DG, Ladusans EJ, Rimmer S, et al: Complications of the naevoid
Maxillofacial. The patient has slight lower right facial swell- basal cell carcinoma syndrome: results of a population based study, J Med Genet
ing isolated to the lateral border of the mandible and not 30(6):460-464, 1993.