cRseward = KILLEY AND KAY'S

pamecower OUTLINE OF
ORAL SURGERY
PART ONE
EWE TOs.
EASE hO Not REMOVE
AN OUTLINE OF ORAL
SURGERY, PART I
 A DENTAL PRACTITIONER HANDBOOK
SERIES EDITED BY DONALD D. DERRICK, DDS, LDS RCS

KILLEY AND KAY’S

OUTLINE OF ORAL
SURGERY, PART |

GORDON R. SEWARD
MDS(Lond), FDS RCS(Eng), FRCS(Edin), MBBS(Lond)
Professor of Oral Surgery, University of London; Head of the Department of Oral
and Maxillo-Facial Surgery, The London Hospital Medical College,
Honorary Consultant, The London Hospital

MALCOLM HARRIS
MD(Lond), FDS RCS(Eng), FFDRCSI
Professor of Oral and Maxillo-Facial Surgery, University of London; Head of
the Departments of Oral and Maxillo-Facial Surgery, The Eastman Dental Hospital
and University College Hospital; Honorary Consultant at The Eastman
Dental Hospital and University College Hospital

DAVID A. McGOWAN
MDS(QU Belfast), PhD(Lond) FDS RCS(Eng), FFDRCSI, FDSRCPS(Glas)
Professor of Oral Surgery and Head of the Department of Oral Surgery,
University of Glasgow; Honorary Consultant Oral Surgeon to Greater Glasgow
Health Board (Glasgow Dental Hospital and Glasgow Royal Infirmary)

Second edition

WRIGHT
BRISTOL
1987
 © IOP Publishing Limited. 1987

All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted in any form or by any means, electronic, mechanical, photocopying,
recording or otherwise, without the prior permission of the Copyright owner.

Published under the Wright imprint by

IOP Publishing Limited, Techno House, Redcliffe Way, Bristol BS] 6NX, England

First edition, 1971

Revised reprint, 1975
Reprinted, 1979
Reprinted, 1981
Reprinted, 1982
Reprinted, 1983
Second edition, 1987

British Library Cataloguing in Publication Data

An outline of oral surgery.—2nd ed.—(A Dental
practitioner handbook).
1. Mouth—Surgery
I. Seward, G. R. II. Harris, M.
II. McGowan, D. A. IV. Series
OTe 22 RK529

ISBN 0 7236 0735 4

Typeset by
Severntype Repro Services Ltd,
Market Street, Wotton-under-Edge, Glos.

Printed in Great Britain by

The Bath Press, Lower Bristol Road,
Bath BA2 3BL.
 PREFACE TO THE SECOND EDITION

The sad demise of both Professor Killey and Mr Kay left a serious gap in the
field of academic oral surgery. Both were skilled and popular teachers
whose books had a deserved popularity. Two new authors have joined me to
write this second edition: Professor Malcolm Harris, who succeeded
Professor Killey at the Postgraduate Institute of Dental Surgery, and
Professor David McGowan from Glasgow Dental School. In revising the
text we hope we have preserved the tradition established by the former
authors.
It has again been our intention that Part I should embrace those aspects of
oral surgery which are essential in the undergraduate course and for daily
general dental practice. Part II deals with aspects of oral surgery seen more
often in hospital, but the division is arbitrary and senior undergraduates will
find that the topics in Part II are also covered during the latter part of their
course. We hope also that general dental practitioners will find Part II
useful for reference.
In Part I sufficient detail of practical technique is covered to ensure that
the beginner develops sound habits, but obviously coverage in depth for all
procedures is impossible in a book of this size and indeed practical surgery
is often best taught by example and by close supervision by a senior oral
surgeon.
Young trainees need to revise what was taught during the undergraduate
course, to round out their knowledge to match their greater clinical
responsibilities and to prepare for higher examinations. We hope this book
will continue to serve them also.
Once again we have omitted consideration of traumatic injuries to the
mandible and maxilla which are covered in other books in the Dental
Practitioner Handbook series.

G.R. S.
M. H.
D. A. M.
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 PREFACE TO THE FIRST EDITION

This Outline of Oral Surgery is written as a guide for postgraduate and

senior undergraduate students and for practitioners with a special interest in
oral surgery. It is not intended as a textbook for the established consultant in
the specialty, for in a book of this size it is impossible to consider the subject
in the necessary detail.
The field of oral surgery covers a wide range of topics and in a work of this
nature it is impossible to discuss the entire specialty. Space has therefore
been devoted to the more important aspects of oral surgery, but even so it
has been necessary to divide the work into two volumes. Although these two
books are complementary, each volume is more or less complete in itself.
Part I is mainly devoted to the practical aspects of minor oral surgery and
should be of value to all dental practitioners who perform surgery, while
Part II deals with the needs of the dental surgeon working in a hospital.
At the request of the publisher, fractures of the mandible and middle third
of the facial skeleton have not been discussed as these subjects have been
dealt with elsewhere in the Dental Practitioner Handbook series, and
illustrations have been cut to a minimum in order to reduce costs.
It is the authors’ sincere hope that this Outline of Oral Surgery will be of
help to students preparing for undergraduate final examinations and for
higher examinations in dentistry.
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 CONTENTS

1. Patient Management, Preoperative Planning, Instruments

and Sterilization

2. Intraoral Incisions and Suturing

3. The Removal of Roots

4. Unerupted and Impacted Teeth

5. Surgical Preparation of the Mouth for Dentures

6. Pyogenic Infections of the Soft Tissues 121

7. Inflammatory Diseases of Bone 174

8. The Control of Infections 208

9. Sinusitis, Oroantral Fistula and Removal of a Tooth or

Root from the Maxillary Sinus 235

10. Surgical Endodontics 254

11. Cysts of the Jaws 263

12. Soft Tissue Swellings of the Oral Mucosa 2971,

13. The Diagnosis and Management of Orofacial Pain S13

14. Drugs and Oral Surgery 34]

Index 367
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 CHAPTER 1

PATIENT MANAGEMENT, PREOPERATIVE PLANNING,

INSTRUMENTS AND STERILIZATION

INTRODUCTION TO PATIENT MANAGEMENT

The practice of any branch of surgery requires diagnostic ability, technical
skill, judgement and compassion. Diagnostic ability is founded upon a
knowledge of the natural history of diseases and of the varied way in which
they are manifest in patients. It depends upon the ability to listen patiently
to the history while establishing a rapport with the patient so as to develop a
level of confidence and trust. The consultation is likely to be accompanied
by an undercurrent of varying emotions for the patient, though often they
are successfully suppressed. If the clinician fails to recognize their presence
and respond appropriately, but in a controlled fashion, the patient will think
him or her unsympathetic. On the other hand, the clinician must preserve a
degree of detachment to ensure that judgement is not impaired. Some
patients will be frankly fearful and indeed if their disease is serious may
have just cause for being so. They may express their fear by a show of
aggression and it is particularly important that the clinician should not
respond to this by irritation or anger. Others may put on a light hearted air or
become garrulous in order to conceal their fear.
The history of the present condition (HPC) is taken first because this is
what the patient has come about and is anxious to relate to you. Initially the
patient is encouraged to tell his or her story with the minimum of
interference or prompting. Then the detail is filled out by more direct
questioning and the order and relationship of events is established. With
tact, facts are gently separated from opinions, including those of the patient,
friends and relatives. A pattern of events will be established which may be
recognized and one or more possible diagnoses can be tested by other
questions designed either to confirm or exclude a particular condition. The
nature of the principle complaint or complaints can now be expressed
briefly as a title to the history and placed before the start of the account
under the heading ‘complaining of (C/O).
It is necessary to review the patient’s general health (GH). This may
involve no more than an enquiry if he or she is generally fit and well,
supplemented perhaps by questions about breathlessness, cough, pain in
the chest, ankle swelling and whether the weight is steady. Alternatively, if
the case so demands, a detailed system by system enquiry may be
undertaken seeking evidence of any other bodily malfunctions.
1
 ORAL SURGERY, PART I

The past history (PH) is usually enquired into next, often briefly by
asking if the patient has had any serious illnesses in the past, any prolonged
periods at home and particularly in bed, or any admissions to hospital.
Problems with the heart or chest and rheumatic fever and chorea in
particular may be specially mentioned.
During a hospital admission and before an operation it may be relevant to
enquire systematically into the patient’s past illnesses from childhood to the
present time. The past history should of course include an account of dental
problems and experiences of dental treatment.
The family history (FH) can be unexpectedly useful, leading the patient
to tell you about the children, of elderly dependent relatives or the ill health
of a husband or wife, all of which may enhance the understanding of the
patient’s own illness or warn of possible problems with postoperative
care.
Similarly the social history (SH) is important as this too may reveal
social and work pressures which may be relevant to the diagnosis or
difficulties to be surmounted as a result of the illness or which might arise
from an admission to hospital. (Who will look after a young widow’s small
child if mother and father live abroad?). Details of medicines, injections or
tablets which are taken regularly must not be overlooked, nor an enquiry
into allergies to drugs, dressings or other substances.
The patient will expect you to examine the site of the complaint first and
will be puzzled, possibly disturbed if your routine of examination doesn’t
permit this. The examination of the lesion should be systematic and
methodical, actively relating what is found to the details of the history. Do
not forget to look for physical signs that are appropriate to the differential
diagnosis which should have formed already in your mind, even if negative
observations have to be recorded as these are as valuable as the positive
ones. Next examine the structures which are functionally related to the part
complained of, such as the regional lymph nodes. Finally, take a look at the
rest of the head and neck and oral cavity. A more general examination of the
patient is always appropriate and normally sufficient information can be
gleaned by simple observation during the consultation. The patient may
have mentioned palpitations and breathlessness. Think back: was he or she
breathless while entering the room or giving the history? Is the patient using
the sternomastoid muscles now when taking a breath? Feel the pulse: is it in
fact fast, and regular or irregular? What about finger clubbing while you are
holding the hand. Is the patient pale and were the mucous membranes pale
when you examined them? Is the thyroid enlarged or is there ankle oedema,
and so on.
However, where in-patient surgery is required and in the case of the
physically ill out-patient, a full general physical examination is indicated.
For a patient attending a general dental practice, the patient’s general
medical practitioner will usually provide the necessary information or will
examine the patient afresh if this is appropriate.
Z
 PATIENT MANAGEMENT

Radiographic and other imaging investigations, clinical laboratory tests

and the question of a biopsy come next. Special investigation should be
requested thoughtfully and sparingly, selecting those which will answer
specific questions, or provide information essential for diagnosis and
treatment planning. Automation of laboratory investigations has made
various tests cheaper to process, provides the results more rapidly, and
often with greater accuracy than when they were all done individually by
hand, but the batch ordering of liver function tests, ‘bone profiles’ and
haematological ‘print-outs’ has worked against precision of thought. It is
too easy to tick all the boxes on the computer form and forget the cost and
resources involved. The results of modern imaging methods have
considerable visual appeal, but their cost can be very high and an
investigation should not be ordered unless it confers a real benefit for the
patient’s management.
A differential diagnosis involves the consideration and comparison
initially of groups of diseases but ultimately of perhaps two or three
individual conditions all of which share various clinical and pathological
features in common. First, whole groups of conditions and then individual
diseases are eliminated because certain of their features are unlike those of
the particular patient’s illness. Ultimately a single condition is chosen on a
‘best-fit’ basis.
A diagnosis therefore involves the recognition of a specific pattern in the
available data. Even with straightforward cases alternative possibilities
should be considered even if they are rapidly dismissed in favour of the
obvious. This way any item of data which may be inconsistent with the
obvious solution and which suggests the possibility of some alternative
explanation will not be disregarded. Dealing successfully with the
variability of the disease and of the patient in which it is manifest is part of
the intellectual pleasure to be gained from surgical practice. Herein lies the
value of a large clinical experience. No clinician has seen it all, but the more
he or she has seen the more valued the opinion.
From time to time all clinicians find themselves unable to make a
diagnosis or reach a conclusion about the best management for a difficult
case and must seek the aid of a colleague. This may be done by a straight
referral or by consultation. The advantage of the latter approach is that one
is able to watch the other practitioner at work and learn directly from him or
her. Sometimes one’s failure is seen to result from not properly following
the basic techniques of clinical and diagnostic methodology. Often one
requires the knowledge and skills of a more experienced dental practitioner,
frequently a consultant or specialist with in-depth knowledge and ability in
a particular field. At other times expert advice from a practitioner in some
quite different discipline appears appropriate. Where this other discipline is
a speciality of medicine rather than dentistry it is usual for the general
dental practitioner to contact the patient’s general medical practitioner
who, if he agrees, will arrange the referral. Indeed, often the medical GP is
3
 ORAL SURGERY, PART I
the appropriate person to whom the patient should be directed, with of
course a letter or telephone call (or both) from the referring dentist. In
hospital practice it is usually more convenient to refer the patient to another
department directly.
Increasingly during practising life the dentist will be able to make the
correct diagnosis even when the condition is unusual in its presentation or is
uncommon. However, it may still be necessary to refer the patient to a
colleague who has the requisite treatment skills or relevant special facilities.
Wise general dental practitioners will develop their own special interests as
a source of professional satisfaction and as a means of increasing the
interests of professional life. Discussion of cases and problems either with
or without the patient being present is always fruitful. Where a decision is
difficult, discussion even with a more junior and less experienced colleague
will help to clarify one’s own viewpoint, and of course enlist the advice and
moral support of one’s fellow practitioner. Simply a different way of
thinking about the matter may be what is required. Without falling into the
trap of always ‘talking shop’, general chat about professional matters at the
practice and at meetings and conferences is an important part of continuing
professional education.
The skills required for successful oral surgery are no less demanding than
those of surgery in other regions of the body and the same basic principles
apply. Dentists trained and experienced mainly in the disciplines of
restorative dentistry bring to oral surgery skills in the handling of patients
and in manual technique but these need to be applied thoughtfully to bone
and soft tissues which respond to cutting in a way which is quite different to
that of the dental hard tissues. Above all the tissues must be handled gently
because rough retraction and unnecessarily vigorous instrumentation
bruises the soft tissues and leads to excessive oedema and delayed wound
healing. Bone which has been overheated by burs or crushed by elevators
will die and must be resorbed or sequestrated before healing occurs and
such damage creates unnecessary postoperative pain. The rigorous
avoidance of bacterial contamination will maximize the healing potential
and ensure that postoperative recovery is as rapid and comfortable as
possible.
Successful surgery depends on thorough preparation which anticipates
the requirements of the operation and avoids the necessity for compromise,
or risk of failure, during the procedure. The preparation involves not only
physical preparation, such as having available all the equipment and
instruments which may be needed from the beginning, but mental
preparation. As much information as possible about the task to be
undertaken and the circumstances and problems to be encountered is
obtained by examining the patient, relevant radiographs and models, etc.
Each stage in the proposed operation is reviewed in the mind and for the
more complicated procedures the order in which the various stages are to be
tackled is determined. Time spent in preparation and planning reduces
4
 PATIENT MANAGEMENT

operating time and the increased efficiency decreases the level of stress for
both the operator and the patient.
Students are always closely supervised and experienced help is never far
away from the postgraduate trainee so that if unexpected difficulties arise
advice can be given quickly or the teacher or senior practitioner can take
over and bring the operation to a successful conclusion. But what does the
experienced surgeon him or herself do under such circumstances? The first
lesson is to keep calm. Apprehension and uncertainty reduce rational
thinking and excited or loud behaviour transmits itself to others, preventing
the effective teamwork which is necessary to meet the challenge.
Most often the answer lies in improved vision and better access.
Difficulties develop at the bottom of deep, dark oozing holes: increase
exposure by extending soft tissue wounds and by removing unimportant
obscuring bone, control ooze—usually by simple pressure with a pack for a
measured period of time—adjust the light and retraction, position the
sucker to remove any blood and get a good look at the problem. If to
continue the operation at one site is difficult, turn your attention to where
progress can be made more easily. This way the area of difficulty will be
reduced until all that is required finally is a limited procedure demanding
the maximum of concentration. If, on rare occasions you have genuine
thoughts about the need to abandon an operation, and this can be done
without immediate hazard to the patient, you should. To proceed under
these circumstances invites disaster. The patient needs to live to be
operated upon another day!
Only three emergencies spell real danger for the patient and you and your
team must know what to do should the occasion arise, and must be prepared
to act promptly and efficiently to give effective treatment. You must know
how to clear an obstructed airway, how to inflate the chest if there is
respiratory failure and, if the form of the obstruction warrants it, how to
perform a tracheostomy. Cardiac arrest requires immediate, effective,
external cardiac massage in addition to ventilation of the lungs. Serious
haemorrhage is the third life-threatening emergency. During surgery
pressure on the bleeding site will always control haemorrhage. Mostly a
general ooze will be stopped by sustained pressure and it will reduce
bleeding from vessels to a level where the source can be seen and dealt with.
Postoperative bleeding manifests itself by a rapidly increasing swelling,
blood seeping through the suture line, or a sudden flow of blood along a
drain. With small wounds a local anaesthetic with a vasoconstrictor is
injected and the wound re-opened to stop the bleeding. With bleeding from a
large operation site the patient is promptly re-anaesthetized with a general
anaesthetic while an intravenous infusion of blood is set up. Usually the
wound is not reopened before anaesthesia is achieved as this releases the
pressure in the wound and increases the bleeding before it can be controlled.
Only where the swelling threatens the airway is the wound opened at once.
Once the bleeding can be controlled by direct pressure haste is no longer
5
 ORAL SURGERY, PART I
appropriate. Then deliberate action can be taken to remove clot, improve
visibility and to search for the bleeding vessel, so achieving precise control
without damage to nerves and other adjacent important structures.
Most textbooks give the impression that the prescription of treatment
follows automatically once a diagnosis is reached. In practice things are
rarely quite that straightforward. There may be several choices of
treatment, or even a decision not to treat at all. The patient’s age, general
health, family and work responsibilities and the distance to the surgery can
all affect the particular mode of treatment to be proposed. Also the broader
concept of patient management embraces not only advice but patient
participation in the selection of appropriate therapy. Possible complica-
tions, the degree of temporary disability and discomfort, and the chances of
a successful or satisfactory outcome must all be weighed where the
proposed treatment involves an operation. Sound advice is difficult to give if
the condition is not currently causing trouble and where it is difficult to
predict when or whether—or if ever—it will do so. The patient may be
pleased now if you decide that nothing needs to be done, but sorry if in years
to come an operation becomes essential, and is by then more difficult and
more hazardous because the patient is no longer fit and well. Conversely, to
persuade an unwilling patient to have elective surgery can lead to
considerable trouble, particularly if through a mischance, it results in some
permanent deficit, say a numb lip. The patient may make the decision for
you if the reasons for and against the procedure are carefully explained, but
often the final choice is thrown back to you. This informed approach
enables the patient to give what is termed ‘informed consent’ to the surgical
procedure.
For minor procedures on conscious, unsedated patients operated upon
under local anaesthesia, a reasonable explanation with agreement by the
patient in front of the staff is sufficient. Where sedation or a general
anaesthetic is involved the more formal signing of a consent form by the ©
patient, or a parent or guardian in the case of a child, is necessary with a
counter signature by the clinician. Most operations carry some risks of
complications or unwanted sequelae. Patients are usually warned about
these and a formal note should be made to record what has been said. The
list of rare and occasional complications can be long and quite frightening.
It is not usual to add unreasonably to the patient’s natural preoperative
anxiety by recounting them unless a particular hazard is recognised. Where
the surgeon foresees serious, possibly untreatable problems for the patient if
nothing is done, it is right for him to urge an unwilling patient to have the
surgery, but if after sensible discussion the patient declines, clearly he or
she has the right to do so. Under the circumstances the clinician should
continue to see the patient and offer what help will be accepted. If decisions
are made thoughtfully and compassionately, in conjunction with the
patient, on the basis of the data currently available, there should be no
personal recriminations if in the light of future events the decision proves to

6
 PATIENT MANAGEMENT

be faulty. Any lessons that might be learnt should be added to one’s

experience.
Oral surgery operations are generally performed either under local
anaesthesia in the general practitioner’s own surgery or in a hospital out-
patient clinic, or under general anaesthesia in the operating theatre either as
an in-patient or on a day-stay basis. As the demands of these two situations
are different, they will be discussed separately.

OPERATIONS UNDER LOCAL ANAESTHESIA

IN THE DENTAL SURGERY OR CLINIC
Preparations
A preoperative check-list should include the following points.

1. Preparation of the Patient

The need for accurate preoperative diagnosis and careful assessment of the
patient is obvious, but the need for their psychological preparation is
sometimes neglected. A routine minor procedure for the operator may be a
major traumatic episode for his patient, and every effort must be made to
gain willing co-operation and to reduce mental stress. Time spent at the pre-
operative consultation in explanation of the planned procedure, perhaps
with the help of radiographs, and relating it to the patient’s previous
experience of dental treatment, will help to reduce apprehension. At the
same time the need for sedation as an adjunct to local analgesia, or even the
desirability of general anaesthesia, can be discussed.
Immediately prior to the operation, the patient should be received in a
courteous and unhurried fashion and seated comfortably in the dental chair.
Unnecessary outer clothing should be removed since surgical drapes will be
applied, and the heat from the operating light can lead to discomfort which
may enhance the common tendency to fainting. The proposed procedure
should be confirmed with the patient and a few words of reassurance and
encouragement given. The appropriate local anaesthetic injections are
given and the patient positioned so as to allow the operator a comfortable
working posture and adequate vision. A backwards tilt of the patient of
about 50° usually permits the dentist to see the operation site without
bending. A more horizontal posture may be appropriate for some
procedures, but blood and irrigation solutions must not be allowed to
gravitate backwards into the throat as this produces a sensation of
choking.

2. Patient Information
The patient’s notes, and especially the radiographs, should be to hand and
so mounted that there is no temptation to handle them once the surgeon has
scrubbed. Radiographs must be of adequate quality, show the whole
operative field clearly, and should be displayed on a viewing screen
7
 ORAL SURGERY, PART I

adjacent to the surgery chair. Avoid doing surgical procedures ‘blind’

without radiographs.

3. Light
Standard dental operating lights provide sufficient illumination for minor
oral surgery but a means of adjustment without contamination of the
operator’s hands should be available. This may be either by the use of
sterilizable handles or by the use of a dry swab, later discarded, which acts
as a barrier between the fingers and the handle.

4. Suction
High vacuum, low velocity suction is most suitable for surgery and will be
available in hospital, but the high flow low vacuum aspirators used in
practice for restorative dentistry will suffice, provided a sterile tip of a
suitable size-and shape is used.

5. Instruments
The operating kit will be discussed in detail in the next section. Sets rather
than individual instruments should be prepared and assembled in trays
which can be sterilized and stored dry in sterile paper bags or cloth
wrappings. It may, however, be convenient to prepare separately in
individual bags special instruments which are only used occasionally.

6. Assistance
Skilled assistance is essential to efficient surgery, and no operation should
be attempted without it. Staff have to be trained not only in the anticipation
of the operator’s needs, but also in the discipline of aseptic technique so that
correct reactions are instinctive and the sterile chain is not broken. Even
simple manoeuvres, such as suture removal, require assistance for their
speedy and comfortable achievement. Good team work creates an
atmosphere of efficiency which sustains the patient’s morale.

7. The Operator
The surgeon must be mentally prepared, comfortably positioned and
confident that the preoperative planning has been comprehensive and
complete. The time available while awaiting the onset of local anaesthesia
may be used conveniently for a final check on the instrument set and for
setting up the suction and drill. During this time also the patient should be
engaged in general conversation to prevent him or her dwelling unnecessarily
upon the forthcoming procedure, a task which is often shared by the surgeon
and the surgery assistant.

Sterilization
Scrupulous sterilization of all instruments and material is essential in oral
surgery. Used instruments must be thoroughly cleaned before sterilization

8
 PATIENT MANAGEMENT

and all deposits of blood and debris removed. Though contamination of oral
wounds by the patient’s resident bacterial flora is unavoidable, cross-
infection from one patient to another or from operator to patient must be
avoided.

1. Disposable Items
Many materials are supplied in sterile form by manufacturers, who can
apply methods such as gamma irradiation which are not feasible for the
treatment of small batches. Provided the source is a reputable manufacturer
and the wrappings have not been damaged in transit, the sterility of such
products can be relied upon. The use of manufacturer sterilized, single use
scalpel blades and suture needles is particularly recommended, since
adequate sterilization of such items in the surgery without damage to their
cutting efficiency is difficult to achieve.

2. Autoclaving
Small autoclaves have virtually replaced water boilers, because of the
abundant evidence that exposure to boiling water alone is insufficient to kill
bacterial spores and destroy viruses. A satisfactory autoclave for oral
surgical instruments should reach a temperature of 134° at 32 psi pressure
and maintain it for 3% minutes. If instrument packs are to be stored and not
used shortly after sterilization, the autoclave cycle should end with a drying
phase. Not all small surgery autoclaves have a drying phase and surgical
instruments put away damp to store will tarnish, corrode or rust.

3. Dry Heat Sterilization

Instruments with a sharp cutting edge, such as chisels, are preferably
sterilized by exposure to dry heat at 160°C for one hour since autoclaving
may reduce their sharpness and promote rusting.
Sterilization of handpieces is a particular problem and for some dry heat
is preferable, but it must be preceded by careful cleaning and lubrication
with special heat resistant oils. Others with sealed bearings or handpieces
which have been pressure lubricated with appropriate oils can be
autoclaved.
Knowledgeable manufacturers will offer advice about their equipment
and the way in which it may be cleaned, lubricated and sterilized.

4. Chemical Disinfection
Unfortunately, no chemical solution is available which will sterilize
instruments immersed in it without the risk of producing tissue damage if
drops of the material are carried over into the wound at the time of use. The
formerly common practice of storing cleaned and sterilized instruments in
chemical solutions is unnecessary since both trays of instruments and
individual items can be wrapped in paper or cloth packs for sterilizing. Then
individual items can be unwrapped without contaminating the rest.
!)
 ORAL SURGERY, PARTI

5. Hand Disinfection
Proprietary preparations are now available for preoperative washing of the
hands of surgeon and assistant, which have an effective bactericidal effect
that is cumulative with repeated use and which do not cause excessive
drying of the skin. Three suitable preparations are “Hibiscrub’ and
‘Phisomed’, which contain 4 per cent chlorhexidine gluconate, and
‘Betadine’, which contains 7:5 per cent povidone-iodine. If these are not
available, then a soap containing a disinfectant like hexachlorophane
should be used and washing must be continued for 5 minutes in running
water. Following drying of the hands and forearms, 70 per cent alcohol or
‘Hibisol’ (2-5 per cent chlorhexidine in 70 per cent alcohol) lotion may be
applied as an extra precaution.
Whatever agent is used, nails should be cut short and all jewellery
removed before washing, and the nails should be scrubbed first thoroughly
with a brush. Provided this cleansing routine is conscientiously followed,
the wearing of surgical gloves during the performance of minor procedures
is not essential for the avoidance of wound infection. However, gloves do
help to protect the operator from infection by bacteria and more importantly
from viruses in the patient’s blood, and when worn for this purpose may be
washed and worn for more than one operation, provided that they have not
been punctured or damaged. Dentists are strongly advised to wear gloves
when treating patients and even when merely examining patients.
In dental practice and outpatient clinic conditions a clean, freshly
laundered gown is perfectly adequate and more readily available than
packed sterile operating gowns. A surgical mask in certain circumstances is
a sensible measure, but recent work on wound infection suggest that there is
probably little benefit from its use during out-patient minor oral surgery.
However, some operators prefer to follow the full operating theatre
procedure and set up the appropriate facilities to permit this.
Where the operator has good eyesight and does not normally wear
glasses a pair with plain lenses will protect the eyes from sprayed debris
when rotary cutting instruments are used and from splashes of blood or
pus.

6. Preparation and Isolation of the Operation Site

The circumoral skin should be cleaned with either the same preparation
used for the operator’s hands or aqueous or alcoholic solutions of the same
agents. Disinfection of the oral mucosal surface is more difficult to achieve
effectively, but a rinse with aqueous 0-5 per cent chlorhexidine can be used
if desired. It is much more important that plaque and debris should be
removed from the gingival margin and interdental embrasures before
surgery, and when the oral hygiene has been poor, a preoperative scaling is
desirable. Following this the patient should be instructed in oral hygiene
techniques. Several days of tooth cleaning preoperatively will materially

10
 PATIENT MANAGEMENT

reduce the local bacterial population even where patients have neglected
the mouth for some time.
Needle puncture sites in the oral mucosa should be dried and an
antiseptic, such as alcoholic chlorhexidine 0:5 per cent in 70 per cent
alcohol or povidone-iodine solution may be applied, if desired. It is
probable, however, that the main benefit is achieved by drying the surface of
the mucosa and excluding saliva from the area. Sterile towels may be
draped round the patient’s head to cover the hair, leaving only the mouth
and eyes exposed. A towel covering the chest and shoulders is essential
since this is the area most likely to be touched by the operator’s or
assistant’s hands or the dangling end of a suture. The suction tubing may be
conveniently clipped to this towel so that its weight is supported and so that
loops of tubing close to the end do not trail on to dirty surfaces.

Instruments and Equipment

The selection of instruments for oral surgery is obviously a matter of
personal choice but the basic set which will be described is typical of those
which are currently in general use for out-patient oral surgery in the United
Kingdom (Fig. 1.1). They will be discussed in the usual order of use, which

Fig. 1.1. Instruments for minor oral surgery. Front row, left to right: dental
mirror, probe, college tweezers, cumine scaler, scalpel, Ward’s periosteal
elevator, Howarth’s rougine, Bowdler—Henry rake retractor, Cryer’s elevators
right and left, Coupland’s chisel, Warwick James’ elevators right, left and
straight, toothed dissecting forceps, needle holders, mosquito artery forceps,
toothed Fickling’s forceps, MacIndoe’s scissors. Across the back, left to right:
Astra self-aspirating syringe, Kilner retractor, bone nibblers, sucker tip, Svedia
handpiece and tungsten carbide burs, black silk suture pack and swabs.

11
 ORAL SURGERY, "PART “1

Fig. 1.2. Asmall surgical trolley, suitable for out-patient or practice minor oral
surgery with a built-in Svedia surgical airmotor unit. The rod (/eft, rear) forms a
drip stand and supports the irrigation water bag. An electrical Kavo Oral
Surgery Unit can be installed in a similar way.

is also the order in which they are most conveniently laid out on the
instrument trolley (Fig. 1.2). Many of the instruments described come
originally from a variety of other surgical specialties, but all have been
chosen because of their proven suitability for oral operations.

1. Local Anaesthetic Syringe

There have been major advances in the last two decades in the
development, not only of local anaesthetic preparations, but of syringe
systems for their delivery. Many and varied patterns are available to suit the
circumstances of different practices and clinics, and no single type is
paramount.
A syringe system for administration of local anaesthetic for oral surgery

ip
 PATIENT MANAGEMENT

should be autoclavable, robust and mechanically efficient, convenient and

comfortable to use and should have an aspirating facility. The requirement
for sterility is met also by the use of disposable plastic syringes, which are
pre-packed and sterilized by the manufacturer. Local anaesthetic solutions
prepared in glass cartridges are in general use and those with specially
designed rubber plungers, as in the ‘Astra’ system which allow easy
repeated aspiration prior to injection, are to be preferred.
Disposable single use needles are sharper and therefore more comfortable
for the patient, and of course avoid difficulties with cleaning and
sterilization after use, which used to be the case with the re-usable
type.
Most operators prefer proprietary solutions of 2 per cent lignocaine with
1: 80000 adrenaline for general use, or prilocaine 3 per cent with
felypressin 0-03 i.u. per ml for procedures which can be completed within
45-50 minutes and for patients for whom adrenaline is contraindicated. A
clot forms in the socket more promptly and there is a less frequent
occurrence of reactionary haemorrhage if prilocaine and felypressin can be
used. The shorter acting mepivacaine, 3 per cent without added vaso-
constrictor, is a useful alternative when these two solutions are unsuitable,
and a 5 per cent solution of lignocaine may be valuable when analgesia is
incomplete and a further injection is needed, but should be used only in
small quantities and with particular care to avoid intravenous injection. Six
2 ml cartridges of the 2 per cent solution should normally be regarded as a
maximum dose on a single occasion.

2. Retractors
There are many suitable instruments for retraction of the lips and cheeks,
but a small and large version of the double-ended Kilner cheek retractor is
the most versatile, and when properly held at an angle to the cheek pouches
out the cheek most effectively (i.e. Kilner’s double-ended retractors, small
with 25 mm (1 in) and 19 mm (% in) wide ends and large with 35 mm
(1% in) and 29 mm (1% in) wide ends).
Retraction of the mucoperiosteal flap is more difficult to achieve and
again there are many suitable instruments available, but the Howarth’s
periosteal elevator and the specially designed Bowdler—Henry retractor are
commonly used. A Lack’s retractor is suitable for retracting the tongue or a
palatal flap. Retractors also serve to guard the soft tissue from accidental
damage, especially by burs. The shanks of retractors or other instruments
which may rub against the angles of the mouth should be smeared with
petroleum jelly to prevent frictional sores.

3. Scalpel
The majority of oral surgical incisions can be made conveniently with a
No. 3 Bard—Parker type of scalpel handle and a No. 15 (BP) detachable
blade. A No. 10 (BP) blade may be preferred for skin incisions and the

13
 ORAL TS URIGH RYs SPAR iat

pointed triangular No. 11 (BP) blade is used for the incision of intraoral
abscesses by stabbing it into the swelling and cutting upwards through the
mucoperiosteum.

4. Periosteal Elevators oS
The Howarth’s nasal rugine (curved On flat) is widely used for periosteal
elevation, the flat, round blade end for insertion into the incision beneath the
cut edge of the periosteum to strip it off the bone, and the rugine end for the
detachment of muscle insertions. Some find the smaller and shorter
Fickling type more convenient to use, and a Ward’s fan shaped periosteal
elevator or a Mitchell’s trimmer is also helpful in separating tough fibrous
tissues from around the crowns of unerupted teeth. Retraction of the tissues
with a Howarth’s rugine in one hand while the flap is elevated from the bone
with another periosteal elevator in the other, ensures precise movements
with good visibility.

5. Bone-cutting Instruments
The choice lies between the use of bone-cutting burs in a suitable handpiece
and the use of chisels, but each method has its own advantages and
disadvantages and the most appropriate tool should be selected for the work
in hand. Bone rongeurs are a useful adjunct to remove accessible sheets of
bone and sharp points and edges.
Ideally, burs used for oral surgery should be those specially designed for
the purpose. As compared with those intended for cutting enamel and
dentine, the number of blades is less so as to reduce clogging with debris and
consequent loss of cutting efficiency. Ordinary dental steel burs are
acceptable, but tungsten carbide burs cut more efficiently because they
have a wider clearance between the blades and because they retain their
sharpness during lengthy or repeated use. Specially designed burs are
produced for major bone-cutting procedures and these will be referred to in
the sections concerned with such operations. They are often substantially
more expensive than dental burs.
Either round or ‘fissure’ burs or both can be used according to the
operator’s preference and the demands of particular circumstances. Very
large diameter bone burs may be used for removal of wide areas of bone or
for smoothing the margin of bony defects prior to wound closure. In most
cases, however, the use of either size 6 or 8 dental burs will enable the
production of deep narrow slots in the bone, which are less destructive of
bony tissue, and the edge of the slot provides a fulcrum during elevation of
teeth or roots. Individual burs can be hot-air sterilized in small, paper
packets for convenient storage. A range of burs should always be
available.
Chisels 3 mm wide and 5 mm wide are used to split bone in a controlled
fashion taking advantage of its anatomical grain and the relative thinness of
the alveolar plates around most of the teeth. Bone in young individuals has a
14
 PATIENT MANAGEMENT

marked grain and a predictable direction of split. As a person gets older the
bone becomes harder and more brittle and pieces of an unpredictable size
split off when it is cut with a chisel. Oral surgery chisels should be long
enough to grasp with a fist grip with the hand outside the mouth where it will
not obstruct the field of view. The Eastman pattern chisels which are
191 mm (7% in) long are suitable. The use of an 8% oz, all-metal mallet to
strike the chisel is mainly applicable to operations under general
anaesthesia since conscious patients may be somewhat alarmed by this
approach and upset by the noise which is conducted through the bones of
the face and ears. However, a great deal of bone removal can be achieved
rapidly and atraumatically with a chisel held in the palm of the hand. The
Read’s pattern and Coupland’s chisel are specially designed for this
purpose. Chisels are bevelled on one side and, when driven into a surface,
the bone on the bevel side of the edge is wedged away, creating a split. It is
also crushed by the bevel as it is separated from the undisturbed bone on the
unbevelled side. The direction of split with a chisel lies mid-way between
the plane of the flat side and the bevel and this must be taken into account or
unexpectedly large pieces will be removed.
Gouges, which are chisels with a curved cross-section, are used by some
operators because they can create a trough around a tooth like that cut with
a bur, or cut a round hole in the cortex, but they need to be struck with a
mallet because they cut, not only along, but also across the grain of the
bone.
Osteotomes differ from chisels in that they are bi-bevelled to form a
narrow wedge-shaped end, and cut in a direction in line with the blade.
Therefore they are used to split apart two segments of bone. They may be
used also for splitting teeth. Where part of the crown is to be split off the
tooth should not be loosened in its socket. Indeed a loose tooth requires a
considerably greater force to achieve the split and this may result in the
tooth being driven through the lingual plate. Where it is intended that the
split should pass on between the roots the tooth should be eased a little in the
socket. Care should be taken that the edge of the oesteotome does not strike
the bone during the tooth splitting process or a fracture may be created
through the jaw.
Tungsten carbide tipped or tungsten steel osteotomes and chisels may be
needed to cut hard bone and split teeth (Ward’s tungsten steel osteotomes
3mm and 5 mm wide and 178 mm (7 in) long). All these instruments
require special care in sharpening after use and dry heat sterilization to
preserve the quality of the metal of the cutting edge.
Bone-cutting rongeurs (bone ‘nibblers’) such as the Ward’s pattern with
multiple action joints 178 mm (7 in) long and slightly curved on the flat are
extremely useful for cutting off sharp spikes of bone or biting off thin curved
plates of bone and even the tough accompanying soft tissue of the
gubernaculum which overlies unerupted teeth. They can be used safely only
when the blades can be applied to both sides of the piece of bone without
15
 ORAL SURGERY, PART <I

soft tissue intervening, and this is a limitation. Glasgow pattern contouring

forceps are a simpler but also suitable pattern. Special rongeurs with narrow
blades are available to remove interdental bone and the wall of sockets.
A variety of drills are available for oral surgery and all have their
advantages and disadvantages. The ultra high speed (250000 r.p.m.) air-
rotor drills, so convenient for restorative dentistry, are unsuitable for
surgery since the shape and size of the heads and burs are wrong for this
purpose and many exhaust air and finely dispersed lubricants close to the
cutting area, risking contamination and surgical emphysema. If this type of
rotary cutting instrument is needed, a purpose designed surgical air-rotor
must be used which takes special long shank burs and exhausts air away
from the wound. The relative lack of torque of these tools destroys the
discrimination of touch between bone and tooth substance during the
process of cutting, which is often essential in oral surgery, and they and their
coolant are not easily sterilized to surgical standards. Medium speed drills
(12 000-20 000 r.p.m.) are therefore preferred for dento-alveolar surgery
and they may be driven by air motors (Fig. 1.2) or miniature electric
motors, according to convenience. The relatively old-fashioned electric
bench type motor, with a flexible drive shaft, is perhaps the simplest and
most robust available, and its reliability and ease of maintenance is a great
advantage. Unfortunately the spark hazard rules out its use alongside
gaseous anaesthetics. Furthermore the torque in the flexible drive strains
the hand and reduces accuracy of work. Either sealed bearing handpieces or
surgical handpieces with extra ball bearings must be used as ordinary
handpieces overheat after prolonged cutting with lateral pressure such as is
common in minor oral surgery, particularly when teeth are divided.
Overheated handpieces burn the lip or cheek and the bearings seize up.
Irrigation of the bur with sterile saline during bone cutting is essential
both for lubrication and cleaning of the bur blades, to improve vision and in
order to avoid bone damage due to overheating. This may be arranged in a
variety of ways, ranging from syringing by the assistant to automatic
systems which switch on and off with the drill. A suitably modified infusion
set is the simplest arrangement. Narrow bore spray tubes on handpieces
may become obstructed by salt crystals if saline is passed through them so
sterile water should be used instead. Some form of sterile syringe is also
needed to wash away debris during and after the operation. The simplest is a
20 ml disposable syringe fitted with a sterile anaesthetic drawing up
quill.

6. Dental Forceps and Elevators

A limited range of extraction forceps is useful during minor oral surgery as
opposed to routine exodontia to loosen teeth and finally deliver roots or
impacted teeth. Fig. 76N, 74N, 110 (or 111) and 73S form a suitable
selection. For most surgical cases elevators are required. Many types are
available but a set comprising a right, left and straight Warwick James’

16
 PATIENT MANAGEMENT

elevators and right and left Cryer’s elevators will meet most requirements.
Coupland’s chisels should be keep sharp for bone cutting by regular
sharpening between cases and should not be blunted by use as a heavy
straight elevator, for which purpose anyway they are too thick. However,
they will conveniently wedge out teeth with conical roots or turn out already
loosened curved roots when pushed into the periodontal membrane.

7. Curettes
One of the most versatile instruments for use in oral surgery is the Mitchell’s
trimmer. Designed originally for carving wax patterns in restorative
dentistry, it has been employed for a whole variety of purposes. The spike
end can be used as a probe to pierce thin bone plates or to separate soft
tissues from teeth or as a fine pointed elevator. The round spoon end is
useful as a small periosteal elevator and as a curette, and additional
instruments for this purpose alone are seldom needed. Occasionally, access
may be difficult and a double ended and bi-angled curette such as Exner’s is
required. Large spoon bi-angled excavators are also useful as miniature
curettes to separate the lining of small cysts or to reach into difficult corners
of bone cavities.

8. Artery Forceps
An incision should not be made unless suitable artery forceps are available
to control haemorrhage from cut vessels. The curved Halsted’s mosquito
type (125 mm; 5 in) are most useful in minor oral surgery and a minimum of
two should be available. The blades and hinges of these fine forceps can be
damaged if they are used to grasp fragments of hard tissue so that a longer
and more robust pair such as Spencer Wells (152 mm; 6 in) should also be
available and kept solely for this purpose. Fickling’s angled forceps are
invaluable for the removal of small fragments from deep wounds or sockets,
the toothed version being used for soft tissue and the non-toothed for hard
tissue.

9. Suturing Instruments
The essential instruments for suturing are needle holders and toothed
dissecting forceps. Needle holders are either ratchet or non-ratchet in type,
and many variations of each are available. The instrument kit should
contain one of each type since, though most operators prefer one or other for
general use, occasions arise in which a change to the alternative type may
greatly simplify suturing. With a ratchet type of needle holder (e.g. Mayo or
Crile Wood pattern with tungsten carbide jaw inserts) the needle is held
rigidly in the blades by springing closed the ratchet between the handles,
whereas the non-ratchet type, e.g. Gillies’ or Ward’s, the needle is held
firmly in the blades by finger pressure alone. The Gillies’ needle holder with
tungsten carbide jaw inserts 165 mm (6% in) are combined with suture
scissors, which facilitate the cutting of thread while working with only one
17
 ORAL SURGERY, (PART =i

assistant. Mobile soft tissues must be held firmly by dissecting forceps, such
as Gillies’ toothed dissecting forceps, or with skin hooks, while the flap is
positioned and pierced by the suture needle (Gillies’ dissecting forceps,
light model with 1 X 2 teeth, 152 mm(6 in) long and either Gillies’ fine skin
hooks 165 (6% in) or McIndoe’s skin hooks 191 mm (7% in), two of
each).

10. Scissors
A pair of sharp pointed scissors such as Kilner’s straight fine sharp pointed
115 mm (6% in) scissors, is required for cutting and removing sutures and
occasionally for sharp dissection of soft tissues. It is wise to reserve the
suture cutting scissors exclusively for this purpose as the hard thread blunts
the blades, and to have available another pair of scissors for cutting tissues.
MclIndoe’s light blunt tipped 191 mm (7% in) long curved on flat scissors
are also needed for soft tissue dissection.

11. Suture Materials

A traditional material for routine suturing of intraoral wounds is 3/0 (metric
size 2) black silk. It is easy to handle and knot, sufficiently strong without
being too bulky, and the cut ends are soft and comfortable for the patient.
However, the braided, coated, synthetic polyglactin suture, Vicryl
(Ethicon) is becoming increasingly popular, particularly as it slowly
resorbs and therefore may be left in inaccessible parts of the mouth.
Catgut is also popular to close intraoral wounds, especially when suture
removal is likely to be difficult or impossible. Conventional gut is more
difficult to handle and knot than silk, and the knots tend to absorb moisture
and unravel in the oral fluids. The cut ends of chromic gut are sufficiently
stiff to be irritating to the patient and as the catgut is a foreign protein an
intense polymorphonuclear leucocyte tissue reaction surrounds the suture
material. The synthetic, resorbable materials do not induce this reaction,
but may persist for 3 weeks or longer when used to close the oral mucosa.
However, the new ‘soft gut’ (Davis and Geck) has overcome many of these
disadvantages, knots well and can be left to slough off the healed wound
margin.
The cut ends of many of the non-absorbable synthetic materials are also
sharp and uncomfortable and they seem to offer little advantage over the
traditional black silk.
For intraoral suturing a 21 or 22 mm half-circle or a 25 mm, % circle
cutting needle is commonly used, although individual oral surgeons may
have a preference for other sizes and patterns for particular purposes.
Individually packed sutures, which are supplied attached to the needle and
sterilized by the manufacturer, are the most convenient. Examples are
Ethicon 577 which is 2 metric (3/0) black silk on a 22 mm half-circle
cutting needle. Ethicon 576 is the 25 mm Denis Browne % circle cutting
needle with 2 metric (3/0) black silk, and Ethicon W9730 is the same
18
 PATIENT MANAGEMENT

needle with 2 metric (3/0) Vicryl. Plain or chromic 3/0 and 2/0 softgut are
also supplied by Davis and Geck on oral surgery needles, i.e. the 21 mm 4
circle cutting or the 25 mm % circle cutting. Where supplies are difficult or
economy is necessary, sutures can be prepared on eyed needles from a roll
of suture silk or thread and then sterilized. The best method of attachment is
to insert the end of the suture thread through the eye and pass the short end
round and back through the same side of the eye. This procedure will attach
the thread firmly to the needle without the necessity for a knot, which would
drag in its passage through the tissues.*

12. Suction Tips and Tubing

A fine metal suction tip is required to keep the operation field clear of blood.
Fraziers’ (8FG or 9FG) suction tips have a small side hole in the finger
plate which, when uncovered, reduces the strength of suction at the end of
the tube which might damage delicate tissues. Hu—Friedy’s self-clearing
suction tubes (2 mm and 3 mm diameter) have a built in stylet with which a
blockage in the tube can be cleared. It is also wise to have either a metal or
disposable plastic pharyngeal sucker which is useful if there is gross
bleeding or vomiting or other emergency situation.
Suitable autoclavable plastic suction tubing is also necessary to connect
the tip to the vacuum outlet via, of course, a water trap bottle and filter to
prevent aspirated liquids entering the vacuum pipe.

13. Swabs and Dressings

Ten cm square sterile gauze swabs with radiopaque markers (BP) should be
available in sufficient quantity. A pre-packaged bundle of 5 will serve for
most simple procedures but more should be immediately to hand if needed.
Most oral wounds are repaired by suturing but, in some circumstances, a
material is required to cover or pack a tissue defect. One cm wide sterile
ribbon gauze impregnated with iodoform paint (BP) (Whitehead’s varnish)
or Bismuth in iodoform-paraffin paste BIPP (BP) is widely used for this
purpose and is usually retained by suitably placed sutures. An alternative
approach is to use a packing material designed for periodontal surgery (e.g.
Coe-Pak) which can be ligated to or packed round neighbouring teeth or
which can be held in position by a plate or denture.

OPERATIONS UNDER GENERAL ANAESTHESIA

IN THE OPERATING THEATRE
Every hospital has its own particular customs and practice so that the
description which follows can only be a general guide to procedure and will

*The correspondence between metric and gauge size for catgut differs from that of other suture
materials.

19
 ORAL SURGERY, PART I

be modified by local circumstances. The oral surgeon has to fit in with

general surgical practice while ensuring that his own special needs are
met.

1. Preparation of the Patient

Patients are usually admitted to hospital for major oral surgery at least 24
hours before the operation so that their general health and fitness may be
assessed prior to the anaesthetic and so that any necessary preoperative
investigations can be arranged. These will include a haemoglobin
estimation, urinalysis and, where appropriate, a chest radiograph and
electrocardiogram. The surgeon has a further opportunity to discuss the
operation and its effects with the patient and to obtain informed consent in
writing. The history is reviewed and the adequacy of available radiographs
is checked. Every effort is made to allay anxiety and ensure that the patient
has acomfortable and restful night, using sedative drugs if necessary. Food
and drink are withheld for at least 4 hours before the anaesthetic (nil after
midnight for a morning list and nil by mouth after 8 a.m. for an afternoon
one). On the morning of the operation, the patient should have a bath using
an antiseptic preparation such as Savlon (cetrimide and chlorhexidine
gluconate) which is added to the water or Phisomed or Hibiscrub which are
used instead of soap. They should clean the teeth carefully with brush and
paste even though they haven’t eaten and male patients should have a close
shave. Premedication is administered as prescribed by the anaesthetist.
The patient is robed in a loose gown and transported to the anaesthetic
room.

2. Preparations in the Operating Theatre

Theatre staff have to be notified in advance of the operations which are
scheduled and warned of any special equipment or instruments which will
be required. In the case of a long or complex procedure the order of the
various phases should be given to the theatre sister. In a properly equipped
operating theatre all the instruments etc. listed in the preceding section will
be readily available.

3. Instruments
The basic operating list described above is suitable for most dento-alveolar
operations under general anaesthetic, with the addition of a suitable set of
mouth props (e.g. set of Mackintosh rubber props and a set of 4 Mushin’s
metal props) and spoon shaped ‘cold light’ or plastic concave and convex
tongue retractors. These control a tongue made bulky by a throat pack and
are particularly appropriate if coagulation diathermy has to be used to
control bleeding.
Electric laboratory type motors to drive a slip joint handpiece are no
longer permitted as they are not spark proof and the handpieces tend to
overheat. Surgical air motors may be run off the compressed air supply or
20
 PATIENT MANAGEMENT

compressed air bottles. Some orthopaedic air tools include a straight

handpiece. Alternatively, sealed miniature electric motors specially
designed for surgery may be required.
For skin incisions a No. 10 blade on a No. 3 handle is mostly sufficient
but larger scalpels are required for some procedures. Where the soft tissues
are to be dissected additional artery forceps will be required. Ten curved
mosquito artery forceps and ten Dunhill’s artery forceps are sufficient for
many procedures. Coagulation diathermy and specially insulated
diathermy forceps are normally available. Additional retractors such as two
small Langenbeck’s and two large Langenbeck’s with a set of Seward’s
double-ended retractors will be needed.
A pair of strong scissors, such as Aufricht heavy model straight
dissecting scissors 140 mm (5¥% in), are needed to cut tough tissues and a
Farabeuf’s periosteal elevator to raise obstinate tendons from bone.
Not infrequently bones have to be cut and joined and on rare occasions
jaw fractures occur as an unexpected complication, so a suitable wiring kit
is required. It may be necessary also to apply eyelet wires or arch bars to the
teeth or attach plastic splints such as Gunning’s splints, and the necessary
forceps and awls to do this should be assembled as a basic wiring kit. Artery
forceps used for this work should be specially marked and those used for
haemostasis should not be misused. Neither should the theatre wire cutters
be sent with the patient to recovery and to the wards. Additional wire
cutters should be available for this purpose.
Complex fractures, operations for facial deformity, bone and skin
grafting and other special procedures all require additional sets of
instruments which the operator will order to meet his own particular
techniques and preferences. These should be assembled as add on sets
which do not duplicate the basic instruments.

4. Scrub Technique and Theatre Dress

Access to the operating theatre, anaesthetic rooms, theatre corridor and
immediate recovery area is usually restricted to staff who have changed into
special clean clothing and footwear. Caps to cover the hair and masks are
also worn in theatres, but may be put on outside the anaesthetic or scrub
room rather than in the changing room. In this and other details practice
varies between hospitals.
The correct methods of gowning and gloving can be learned effectively
only by demonstration and practice and those unsure of the procedure
current in a particular theatre suite should seek the guidance of the theatre
staff. Nails should be kept short and either the hair worn in a relatively short
style, or arranged so that it can be completely enclosed in the theatre cap or
hood. Surgeons view beards which cannot be completely contained within a
face mask with concern.
In the scrub room the hands are washed under running hot water and the
nails scrubbed with a brush. The hands themselves are not usually scrubbed
21
 ORAL SURGERY, PART I

Fig. 1.3. Gloving with gown without cuffs (it is a matter for personal preference
whether the right or the left glove is put on first). a, Pull on the right glove by
grasping the turned back cuff. b, Pick up the left glove by inserting gloved fingers
of the right hand under cuff. c, Insert left hand. d, Grasp outside of sleeve and
fold tightly across the wrist. To prevent the cuff rolling, keep the left thumb
across the palm of the hand. e, Hold sleeve with right thumb and insert right
fingers under the left cuff. £ Pull left cuff over gown at the wrist by spreading
right fingers and rotating left wrist. g and h, Repeat as in diagrams e and fwith
the opposite hand.

as this abrades the skin and spreads organisms out of the pores. The hands
and arms, up to the elbows, are washed and rinsed repeatedly with scrub
solution, for between 3 and 5 minutes, keeping the elbows down so that the
water runs away from the hands. Each hand and arm is dried separately
from the hands down to the elbows, after which a sterile gown may be
picked up. The gowns are folded inside out so that only the inside is
touched. As it is unfolded the hands are inserted into and through the
sleeves. A ‘circulating nurse’ ties the gown at the back and any covering
back flap and waist ties are drawn around by a gowned and gloved
colleague. Gloves may be put on by holding the turned back cuff with the
opposite hand and the palm side of the folded cuff with the opposite gloved
hand. Alternatively, gloves are handled with the ends of long sleeves to the
gown which are drawn back onto the wrist under the cuffs as the gloves are
pulled on (Figs. 1.3 and 1.4).
Once gowned and gloved self-discipline is essential as any sterile item of
clothing or equipment which becomes contaminated as a result of
accidental or thoughtless contact with an unsterile area must be removed
and replaced immediately. Gloved hands are best held above waist height in
front of the chest so that such accidental contacts are avoided. Common
errors by students which can attract censure by the theatre sister are to hand
22
 PATIENT MANAGEMENT

Fig. 1.4. Gloving with a cuffed gown. a and b, The left glove is picked up by its
cuff with the right hand. c, The glove is placed against the left hand, thumb
towards the hand and fingers lying up the arm. d, The rim of the cuffis gripped by
thumb and fingers, by both hands. e, The part of the cuff held in the right hand is
flicked over the gown cuff ofleft gown sleeve, inside of which are the tips of the
fingers ofthe left hand.f The glove cuffisgripped by the right hand through the
gown sleeve and both glove and the left arm sleeve are pulled together over the
left hand, until the hand is fully in the glove. g, The sleeve of the gown is pulled
down until the gown cuff sits on the wrist inside the glove cuff. h, The right-hand
glove is picked up by the already gloved left hand. 7, It is placed over the right
hand which is still within the gown sleeve, thumb of the glove towards the hand
and fingers up the arm./,The glove cuffis gripped with the fingers and thumbs of
both hands. k, And flicked over the gown cuff. /, Glove cuff and gown are pulled
together down over the right hand until it is fully within the glove. By pulling on
the sleeve the gown cuff is settled around the wrist.

instruments across behind operators backs, to touch the gowned back of

another assistant, to move a light other than by the sterile handle or to
retrieve an instrument which has slipped down the side of the drapes.

5. Preparation and Isolation of Operation Area

The patient is laid on the operating table with the head firmly supported by a
suitable rest, such as the horseshoe-shaped Whitlock pattern which will
prevent it from rotating from side to side. Special care should be taken to
protect the patient’s eyes (Fig. 1.5). Petroleum jelly gauze is placed over
the closed lids with thick protective pads taped into place on top. A throat
pack is placed by the anaesthetist to protect the airway, even if a cuffed tube
is used. The skin of the lower part of the face, the mandibular angle and
23
 ORVAIUS SIU GIEIRAYE mb AsRuea

Fig. 1.5. Protection of the patient’s eyes during anaesthesia. Each eye is
covered with a5 cm square oftulle gras and this is in turn covered with a sheet of
cellophane and then a sheet of polythene sponge. These Dee layers are
secured by the anaesthetic harness.

mastoid region and the upper part of the neck are thoroughly washed with an
antiseptic solution such as 0-5 per cent Hibitane or Savion. The mouth may
be irrigated with a similar lotion. During all these procedures the surgeon or
assistant must avoid contact with unsterile areas and the swabs used in the
washing process are held in a pair of sponge holders which are discarded
after use.
When operative procedures more extensive than dento-alveolar surgery
are to be performed more elaborate procedures may be necessary to control
contamination of the operation site. Not only does the patient have a
preoperative bath but the hair is washed with an antiseptic scrub
solution.
Bone graft donor sites are shaved and a preliminary skin preparation may
be made before the patient is given the premedication. Hibitane pastels or a
chlorhexidine mouth wash can be used for two hours preoperatively,
provided the mouth is checked free of pastille fragments before the
premedication is given. Skin graft sites are not shaved in case hair bearing
skin is transferred to the mouth.
The operation site is washed, prior to draping, with lotion, then dried and
an alcoholic povidone-iodine 10 per cent preparation applied. Adhesive
skin drapes may be applied and the incisions made through them, but if they
are in place for any considerable period of time the patient may sweat
beneath them, bringing organisms to the surface. Extra towels sewn to the
wound edge (wound towels) may be preferred for this reason.
24
 PATIENT MANAGEMENT

In normal circumstances the face and the endotracheal tube end and
anaesthetic tubing are covered by surgical towels. Two towels and a
waterproof sheet are placed under the patient’s head and the top towel is
folded across the face with the lower edges beneath the nose. It is secured at
the edge by towel clips, taking care to avoid piercing the ears or placing the
clips near the eyes. A sterile sheet covers the patient’s torso and legs and is
drawn up under the chin to be clipped to the head towels at either side. Two
side towels are placed, one on either side of the head, to cover the side of the
table. Sterile petroleum jelly or 18 per cent hydrocortisone cream is applied
to the lips to avoid drying and to lubricate them and prevent friction
sores.
If other operative fields are required as well the arrangement of the drapes
is adjusted accordingly. Prepared areas which are not needed until later in
the operation are covered by a sterile towel after the drapes have been
placed and clipped in position. This towel is removed just before the site is
operated upon. A further wipe with alcoholic povidone-iodine can be
applied before the procedure is commenced.

The Operation Record

Details of the operation are usually written up on a special sheet. The date,
the theatre number or name, the time at which the operation began and
ended, who performed it and who assisted, and the names of the
anaesthetist, scrub nurse and circulating nurses are usually entered at the
top. While a lengthy ‘blow by blow’account is unnecessary the type of
operation performed, the surgeon’s findings and in particular any unusual
findings or problems and how they were dealt with are recorded. Where it is
usual to safeguard any important structure at risk the fact that this was done
should be mentioned. For lengthy and complex procedures a summary of
what took place and how the operation was performed in this instance is
necessary. The mode of closing the wound and the use of drains, packs and
dressings should be noted. Finally the account should be signed. Some
intra-operative happenings, such as unusual or unexpected haemorrhage,
can be of importance during the postoperative period and these may be
highlighted.

Postoperative Care
The initial recovery and in some cases the patient’s management during the
first twenty-four or forty-eight hours may be controlled by the staff of the
recovery ward or intensive care unit. Routine cases are usually returned to
the general ward once the patient is conscious and orientated. Postoperative
care involves two facets, the general care of the patient and local care of the
operation site. Even with relatively minor procedures, incorrect general
management of the patient postoperatively can lead to life threatening
incidents. Few complications are directly related to inadequate post-
operative care of dento-alveolar wounds, but a carefully conducted major
2
 ORAL SURGERY, PART 1

procedure can be ruined by inept handling in the postoperative period.

Resident staff must be assiduous in monitoring the progress of patients
under their care and must be certain of the way in which the consultant
would wish the operative sites to be cared for. Ward sisvers can be a
valuable source of information upon the correct procedures and upon
individual consultant’s personal likes and dislikes.
The nursing staff will always provide the patients with mouth washes on a
regular basis but it is up to the resident dental staff to see that the patients
are encouraged to clean the teeth with brush and paste as far as is practical.
Where splints or other forms of intermaxillary fixation have been applied a
dental hygienist can provide a valuable service in maintaining oral
cleanliness while the patient is in the ward and teaching the patient
appropriate oral hygiene methods for use at home.
One aspect of drug therapy which may be given inadequate attention is
the question of postoperative pain control and sedation. Too little, too
infrequently will permit the patient to suffer unnecessarily. Too frequent
administration of potent drugs will produce an over-sedated and drowsy
patient. Even after quite major procedures, pain often gives way to soreness
and discomfort after 24-48 hours. Severe pain after this time may signify
complications. Sometimes there is a simple mechanical cause of the pain
such as an appliance which is pressing into the soft tissues. Be certain you
know why a patient is in pain. Do not ignore any complaints from patients
which suggest that something is wrong even when a particular patient seems
to make a habit of complaining for trivial reasons.

The Discharge from Hospital

Ask well ahead of the time where the patient will go when discharged and
who will look after them. This is a matter which can be enquired into with
the admission procedure, but may be more relevant as the day approaches
and relatives or friends can see for themselves what home care is likely to be
needed. Preferably patients should be accompanied on the way home even
if the stay in hospital has been short. They may well feel tired or even unwell
after travelling for a while. They should be discouraged from driving
themselves in a car until fit to do so and in any case not for the first 24 hours
after leaving hospital for the same reason. Find out how far the journey will
be. This may influence the date of discharge. Patients should take with them
any medical certificates which they may need and it is helpful to give the
patient a brief note to be delivered as soon as practical to their general
medical practitioner. This should outline what has been done, give details of
any drugs or prescriptions given to the patient and record the name, address
and telephone number of the surgeon.
A more detailed report is usually sent to the GP by post and if the patient
has been referred by a dental colleague it is usual to write to the referring
practitioner also, giving a summary of the operation, what was found and
events in hospital. All patients must be given clear instructions as to whom
26
 PATIENT MANAGEMENT

to contact in the event of problems. The first postoperative out-patient

appointment is best fixed before the patient leaves the ward, rather than
sending it by post. While the removal of any sutures may loom large in the
patient’s mind, at this appointment the opportunity should be taken to
assess thoroughly the patient’s general progress and the healing of the
wounds. Any symptoms must be recorded and evaluated and all operative
sites carefully examined. If appropriate, postoperative X-rays or other
follow-up investigations are arranged. Once healing is complete or at least
progressing normally such that uneventful further progress is likely the
patient can be discharged with advice to contact the surgeon and return if
necessary. It is as well to remember the aphorism that the operation is not
complete until the patient stops complaining. In discharging the patient see
that they understand that they are being returned to their dental practitioner
for routine care, and where the surgery forms part of some overall treatment
plan, such as a course of orthodontic treatment, make sure that a further
appointment is booked with the appropriate practitioner so that the
remainder of the treatment may be completed.

SUGGESTED READING
Editorial (22 November 1980) The risk of assessing risk. Br. Med. J. 281,
1374.
Listening and talking to patients:
1. The problem: Br. Med. J. 281, 845-846 (1980).
2. The clinical interview: Br. Med. J. 281, 931-933 (1980).
3. The exposition: Br. Med. J. 281, 994-996 (1980).
4. Some special problems: Br. Med. J. 281, 1056-1058 (1980).
Hoy A. M. (1985) Breaking bad news to patients. Br. J. Hosp. Med. 34, 2,
96-99.
Kirk R. M. (1978) Basic Surgical Technique, 2nd ed. Edinburgh, London & New
York, Churchill Livingstone.
Shovelton D. S. (1982) The prevention of cross infection in dentistry. Br. Dent. J.
153, 260-264.
Simpson H. E. (1960) Experimental investigation into the healing of extraction
wounds in Macacus rhesus monkeys. J. Oral Surg. Anaesth. & Hosp. D. Serv.
18, 391-399.
Simpson H. E. (1961) Healing of surgical extraction wounds in Macacus rhesus
monkeys: I. The effect of burs. J. Oral Surg. Anaesth. & Hosp. D. Serv. 19, 3-9.
Il. The effects of chisels. J. Oral Surg. Anaesth. & Hosp. D. Serv. 19, 126-129.
Ill. Effect of removal of alveolar crests after extraction of teeth by means of
forceps. J. Oral Surg. Anaesth. & Hosp. D. Serv. 19, 228-231.
Simpson H. E. (1960) Effects of suturing extraction wounds in Macacus rhesus
monkeys. J. Oral Surg. Anaesth. & Hosp. D. Serv. 18, 11-464.
Trieger N. and Goldblatt L. (1978) The art of history taking. J. Oral Surg. 36,
118-124.

Js)
 CHAPTER

INTRAORAL INCISIONS AND SUTURING

INCISIONS
A gingival margin incision which divides the mandibular interdental
papillae will permit the insertion of a periosteal elevator and the reflection
of either the buccal or lingual mucoperiosteum or both. If necessary, the
papillae can be divided from one third molar around to the other without the
operator encountering any sizeable vessel. Similarly, an incision along the
crest of the mandibular edentulous ridge will also permit buccal and lingual
mucoperiosteal flaps to be raised. Such flaps are described as envelope
flaps.
If required the incision can be extended backwards into the retromolar
region and then distobuccally up the external oblique ridge and anterior
border of the coronoid process. No vessel of a size requiring formal ligation
will be encountered until this upwards extension of the incision reaches a
point just below the level of the occlusal surface of the upper 3rd molar.
Here, the buccal artery and long buccal nerve lie side by side and cross the
anterior border of the coronoid from medial to lateral on the superficial
aspect of the buccinator muscle. The deep facial vein runs either with the
artery and nerve or a little higher up.
By dividing the interdental papillae or by incising along the edentulous
ridge, depending upon whether teeth are present or not, and then raising
flaps, the outer and palatal aspects of the maxillary alveolar process can be
exposed in a similar fashion. Again no sizeable vessel will be cut while
making these incisions.
A second incision can be added which starts at one end of the crestal
incision and is carried towards the buccal sulcus. The second incision can
be a straight one which leaves the first at an obtuse angle, or with the
edentulous ridge the crestal incision can be continued in a curve onto the
buccal aspect of the alveolar process. In the dentulous patient the oblique
relieving incision should include an interdental papilla at the corner to
locate the flap on replacement. This two-sided, or triangular, flap is easy to
retract and allows sufficient access for many small dento-alveolar
procedures to be carried out, and is easy to suture. The addition of a second
buccal incision at the other end of the crestal incision so creating a three-
sided rhomboidal flap increases still further the degree of surgical access.
By curving the sulcus ends of the incisions along the bottom of the sulcus in
a direction away from the centre of the flap the length of these relaxing

28
 INTRAORAL INCISIONS AND SUTURING

incisions can be increased. This permits the reflection of the tissues to a

higher level in the case of the maxilla or a lower one in the case of the
mandible.
It is a basic principle of flap design that the base of the flap should be as
wide as is practical to ensure a good blood supply. However, where teeth
are standing, the angle at the gingival margin should be no more than around
100 ° or a narrow V-shaped strip will be left which will have an inadequate
blood supply at its tip.
In order to raise the flap along the gingival margin of the teeth the papillae
needs to be divided interdentally. A No. 15 scalpel blade on a No. 3 handle
is held parallel to the long axis of the teeth with the back of the blade
interproximally and the cutting tip used to incise vertically downwards, first
the distal attachment of the papilla then the mesial attachment so dividing it
like a wedge of cake (see Fig.3.1). The blade may then be passed along the
gingival crevice to divide the next papilla, but if this is done it should not cut
the periodontal fibres below the alveolar crest. Often as the flap is reflected
it will separate readily from the alveolar bone and the neck of the tooth so
that the connecting incisions are not essential. In the edentulous jaw,
however, the attachment of the mucoperiosteum to the crest of the ridge is
particularly strong and not only must the crestal incision be made firmly
down to bone but reflection of the flap may need the assistance of the knife
to cut the tough fibrous connections and to free it from the adjacent bone.
The use of excessive force with a periosteal elevator may tear the flap,
either at this narrow zone of strong attachment, or at the sulcus end of atwo
limbed incision.
It is important to design the incision so that a complete interdental papilla
is present at each end of a three-sided flap, because this facilitates suturing
through each interdental space. Bringing together the buccal and lingual
papillae in this way produces excellent healing without clinically detectable
increase in the depth of the gingival crevices. If such an incision is made in
the experimental animal and the healing studied, a small downgrowth of
epithelium will be found at the depth of the gingival crevice. The extent is
microscopic, however, and not detectable clinically.
Recommendations have been made from time to time that the marginal
gingiva should be avoided when outlining a flap, in order to prevent injury to
the epithelial attachment. Those who follow this advice make a horizontal
incision 2—3 millimetres away from, and parallel to, the gingival margin.
Unfortunately the strip of gingiva which is left covers the margin of the
alveolar bone. Should the excision of bone be carried too close to the
concealed socket margin while, for example, removing an unerupted upper
canine, the crestal alveolar bone may be damaged. Loss of the marginal
bone will not be repaired and permanent damage to the tooth attachment
will result. Retention of such a strip of gum also reduces surgical access with
the result that it becomes traumatised both during the operation and when
suturing, so producing necrosis with breakdown of the suture line. In
29
 ORAEASURGERY.SPARIey

addition, at the end of the operation, a bone cavity, such as the socket of a
tooth or a cyst cavity, may lie close to the line of closure so that the wound
edges are not adequately supported. Again the suture line will tend to break
down and the flap fall into the underlying bony defect.
In general incision lines should be planned so that at the end of the
operative procedure there is still an untouched zone of bone at the cavity
margin to support the edge of the flap that has been reflected. This will
provide a broad area of contact through which the process of healing can
reattach the wound margin and develop an adequate degree of early wound
strength to resist any tension during movement of the face and jaws in the
period immediately after the removal of the sutures.
Mucoperiosteal flaps are relatively thin and do not possess layers which
can be closed separately. Of necessity any surgically created bone cavity
forms a dead space and creates a haematoma. It is important to seal this
effectively from the mouth and the possible ingress of infection. Failure to
achieve primary wound healing for this or other reasons leads to exposure of
the underlying clot, which lyses, leaving a cavity which will be repaired
slowly by ‘secondary intention’.
As alveolar wounds cannot be closed in layers a valve-like closure is the
best that can be achieved. Siting the incision so that there is a zone of intact
bone between the cavity margin and the line of the soft tissue wound
provides for such a valve-like closure. Where unavoidably the incision line
crosses the cavity, eversion of the wound edge by mattress sutures creates
an additional zone of tissue contact, but not as secure a closure as one
supported on bone.
Provided incisions are confined to the mucoperiosteum of the alveolar
process or the palate, that is the masticatory mucosa, the sutured wound is
subject to little tension. The sulcus tissues in contrast are elastic and the
wound edges contract away from one another, though normally not so as to
create a significant tension in the sutured wound. Incisions made in the
sulcus radially or at right angles to the outer aspect of the jaw are not subject
to muscular pull and are readily closed with little risk of wound dehiscence
during healing. On the other hand, horizontally aligned incisions in the
sulcus in some parts of the mouth are subject to tension during movements
of the jaws, lips and cheeks and are best avoided. If such an incision is
necessary, special care is required in its closure to avoid wound
breakdown.
For example, the design of flap often used when an apicectomy is
performed upon an anterior tooth is a semilunar one with the convexity
towards the gingival margin. The incision for such a flap should not
approach closer to the gingival margin than one third of the depth of the
sulcus. Such a flap suffers from all of the disadvantages mentioned above. If
the incision approaches closer to the gingival margin, the remaining strip of
gum may slough, because its blood supply may be inadequate, particularly
after sutures have been passed through it. Furthermore, it is not always easy
30
 INTRAORAL INCISIONS AND SUTURING

to predict how large the surgical cavity may be at the end of the operation,
particularly if a small cyst is to be dealt with during the apicectomy, and the
flap may be inadequately supported at its margin. Finally the suture line
will be under tension. This can be seen as soon as the sutures are inserted
because the wound edges will gape between the sutures. Some operators
attempt to overcome this problem by using horizontal mattress sutures, but
there is a danger with such a small wound that they will be drawn too tight
and strangulate the wound margin, particularly on the gingival side. A
three-sided flap which includes the gingival margin of the tooth to be
operated upon and its interdental papillae is more satisfactory.
The problem of tension from muscular activity is encountered again
when horizontal incisions are made either to ‘deglove’ the chin or to expose
the anterior part of the maxilla during a Le Fort I level osteotomy. Such
incisions should be made so that a generous skirt of sulcus mucosa is left on
the gingival aspect. In the case of the mandible the incision should be
carried out on the labial aspect of the sulcus and then obliquely downwards
through the mentalis muscles to provide a sufficient thickness of tissues on
the gingival side to hold sutures. A continuous horizontal mattress suture
line will bring the deeper tissues together and evert the wound margin, but
should not be drawn excessively tight, nor should large bites of tissue be
taken at each horizontal step or the wound edge will be strangulated and
slough. The epithelial edges are coadapted by oversewing with a continuous
plain suture.

FLAP REFLECTION
Flaps are raised by dissecting parallel to the surface at the junction oftissue
layers. Where these have similar mechanical properties, such as the
junction of soft tissue layers, sharp dissection is used. Mostly dental
surgeons are intent upon exposing the mandible and maxilla so that flaps
are raised subperiosteally. This is done by blunt dissection with a periosteal
elevator, making use of the well defined plane of mechanical discontinuity
between the soft tissues and the hard bone. The attachment of the
periosteum to bone varies in strength from place to place. The interdental
papillae are firmly attached to the cribriform surface of the tops of the
interdental septa. In the edentulous jaw this cribriform bone forms a narrow
continuous strip along the crest of the ridge. Connective tissue fibres and
vessels which pass from bone to periosteum resist separation by the
periosteal elevator and it may be necessary to cut them with a scalpel.
The surface of the bone beyond the alveolar process can be exposed by
further elevation of periosteum and overlying soft tissues, but a sufficient
mesiodistal length of flap needs to be developed to permit adequate
retraction and comfortable access to the bone at the operation site.
On the outer aspect of the body of the mandible several structures are
encountered which require special attention. Foremost of these is the
31
 ORALMSURGERY PARI: a1

mental nerve. As the periosteum is reflected in the region of the apices of the
mandibular premolar teeth, care should be taken until the foramen is found.
Gentle use of the periosteal elevator will preserve the mental nerve and
vessels inside their conical sleeve of periosteum.
Special care should be taken where the patient is edentulous. If the
alveolar process is atrophic the mental foramen will be relatively close to
the crest of the ridge. Indeed where resorption has been extreme the nerve
may emerge on the crest of the residual ridge and can be seen radiating
outwards beneath the mucosa.
Anterior to and below the mental foramen there are the origins of the
depressor labii and depressor anguli oris muscles and the insertion of the
platysma muscle. These add only a marginally stronger attachment of the
soft tissues to the mandible. In contrast, the origin of the mentalis muscle
below the incisors requires a substantial effort with a rougine to detach it.
Indeed the periosteum is firmly attached over the whole mental
eminence.
The attachment of the buccinator to the mandible is easily disrupted, but
it should not be raised unless the additional access is definitely required.
Once the edge of the muscle has been separated oedema of the buccal space
is facilitated producing a greater degree of facial swelling postoperatively.
As the body of the mandible is uncovered buccal to the second molar it
should be remembered that the facial artery and vein lie immediately
external to the periosteum at this point.
More posteriorly the insertion of the masseter needs to be separated to
expose the outer aspect of the mandibular angle. This requires little effort
until the posterior border of the ramus and the lower border of the angle are
reached. However, the tough, inelastic periosteum may need to be incised
by a few gentle strokes across the inner surface to permit adequate
retraction of the muscle to allow work on the underlying bone.
The shape of the mandible makes surgical access to its inner aspect
awkward and this difficulty is increased by strong muscle origins. The
genial muscles can be detached only by cutting through their origin, close to
the tubercles and of course if complete detachment is necessary, they
should be reattached. The sublingual arteries enter the mandible through a
single foramen just above the tubercles and if divided they must be ligated or
the bleeding from them arrested with coagulation diathermy. The
mylohyoid origin extends from the third molar region to the midline and is
not at all easy to separate from the bone, mainly because the muscle slopes
downwards and the periosteal elevator more easily perforates the thin
lingual periosteum and slips over the surface of the muscle rather than lifting
it from the bone. It may be detached, if this is necessary, by hooking a
narrow, curved elevator beneath the posterior border and detaching it from
below upwards. This should be done with care and it may damage the
mylohyoid nerve producing a transient patch of cutaneous anaesthesia on
the point of the chin. Naturally in the elevation of the mucoperiosteum on
32
 INTRAORAL INCISIONS AND SUTURING

the lingual aspect of the 3rd molar region the lingual nerve must be
safeguarded. Even the exposure of no more than the lingual aspect of the
alveolar process requires care because, except in the 3rd molar region, the
mucoperiosteum is thin and easily torn. Any tear in the lingual periosteum
will permit blood to spread into the lax tissues of the floor of the mouth
forming a bulky haematoma.
As the outer surface of the maxilla above the alveolar process is
uncovered few obstacles are encountered. The buccinator attachment is
barely noticed and there is only little resistance from the levator anguli oris.
In contrast the depressor septi muscles form a fleshy zone over the central
incisors which requires some care during flap reflection. Once the anterior
bony aperture of the nose is reached the reflection of the periosteum into the
nasal aspect of the maxilla impedes further mobilization of the soft tissues.
Caution should be exercised high on the anterolateral aspect of the maxilla
to identify and preserve the infraorbital nerve. This is done by elevating the
soft tissues with a swab enclosed finger. Behind the zygomatic buttress or
zygomatico-alveolar crest on the posterolateral aspect of the maxilla again
the periosteum should be raised gently. It is easily stripped from the bone
but care is necessary to avoid unnecessary damage to the posterior superior
dental artery as it enters the bone. Exploration high up on the back of the
maxilla leads to its disruption and the onset of a brisk ooze. While the
haemorrhage is usually on a small scale, it can be troublesome in this corner
where visibility is bound to be poor. Also a breach in the periosteum will
release the buccal pad of fat, creating an even greater impediment to
vision.
The mucoperiosteum of the hard palate is normally raised by incising the
interdental papillae or by making an incision around the crest of the
edentulous ridge. The palatal mucoperiosteum is tightly attached at the
margin of such a flap so care must be taken not to use a tooth as a fulcrum for
the periosteal elevator when it is raised. Initial elevation of the margin may
be facilitated by using the spoon-shaped end of a curved Warwick James’
elevator. The mucosa is also tightly attached to the median palatal suture
and tethered to the contents of the incisive fossa. Normally a generous
length of the curvature of the upper dental arch is needed to form a useful
flap. However, radially placed relieving incisions can be made to limit the
amount of mucosa which is raised to gain access to the surgical site. These
should be short so as not to cut the greater palatine neurovascular bundle.
Division of the palatine artery leads to a brisk haemorrhage which is best
controlled by elevation of the posterior margin of the cut, the application of
a haemostat and underrunning the vessel with a resorbable stitch which is
then tied to form a ligature.
In order to raise the full width of the palate elevation is started at a
premolar interdental papilla on each side and separation is carried up to and
around the incisive fossa structures. The nasopalatine nerves and vessels
are divided as they enter the deep surface of the flap and rarely cause
33
 ORAL SURGERY, PART I

trouble either with haemorrhage or postoperative loss of sensation.

Posteriorly the greater palatine neurovascular bundles in the adult emerge
opposite the second molars and must be preserved with care. Damage to
both can result in death of the flap. Damage to one may result in cyanosis of
the edge of the flap. If appropriate one-half only of the palatal mucosa may
be raised by making an incision along the centre of the palate.
Access just to the centre of the palate can be made by a midline incision.
The mucosa is thin, as well as tightly adherent on either side of the midline,
but can be raised with care and retracted to expose the underlying bone. A
V-shaped extension about the incisive fossa anteriorly increases access if
this is necessary, but should not extend so far laterally as to divide the
palatine vessels. Further reflection of the mucosa can be achieved by a V-
shaped cut at the posterior end but the thickness of the mucosa at this site
makes such an extension less helpful. In making a posterior V-shaped cut
the incisions should not be carried on to the soft palate nor should they be
made so as to endanger the greater palatine vessels.

INSTRUMENTATION
In general, incisions in the perioral tissues are made with a No. 15 blade.
The scalpel handle is held at an acute angle with the proposed incision line
but with the flat of the blade at right angles to the surface. This way much of
the length of the cutting edge will be employed in making the incision and it
will be deepened progressively down to the level of the tip of the blade. Ifthe
knife is held with the blade vertically in the tissues they will tend to bunch up
ahead of the blade and a ragged cut will result. Where mucoperiosteum is
being incised, the tissues are held steady by the underlying bone and a clean
cut is easily produced. Where soft tissues unsupported by bone are being
cut they must be stretched gently at right angles to the line of incision, for
example on the inner aspect of the lip. Where thick tissues are to be divided,
such as those over the anterior border of the coronoid process, the incision
can be deepened progressively by a succession of passages of the knife. This
way the direction of the cut can be controlled, divided vessels identified and
picked up with artery forceps and damage to any important structures
avoided. If an attempt is made to divide the full thickness in one sweep of the
knife the operator will be tempted to plunge the scalpel blade in at right
angles to the surface so bunching up the tissues as described above or
resorting to a sawing motion, all of which will result in a ragged
incision.
In order to incise the periosteum cleanly, a degree of pressure onto the
bone must be maintained as the blade is advanced. After a short while this
will blunt the edge of the blade. Incising over an unerupted tooth will also
damage the scalpel edge and a new blade should be fitted before further
incisions are made.
Loose connective tissue can be broken down by pushing the ends of the
34
 INTRAORAL INCISIONS AND SUTURING

closed blades of a pair of scissors into the tissue then opening them.
Performed with care this type of blunt dissection will permit vessels and
nerves which are passing through such tissue to be displayed. The excessive
use of blunt dissection, however, is a bad habit which will cause
unnecessary tissue damage, untidy wounds and imprecise surgery.
Scissors can be used as an alternative to a scalpel to divide sheets of soft
tissue, usually thin muscles and sheets of connective tissue and mostly in a
direction across the fibres. They are also used to divide loose connective
tissue to avoid excessive blunt dissection.
Periosteum is raised from the bone with periosteal elevators. These may
have a thin rounded edge or a sharpened edge flush with one surface and the
end may be curved to enable it to be applied closely to curved bone surfaces.
A blade end set at an angle to the handle like a hockey stick is used in cleft
palate surgery and angled Warwick James’ root elevators may be used as
substitutes for such periosteal elevators to raise the edges of palatal
incisions.
Large bi-angled spoon excavators also form excellent miniature
periosteal elevators when it is necessary to raise soft tissues from bone in a
confined space such as a cyst cavity.
A periosteal elevator in which the blade ends in a sharp, straight edge is
called a rugine. This chisel-like end is turned over so that the sharp edge can
be applied firmly to the surface of the bone, to separate tendinous muscle
insertions. The fibres of most such tendinous insertions lie almost parallel
with the surface and a periosteal elevator advanced from the bone to the
edge of the insertion will slip up over the surface of the tendon. The muscle
insertion should be approached from the side, if possible working one
corner of the rugine blade between the muscle and the bone so as to detach
the tendon from this aspect. In this way even strong tendinous insertions can
be raised cleanly and easily.

SUTURING
Incisions are closed and the tissues held in contact with one another to
permit healing by first intention by the use of sutures. Haemostasis should
be secured always before the wound is closed. While the act of suturing the
wound will arrest a slight ooze from the surfaces which the stitches bring
together this cannot be relied upon. If bleeding continues after the wound
has been closed a haematoma will form. This may either take the form of a
clot which creates a dead space in the tissues, or a suffusion of loose
connective tissues with blood which later clots.
Haematomas increase the volume of the tissues, expand flaps from the
underside impairing their blood supply and creating tension at the suture
line. The tissues within the bite of the sutures are also excessively
compressed and necrose so that the suture cuts out and the wound opens,
oo
 ORAL SURGERY, PART I

the so-called ‘burst’ suture line. Secondary infection will follow. Haemo-
stasis therefore must precede wound closure.
The cheapest sutures are undoubtedly those made from eyed needles and
a suitable length of suture material cut from a reel. However, most suture
materials and needles are difficult to sterilize. The needles are also difficult
to clean after use and become blunt and work hardened so that they
snap.
Modern sutures are prepared commercially and sterilized by gamma
radiation. The needles are eyeless, with the end shaped as a tube into which
the suture thread is swaged. These ‘atraumatic’ sutures pass through the
tissues with minimal effort and damage.
Needles may be either round bodied or cutting. Cutting needles are
flattened on two or more aspects behind the needle point to raise sharp
edges which aid penetration of tough tissues. Round-bodied needles dilate a
hole for the thread so that delicate tissues are less likely to tear and the
stitches cut out. The thread also fits tightly in the hole to make a water-tight
suture line in, for example, the wall of a blood vessel. Large needles may be
hand held, but small needles such as are required for suturing in the mouth
are held in needle holders. There should be a portion of the needle shank
which has flattened surfaces which may be held by the needle holder and
which prevent the gripped needle from rotating. It is a fault of some modern
needles that this necessary flattening of the surface may not be present.
Needles are also either straight or have varying degrees of curvature.
Suturing in a limited space is facilitated by a curved needle, so that the point
can be readily seen and grasped after rotating it through the tissues. A half
circle (Lane) or a % circle (Denis Browne) needle is usually chosen. These
are 22 and 25 mm in length measured around the curve, and are well suited
to relatively thin layers oftissue and the small ‘bites’ required to close them.
Suture material of 2metric (3/0) silk or polyglycollate is usually used in the
mouth. Where appropriate thinner suture materials may be chosen.
The sutures may be either absorbable or non-absorbable, and mono-
filament or braided. The traditional absorbable suture material is catgut and
despite the appearance of new synthetic materials it is still widely used.
Catgut is prepared from the collagenous adventitia of lambs’ intestines and
is prepared either plain and simply stranded, twisted and sterilized with
gamma irradiation, or treated with chromate, i.e. chromic gut, to increase
its tensile strength and delay absorption. However, synthetic polymers, the
polyglycollate and the polyglactin suture materials, are stronger and less
irritant to the tissues. Unfortunately if uncoated these sutures may be
difficult to knot securely and will spontaneously untie unless the surgeon is
familiar with their behaviour and triple ties each knot. Polyglactin sutures
are coated with polyglactin 370 and calcium stearate (Vicryl-Ethicon)
which reduces drag.
In general, non-resorbable materials excite little tissue reaction but
because they are not destroyed by the tissues are only used where they can

36
 INTRAORAL INCISIONS AND SUTURING

be removed or buried deeply in situations where permanent support from

the sutures is required and where subsequent infection of the foreign
material is unlikely. They may be either monofilament or braided. Braided
materials are generally more flexible and are easy to knot and so are more
suitable for suturing the mucous membrane of the mouth.
Natural fibres, such as silk, with their slightly roughened surfaces hold
knots better than smooth surfaced artificial fibres. However, a braided
thread will act as a wick for moisture and accumulate debris and micro-
organisms which can irritate the wound. To prevent this, braided sutures are
often coated and made water repellent with wax or silicone.
Monofilament synthetic polyesters such as polypropylene or polyamide
(nylon) will not absorb and conduct liquids in this way but are more difficult
to knot as they have an intrinsic springiness. Therefore only 4/0 or finer
gauge monofilaments are used in the mouth.
As elsewhere in the body, catgut or other absorbable material is used for
buried sutures although these are not often required during operations
performed through the mouth. Absorbable sutures are also used for
mucosal flap closure when operating on young children to avoid the need for
suture removal, or in all age groups for suturing the inside of lips and cheek
or the floor of mouth where postoperative oedema may make the sutures cut
in to a degree that they are difficult to remove. Sizes 3/0 (3 metric) to 6/0
(1 metric) of catgut are chosen, dependent upon the tissues to be sewn. Size
3/0 (2 metric) braided silk or polyglycolic acid or 4/0 (1-5 metric) polyester
sutures are used for mucoperiosteum.
Needle holders with narrow beaks are required to hold small, curved
needles without flattening their curvature. The handles should be
sufficiently long that the holding fingers do not obstruct the surgeon’s view.
Modern eyeless needles are difficult to hold without a ratchet type needle
holder and this can be a disadvantage in awkward corners of the mouth.
However, they are less highly tempered than the eyed needles and much
less likely to snap if accidently bent.
The needle holder is clamped on to the needle at a position about two-
thirds of the distance from its tip. If the needle is held correctly in this
manner the length between the jaws of the needle holder and the point is
sufficient to allow the needle to be inserted about 2-3 mm from the wound
edge, and rotated through the tissues so that enough of the pointed end
emerges from the wound to be gripped and drawn through. The flap is
controlled with either toothed dissecting forceps or a skin hook and the edge
is everted as the needle is passed. The needle point enters at right angles to
the surface and it should penetrate completely through a mucoperiosteal
flap to obtain the maximum grip, but emerge near the bottom of the soft
tissue incision to ensure that there is no dead space left after it has been tied.
Eversion of the first side of the flap enables the curved needle to travel
through the tissue obliquely away from the incision to enclose a slightly
larger bite on the deep aspect than at the surface.
eK]
 ORAL SURGERY, PART I
In general the needle should be drawn out of the first side of the wound
before the point is engaged in the other. Now the second side is everted with
toothed forceps or a skin hook and the needle inserted from the underside of
the flap. The needle is inserted into this side of the wound at the same depth
that the thread emerges from the first side. Now, once the needle has
penetrated into the second side the forceps or skin hook is detached from the
edge of the flap and pressed against the surface of the tissues just beyond the
hidden point of the needle. This action pulls the superficial tissues over the
point so that the needle emerges closer to the wound edge than it would
otherwise. This way again the needle embraces a greater width of tissue
deeper in.
Now when the stitch is tied the wound edges are everted slightly.
Eversion of the wound edges increase the area of contact and so improves
the early strength of the healing wound. As the scar contracts a flat surface
results. The distance of the needle punctures from the edge of the flap
should be less than the depth to which the stitch penetrates into the tissues,
particularly with mucoperiosteal flaps, or one edge will overlap the other as
the knot is tied. Overlapping will also result if unequal depths of flap are
embraced by the stitch. Excessive depth of bite in relation to width, on the
other hand, results in excessive eversion and gaping of the approximated
wound at the surface.
In the mouth, one side of the wound often constitutes the flap and has
been freely elevated from the bone and the other side remains attached to
the bone almost up to the incision. The edges of the fixed margin, however,
will have been raised for a sufficient distance to permit penetration of the
full thickness of the flap by the needle. Suturing from loose to fixed flap
usually enables finer repositioning and reduces the chance of the suture
tearing through the fixed thin tissue layers. However, comfortable suturing
is important to good technique and to this end it is preferable, where
appropriate, to sew from the edge further from the operator to the nearer
one. A supinating action of the wrist is usually more easy to perform than
the reverse.
A knot is now tied, either by hand or with instruments. If the knots are tied
by hand more thread is wasted than when instrument tying is employed,
particularly where the knots have to be formed towards the back of the
mouth. The technique of instrument tying therefore will be described (Fig.
2.1). Furthermore, it is easier to see what is happening if instruments are
used in the confined space of the mouth.
The needle is drawn out of the second side of the wound and the thread
pulled through until a length of about 4 cm remains protruding from the
entry puncture. The needle is taken from the needle holder with the index
finger and thumb of the left hand. If no previous stitches have been inserted
about 42 cm (17 in) of thread will hang between the needle and the wound.
The excess suture is taken up into the palm of the left hand, using third and
fourth fingers and the thread grasped again with finger and thumb about

38
 INTRAORAL INCISIONS AND SUTURING

Fig. 2.1. Tying surgical knots with needle holders. a, The needle is grasped with
forefinger and thumb of left hand and the thread drawn through to leave a short
end at the other side of the wound. With a clockwise movement the needle
holder picks up two clockwise turning loops of thread. b, The short end is
grasped with the needle holders and the loops drawn off the ends of the beaks. c,
By pulling further on the long end only the loops are tightened against the exit
puncture. d, A single loop is twisted around the needle holder in an anti-
clockwise direction. e, The short end is grasped again and mainly by traction on
the long end of thread the second throw is tightened upon the first to complete
the knot. f The shape of the surgical knot.

39
 ORAESS URGE RY PARIS!

8 cm from the wound. The beaks of the needle holder are brought across the
front of the thread and rotated in a circle to pick up two loops of the thread.
The short end is now gripped at its end with the needle holder and the loops
slid off the beaks onto the thread by rotating the needle holders so that the
beaks point towards the left and by drawing on the long end with the left
hand. The short end is given a short downwards jerk which tumbles the
loops into a slip knot, which is positioned just beyond the tips of the beaks
and with the short length emerging from under the loops. By drawing on the
long thread the knot may be made to slide down onto the tissues at the exit
puncture. The short end should not be pulled as if this is done an unstable
knot will result. Tension upon the long end also results in a short, short end
which needs minimum trimming subsequently. The short end will emerge
between the loops and the tissues and the knot will not slip while the long
end only is under tension. As this first knot is tightened the left hand moves
away from the operator’s body and across the wound.
To form the second throw of the knot the needle holder beaks are brought
across the long thread from behind and the points rotated downwards, away
and to the right to pick up a single loop. The short end is again clamped but
should not be pulled upon. The loop is drawn off the needle holder beaks
and the knot tightened by traction upon the long end only with the left hand.
Final tightening is accomplished by drawing the long thread towards the
operator and the short end away, across the wound. A third throw will
prevent any chance of a knot slipping, particularly if a synthetic suture is
being used, or of the knot untying as it absorbs moisture from the saliva in
the case of catgut. The loop is formed as for the first throw, but only one loop
is picked up. The left hand travels away from the operator and across the
wound to tighten the knot. The thread ends are held up and cut off by the
assistant.
It is essential to close a wound with the correct suture tension, sufficient
to keep the edges of the wound firmly together, but no more. Slight oedema
of the soft tissue margins can be anticipated postoperatively and allowance
must be made for this, particularly when suturing the inside of the cheek or
lips or the floor of the mouth. If a suture is too tight it will cut into the tissues
and produce scars at right angles to the healed incision, or stitch marks.
Permanent suture scars depend more upon the tension of the sutures than
upon the length of time before they are removed. To avoid irritation of the
healing wound the knot should be manipulated so that it lies over the
puncture point to one side of the wound. If an angled incision is used the
apex between the two edges is correctly positioned first. Then the next two
sutures are inserted at each mid-point between the ends of the wound and
the first suture. The remaining sutures are interspaced at regular
intervals.
Interrupted, simple loop sutures are used for most oral surgical
procedures though where long incisions are to be closed, continuous sutures
are used. Where a continuous suture has been inserted the thread is drawn
40
 INTRAORAL INCISIONS AND SUTURING

out after the last penetration of the needle leaving a short loop on the other
side of the wound. The mid point of this loop is grasped with the needle
holder as the knot is tied, instead of the usual short end.
Mattress sutures, which may be either horizontal or vertical in design,
embrace a greater volume of the tissue which increases the grip upon the
wound margin and produces pouting of the wound edge. In the case of the
former, the needle is introduced through one wound edge and passed out
through the other in the usual manner. Then the needle is re-inserted about
3 mm further along the wound from the point of its emergence, carried back
through both wound edges and tied. The vertical mattress suture is made by
inserting the needle 4-5 mm from the wound margin and through the tissues
in a deep bite. The needle is then re-introduced close to the wound margin
and taken through more superficially in line with the previous direction of
insertion, but of course in the opposite direction. The suture is then tied on
the side of its original insertion. A vertical mattress will coadapt the wound
margins where there is a small degree of tension and at the same time ensure
eversion of the wound edges.
Absorbable sutures can be inserted to close layers below the surface, to
ensure complete closure of a wound in depth, to reconstitute sheets of
muscle or fascia and to eliminate potential dead spaces. The part of the
suture which will persist longer than the rest and be likely to form a nidus for
infection is the knot. If it lies under the outer suture line the bulk may affect
the soundness of closure. For both these reasons the knot should be buried
on the deep aspect of the suture line. The needle is inserted from the deep
side of the layer to be sutured and reinserted from above downwards on the
other side of the wound. When the knot is tied it will slip through between
the approximated tissues.
The removal of sutures should be performed with care. They should be
swabbed gently with chlorhexidine then each knot gripped in turn with non-
toothed forceps. The external part of the suture is raised and the thread cut
below the knot and flush with its point of emergence. In order to avoid a
strain upon the healing wound the suture is drawn out across the wound.
This draws the deep part of the suture out of the opposite puncture creating
tension towards the wound rather than away from it. This prevents
dehiscence of the healing wound and also draws only the previously buried
part of the stitch through the wound. Never cut through a stitch in such a
way that part of the contaminated external loop is drawn through the
wound. Above all, avoid cutting the suture in two places so that part of the
suture is left in the tissues. As the suture is divided some compression of the
tissues is released and the retained segment retreats into the depths of the
tissues. Even if some organisms have travelled along the suture material
they do not produce a clinical infection in the ordinary way because a suture
creates a wound which is drained at both ends. Leave a cut segment buried
in the suture track and allow the puncture points to close so that there is no
longer drainage, and a stitch abscess will result.
4]
 ORAL SURGERY, PART I

Sutures are normally left for 5-7 days where closure is completely
without tension. Where tissues have been displaced and some degree of
tension created, as in the rotation or advancement of a flap to close an
oro-antral fistula, it is better to leave them for 10-14 days. Preferably
sutures should be left until local tissue oedema has subsided at which time
the loop will probably lie loosely over the wound and can be removed easily
and without causing the patient discomfort.

42
 CHAPTER 3

THE REMOVAL OF ROOTS

THE FRACTURED ROOT

General Considerations
A decision must be made whether to leave or remove a residual root. This
requires anticipating whether the root fragment will remain asymptomatic
or whether it will become infected and cause pain (non-infected roots do not
cause pain), perhaps lead to an abscess and a discharging sinus, develop a
cyst or interfere with a denture. Occasionally mandibular roots may even
‘sink’ towards the lower border creating greater problems in their
removal.
If the root breaks after the tooth has become mobile the missing piece
should be recovered for it is almost certain to become infected and cause
pain. Conversely when the apex of a tooth with a vital pulp snaps off before
the main body of the tooth has been loosened, the fragment is likely to be
enclosed by the bone of the healing socket, and remain asymptomatic, and
its removal can be deferred if necessary. Minute portions of root in the
upper 3rd molar area are best left and put on probation, because they are
often difficult to extract while the 2nd molar is still standing. Following
alveolar resorption such a root lies nearer the surface and is therefore more
amenable to surgical removal. Perhaps the only absolute indication for root
removal is for patients for whom unpredictable local infection may become
a major risk such as those who have rheumatic or congenital heart disease or
who are immunosuppressed.

Forceps Removal
The narrow bladed forceps, 74N for mandibular and 76N for maxillary
teeth, are invaluable for the removal of sizeable retained roots if used with
care as follows:
a. Always ensure that the blades are inserted beneath the gingiva which
may have to be elevated locally first.
b. Always obtain a grip on an identified root rather than just grip the
alveolus blindly.
c. Press the forceps well down over the root. In the mandibular molar
region a small amount of alveolar bone may have to be included. This has
been condemned but done with care and discretion will not damage or
remove any more bone than a surgical extraction.
43
 ORAL SURGERY, PART I

d. In the maxilla, apply the palatal forcep blade between the palatal and
one buccal root and the outer blade buccal to the cther buccal root where
retained molar roots are being tackled.
e. Apply a firm continuous_force with a strong grip to expand the
alveolus, at the same time moving the root only through a small arc while
maintaining an apically directed pressure. Rapid rocking movements
although popular are likely to fracture the roots.
f This approach is likely to remove one mandibular root or in the maxilla
two roots, making the removal of the remaining one easier.
After a root has been recovered, verify that the removal is complete by
fitting the tip to the previously extracted portion of the tooth. If this
precaution is neglected, the surgeon may discover that he has failed to
retrieve the whole of a missing root. Indeed all teeth should be inspected
carefully after extraction because some have an extra root and if this is
fractured and retained, its absence may be overlooked by a casual glance at
the tooth.

Other Non-surgical Methods

There are a number of other manoeuvres which will enable the operator to
remove a fractured root without resorting to a surgical procedure. However,
too much time should not be spent in this way and if success is not soon
achieved the attempt should be abandoned and a flap reflected.
In certain cases one complete root of a multirooted tooth is fractured off
and retained. With care it may be possible to place a sharp pointed elevator
in the empty socket and rotate it to remove first the inter-radicular septum
and then the root. This is often a successful method for removing lower
molar roots but is less successful in the maxilla. The distobuccal root from
an upper molar may be extracted in this way provided only gentle pressure
is used with an elevator inserted in the mesial socket. Unfortunately the
mesial root is difficult to remove through the distal socket, as the root
curvature is unfavourable for the application of an elevator from the distal
aspect. Mesiobuccal roots can be elevated by introducing a Coupland
chisel or straight Warwick James’ elevator up the mesial periodontal
membrane in order to turn the root downwards and backwards.
Elevators should not be used to remove the palatal root of an upper
molar. The buccal wall of the socket does not form a satisfactory fulcrum
and can be crushed by the elevating force. Furthermore there is always the
danger of forcing the root into the antrum. The palatal root must be seen
clearly, which usually implies the removal of both of the buccal roots and, if
necessary, some surrounding bone which can be done with a bur. Then
gentle dislocation with a narrow Coupland’s chisel or rotation with upper
root forceps should deliver the root. If an oro-antral fistula has been created
this may be readily closed with sutures or by advancing a buccal flap as
described in Chapter 9.
44
 THE REMOVAL OF ROOTS

Sometimes a root apex is heard to fracture after the tooth has been
loosened with forceps and it may be possible to see the apex clearly with the
aid of a sucker. A probe or a thin root canal reamer or file can be introduced
into the root canal and the loose apex withdrawn with its aid.
So-called apical elevators are usually too thick to use to dislodge the
apical third of a tooth root from its socket, but a stout, bi-angled spoon
excavator or a Cumine scaler may enter the periodontal space and topple it
out. However, the movement will be a tilting one, pushing the sharp
fractured edge on the other side of the root against the socket wall. This may
be sufficient to prevent the operator dislodging it out of the socket. A narrow
groove cut around the end of the root with a No. | rose-head bur may be
sufficient to overcome this obstruction.
Used with discretion, these manoeuvres can neatly remove a number of
small retained fragments but again it must be emphasized that unless
success is achieved early, further attempts will prove frustrating and time
consuming. It is then much quicker to raise a flap, cut away some buccal
bone and tease out the fragment with a fine elevator. Indeed if socket
surgery is performed incautiously, it can lead to roots being forced into the
maxillary sinus or the inferior dental canal.
Blind elevation of a lower 3rd molar root can result in its deflection into
the lingual space, through a thin or deficient lingual plate. To retrieve it, a
long incision is made along the lingual gingival margin and the muco-
periosteum elevated and retracted towards the midline with a Lack’s
retractor. The floor of the mouth can be elevated by the fingertips of the
assistant’s hand placed externally just medial to the lower border of the
mandible, and with good suction and light the apex should be readily seen
and retrieved. Occasionally the mylohyoid muscle may have to be detached
from its linear origin to reveal a more deeply displaced root.
Where immediate simple measures have failed to deliver a root, a formal
surgical removal is essential. This should not be undertaken without clinical
reappraisal and adequate radiographs to localize the root fragments and
identify the features which might explain the problem, e.g. bulbous or
hooked apices or adjacent unerupted teeth.

Accurate Localization of the Retained Root

A root may be so superficial that it becomes visible immediately the
alveolar mucosa has been dried. Alternatively, an apex may be detected on
probing a patent sinus, or an area of mucosal hyperplasia at an edentulous
site. The brownish-yellow colour of dentine helps to distinguish the root
from a sequestrum of bone. More often the position of a buried root can be
determined only by a radiological examination. There is usually no problem
when a Standing tooth is present in the vicinity to act as a visible landmark
from which to estimate its position.
Difficulty in localization arises when a root is discovered in the maxillary
molar region where its situation may be either buccal or palatal and the only
45
 ORAL SURGERY, PART I

helpful pointer may be the root shape. In such circumstances two

radiographs should be taken in planes at right angles to each other, such as
intraoral periapical and occlusal films. In the edentulous jaw identifiable
anatomical landmarks provide effective guides to the site of a root fragment
and so avoid the need for localizing plates. The midline of both jaws is an
obvious starting point. In the mandible this is marked by the median lingual
foramen surrounded by its ring of dense bone. The mental foramen
coincides with the mandibular premolar region while more posteriorly the
external oblique ridge casts a dense image over an area corresponding to the
2nd and 3rd molars. Of importance as landmarks in the maxilla are the
median suture and incisive fossa in the mid-line, the fork of the Y of Ennis
(formed by the diverging limbs of the anterior wall of the antrum and the
floor of the nose), and more posteriorly the superimposed V- or U-shaped
opacity of the zygomatic process of the maxilla. The former corresponds to
the canine-premolar region and the latter to the 1st molar position. Finally,
the tuberosity identifies the 3rd molar region.

OPERATIVE TECHNIQUE FOR THE REMOVAL

OF RETAINED ROOTS
The Reflection of a Flap
There should be no hesitation to reflect a flap whenever this is necessary to
see the retained root clearly (Fig. 3.1). It is also essential to remove
adequate bone to enable unimpeded elevation of the fragment along the
appropriate line of withdrawal. This will avoid much frustration from
repeated premature attempts to dislodge the root.
In the edentulous jaw the incision is made along the crest of the ridge or, if
adjacent teeth are standing, the incision is made along their gingival
margins. The flap must be ample in length and vertical depth in order to
provide adequate access for surgical manipulations without damage to the
soft tissues.
Where there are standing teeth the incision should be carried through the
gingival crevice of the tooth on either side of the retained root and continued
into the sulcus at an obtuse angle. This will produce a two-sided flap with a
single relieving incision, or a three-sided flap with two relieving incisions
depending upon the amount of access which is required. An entire papilla is
included at each corner to facilitate closure (Fig. 3.1 d). If a flap is to be
raised to remove a lower premolar root, care should be taken to identify the
mental nerve at an early stage during elevation of the flap so that it can be
preserved intact.

Bone Removal
What constitutes adequate bone removal can be learned only by experience
but, within reason, it is better to remove rather too much bone than too little.

46
 THE REMOVAL OF ROOTS

Fig. 3.1. a, An envelope flap to expose the roots of [6. b, A two-sided flap to
uncover |5 root. c, The correct way to divide an interdental papilla. d, A three-
sided flap to uncover the upper incisor region up to the nasal floor over [ae

Bone is usually cut away from the buccal aspect of a root, because this not
only improves the access but brings the fragment into full view. The socket
wall can be removed either with a hand chisel or gouge, a mallet and chisel,
or a drill.
In general a bur in a dental drill is preferable to a chisel or gouge for the
removal of bone around a buried root because if a hammer and chisel are
used inexpertly the edge of the chisel may strike the root itself and fracture it
at the level of the bone cut so necessitating more bone removal.
Furthermore, most conscious patients undergoing surgery under local
anaesthesia find the sensation produced by a mallet and chisel objection-
able. If the bone surrounding the root is very hard, the mandible thin, or the
root brittle then a chisel is definitely contraindicated.
When using a bur, care must be taken not to damage the adjacent teeth or
to cut into the root fragment itself to a degree that weakens it and results in
fracture when elevation is attempted. A No. 8 rose-head bur is excellent for
the removal of the overlying buccal or labial bone. When bone has to be
removed alongside the root to provide for mesiodistal movement and for the
application of an elevator, a No. 4 or No. 6 rose-head should be used. Rose-
head burs have two advantages over fissure burs for the removal of bone:
they are more easily cooled and washed by a water or saline jet, and the site
47
 ORAL SURGERY, PART I

at which they are cutting is more readily seen, even where a gutter is being
cut by the side of a root.
Burs are also used to separate divergent or recurved rcots. A tapered
fissure bur is best for this purpose. Separation of roots with a bur may take
longer than splitting them apart with an osteotome, but is more certain. If
the roots are shattered by the splitting blow their removal may be made
more difficult. What is more, a space is created between the root ends by the
bur cut permitting recurved or divergent roots to move towards one another
as they are elevated. If the roots are split apart the split surfaces may still
impact against one another as elevation is attempted (Fig. 3.2).
The least complicated but not necessarily the most successful way to
remove bone from around a retained root is by means of hand gouges. A
Coupland’s chisel with its straight cutting edge but gouge-like blade is the
most frequently used instrument of this type. The special shape of the
Coupland’s chisel permits bone to be removed accurately around the
curved surface of a root. There are none of the problems of sterilization,
lubrication and cooling associated with the use of a dental handpiece and
bur when hand-held cutting instruments are used. Some patients find the
pressure needed to cut the bone uncomfortable but there is none of the sharp
shock and bone transmitted noise associated with the use of a mallet and
chisel. Hand-held cutting tools will remove the soft, thin bone on the outer
aspect of the maxillary alveolar process and on the labial surface of the
lower incisor region. However, if they are to be used successfully they must
be sharp. A Coupland’s chisel should be sharpened after each use. In most
cases the bone on the palatal side of the maxillary alveolar process and
buccally in the lower molar region is too hard or too thick to be cut with
sufficient efficiency with hand-held instruments. Bone on the lingual aspect
of lower tooth roots is rarely removed as access is difficult. The removal of
small slivers of bone one after another is the most efficient way to use a
Coupland’s chisel.
If the operation is performed under a general anaesthetic it may be
convenient for the operator to use chisels and a mallet instead of a
handpiece and bur. Two vertical cuts are made, one on either side and
parallel to the side of the root. For the more mesial cut the bevel of the chisel
should face distally and for the distal one, mesially. This way the remaining
bone edges are not crushed. A third cut is made horizontally and joining the
other two cuts at a suitable distance from the socket margin so as to expose
at least a third of the length of the retained root fragment. The cuts should
just penetrate the cortical bone and care should be taken not to damage the
adjacent teeth, nor should the chisel strike the root as the third cut is made or
it will be fractured. A gouge of suitable width can be tapped down the side of
the root and between it and the outer alveolar plate, so separating the
overlying bone. A gouge is also used to create a trough between bone and
root on either the mesial or distal aspect. A curved Warwick James’
elevator is inserted into the trough to lever the tooth from the socket. In all

48
 THE REMOVAL OF ROOTS

errr
eg --crer?
- -
-
¢
‘ S92 0ee
Oi err”
wer

Fig. 3.2. Elevation of roots. a, Elevators can be applied either side of a straight
root. b, But can be applied only to the convex surface of a curved root. ¢,
Application of an elevator to the concave surface forces the convexity against
the bone. d, Divergent roots must be separated, creating a space between them,
and then elevated towards one another. e, A similar method is used to elevate
convergent, curved roots.

cases excessive removal of buccal bone should be avoided as this will

damage the foundation for a denture.
Where the retained root, such as one from a lower third molar, is situated
in thick bone a gutter should be created with a rose-head bur all round the
root from above. This will often permit the fragment to be dislocated with a
Warwick James’ elevator without the need to destroy the full thickness of
the overlying buccal bone. Alveolar bone may also be conserved during the
49
 ORAL SURGERY, PART 1

removal of small apical fragments. Instead of removing the whole length of

the lateral wall of the socket to reach the root tip a window is cut in the bone
overlying the apical part of the socket and access gained to the root in this
way. It may be delivered laterally through the opening or it can be dislodged
into the socket and retrieved from this aspect if it is a fresh socket.
If a lower premolar root tip has to be removed bone should be removed on
the side away from the mental nerve.

The Application of an Elevator

The configuration of the root and direction in which it must be moved for its
delivery will determine the correct site of application of the elevator. Roots
may be straight or curved and the only way to establish the shape of a
particular root is by radiography. The operator should aiways try to identify
the reason why the root fractured during the original extraction. Was the
impediment to success during the original extraction of the tooth relieved by
the fracture leaving a readily removable root or does the obstruction still
exist?
Theoretically, an elevator can be applied to any side of a straight root in
order to apply the necessary dislocating force. However, if a root is curved
the elevator must engage its convex aspect. If it is applied incorrectly to the
concave side of the root it will not displace it from the socket but will
produce a further fracture of the fragment (Fig. 3.2).
When dealing with multirooted teeth the roots of which all curve in the
same general direction, the elevator may be applied to the convex aspect of
the whole root complex. However, if the lines of withdrawal of the apices
conflict, because of a divergent or recurved root pattern, then the roots must
be separated before applying an elevator against the convex surface of each
in turn. Occasionally the application of an extraction force to unfavourable
roots in infected or resilient bone will result in successful delivery without
fracture, but in the vast majority of cases, the unorthodox approach will lead
to further fragmentation or to crushing of the socket wall and the formation
of a dry socket. Even in the absence of a suitable preoperative radiograph,
an experienced operator can often feel whether he is applying pressure to
the correct aspect of the root, for on sensing the slightest resistance he will
alter the position of the instrument so that the edge of the blade engages a
more appropriate side of the root. Nevertheless, it is obviously more
satisfactory to avoid guesswork, and obtain the relevant information about
root pattern from a radiograph. The elevating force should always be
modest and controlled as the application of excessive force will result in
further fractures of the tooth fragment or even a fracture of the jaw. A
fractured jaw is most likely to occur during the removal of deeply embedded
roots in a thin mandible.
There are times when, after adequate surgical exposure of the socket, a
systematic search for the root tip proves abortive. Alternative possibilities
for its location should then be considered, namely dislodgement into the soft
50
 THE REMOVAL OF ROOTS

tissues, deflection into the antrum from upper posterior teeth, displacement
into the inferior dental canal or lingual pouch from lower posterior teeth,
loss into the mouth or on to the surgery floor, aspiration up the surgical
sucker or ingestion or even inhalation. Some patients refuse to have a
retained root removed. When this happens the issue should not be pressed,
but an entry should be made in the case notes to this effect.

ay
 CHAPTER 4

UNERUPTED AND IMPACTED TEETH

The most common cause of failure for a tooth to erupt is a lack or loss of
space in the overlying alveolar arch. A discrepancy between tooth size and
jaw size is probably the result of a combination of both genetic and
environmental factors. The inheritance of large teeth in small jaws appears
to be aggravated by a lack of maximal jaw growth due to a softened
sophisticated diet which requires minimal chewing. These factors
particularly affect the 3rd molars and the canines. Sufficient space for the
second premolars to erupt, especially in the mandible, can be lost because
of the premature extraction of the overlying 2nd deciduous molar allowing
the Ist permanent molar to drift forwards.
Maxillary central incisors may be impeded by retained pulpless
deciduous incisors, or the presence of supernumeraries. Sometimes the
tooth may be damaged and have a dilacerate root. Natural or traumatic
displacement of the tooth germ will also lead to an impacted tooth. Less
common causes include impaction against odontomes or cysts, radio-
therapy, hypothyroidism and cleidocranial dysostosis.

THE IMPACTED MANDIBULAR THIRD MOLAR

Successful 3rd molar surgery is dependent upon detailed preoperative
assessment and treatment planning and the skilful application of an
appropriate operative technique.

The Clinical Examination

A conscious assessment of the general size and build of the patient should
be made. A large patient with a massive mandible presents a different
problem from a small, delicately boned person. The patient’s attitude and
demeanour is important and may give valuable clues as to the way he or she
will respond to the stress of surgery and therefore the type of anaesthesia
and/or sedation which will be required. In the context of any operative
procedure, age and general fitness are important, but undoubtedly
increasing age adds to the difficulty of the removal of lower 3rd molars.
Compared with a teenager the young adult in the late twenties will already
have bone which is significantly more difficult to cut and teeth which require
more force to separate them from the bone. At a variable age between the
early forties and late sixties the mandibular bone will develop a hard, brittle
quality and the attachment of the teeth a rigidity which succumbs to an

a2
 UNERUPTED AND IMPACTED TEETH

extraction force only after a substantial amount of investing bone has been
removed. The presence of facial swelling and enlarged, tender, lymph nodes
of course indicates the presence of active infection and used to preclude an
operation until it had been treated. However, with antibiotic cover, post-
operative morbidity in such cases is not increased.
The size of the oral cavity, the size of the tongue, the degree to which the
patient can open his or her mouth, the size of the rima oris and the
extensibility of the lips and cheeks all contribute to surgical access. A
general inspection of the mouth reveals much about the patient’s oral
hygiene habits, the general state of the dentition, and the degree to which it
has required previous dental care. The health of the 1st and 2nd molars may
affect the decision to remove the wisdom teeth. Large crowns, inlays or
amalgams in 2nd molars can be dislodged during elevation of the wisdom
tooth even when care is being exercised. Teeth which are loose due to
advanced periodontal disease and crowns on anterior teeth should be
mentioned to the anaesthetist if a general anaesthetic is required.
Attention is then focused on each 3rd molar in turn, observing how much
of the crown is visible, or palpable if it is unerupted. Partially erupted teeth
should be explored with a probe to determine which is the occlusal surface
(which feels rough) and which a mesial or distal surface (which will feel
smooth) for at times it is not easy to differentiate horizontal, vertical and
disto-angular impactions by inspection alone. If no part of the 3rd molar
crown is visible, the gingival crevice distal to the 2nd molar should be
explored with a periodontal probe to see if there is a pocket leading down to
the crown of the 3rd molar. The depth of any visible crown below the
occlusal plane and its general relation to the level of the alveolar crest is
noted, as is the distance between the distal surface of the 2nd molar and the
anterior border of the ascending ramus. The external and internal oblique
ridges of the mandible are palpated. If the external oblique ridge is low,
relatively vertical and relatively posterior to the tooth there will be thin
alveolar bone buccal to the 3rd molar. If the external oblique ridge lies high
and well forward relative to the tooth the thick cortex of the ridge will form
the bone buccal to the 3rd molar. Similarly if the internal oblique ridge lies
well back there will be thin bone both distally and lingually to the wisdom
tooth and conversely an anteriorly placed internal oblique ridge carries
thick bone around the 3rd molar on the lingual side.
The condition of the soft tissues over the wisdom itself is noted. Are they
scarred and indented by the upper 3rd molar? Is there active pericoronitis
present, or pus beneath the gum flap? Both conditions require treatment and
there may be a delay before operation. A non-tender flap from beneath
which a whitish, creamy material resulting from desquamated follicular
epithelium can be milked is not a contraindication to surgery provided the
flap is cleaned preoperatively with a sucker and povidone iodine or other
suitable antiseptic introduced under it. Of importance to the future health of
the gingivae around the lower 2nd molar is the relationship of the
53
 ORAL SURGERY, PART 1
masticatory mucoperiosteum to that tooth. If there is a broad zone of
gingival mucoperiosteum buccal to the 2nd molar which extends distally
there are good prospects that there will be a normal gingival margin around
the distal aspect after the 3rd molar wound has healed. What is more, there
will be a sufficient buccal sulcus to permit ready cleansing of the gingival
margin and buccal aspect of the crown of the 2nd molar. If on the other hand
the gingival mucoperiosteum tapers to an end buccal to the 2nd molar then
inevitably the gingival margin around the distal aspect of that tooth will be
composed of mobile sulcus mucoperiosteum. Tearing of the gingival
crevice will be a frequent occurrence and periodontal pocketing most likely
to develop as the years go by. Furthermore there will be at most a shallow
sulcus, lateral to the 2nd molar and cleansing of the buccal aspect will be
difficult. In extreme cases the mucosa will ascend vertically over the
buccinator muscle from the distal aspect of the 2nd molar.
The position and condition of the upper 3rd molar is checked and its
occlusal relationships to the lower 3rd and 2nd molars noted. If the tooth is
in a position which makes it difficult to keep clean, if it is already carious, if
it does not, and will not, occlude with a tooth which is to be retained, and
particularly if it is over-erupted, it should be extracted. Indeed if it bites on
the gum flap of the lower 3rd molar its extraction may cut short an attack of
pericoronitis permitting more latitude in the timing of lower 3rd molar
surgery. Lastly, consideration should be given to its possible future use as a
denture or bridge abutment.
If the lower 3rd molar on one side is considered for extraction the other
side also should be examined, particularly if it is likely that the operation
will be carried out under a general anaesthetic. Finally the related lymph
nodes should be palpated to determine the extent of any infection.

The Radiographic Examination

Periapical radiographs are taken whenever possible because the detail
which they reveal is better than with any other technique and of course most
of the surgical difficulties are to be seen in a lateral view of the tooth and its
related anatomy. The film should be positioned with care. In general the
mesial edge of the film should not lie further forward than the mesial surface
of the Ist molar for vertical, mesio-angular and disto-angular impactions.
For horizontal teeth the mesial edge should not lie further forward than the
middle of the first molar, but the film can be rotated so that the long lower
edge slopes upwards towards the back, parallel to the mylohyoid ridge. This
way a horizontal tooth will lie in the diagonal axis of the film.
An occlusal film should be taken for all difficult teeth and particularly
where the tooth is completely unerupted so as to complete the two views at
right angles necessary for an understanding of the problem in three
dimensions. The occlusal view will provide an alternative view to the
periapical film of the roots of horizontal teeth, particularly where the
presence of a third root is suspected. It is essential for buccolingually placed

54
 UNERUPTED AND IMPACTED TEETH

teeth to identify which way the crown is pointing and to show the shape of
the roots. It is helpful to show the thickness of the lingual alveolar plate
where the 3rd molar is buccally displaced.
Rotational tomographic films have largely displaced oblique lateral jaw
views because they provide a lateral rather than an oblique view and are less
subject to misinterpretation. However, like the oblique lateral jaw view,
rotational tomograms lack much of the valuable detail to be seen in a
periapical film. They are taken particularly:
a. Where good periapical films are not possible because of difficult
access for positioning the film, or where the patient will not tolerate a
periapical film even with the application of a topical anaesthetic.
b. Where the tooth is so far from its normal position that it cannot be
projected on to a periapical film in the mouth.
c. Where there is an associated pathological process larger than can be
demonstrated on one periapical film, such as a cyst or tumour, infected
bone, multiple impacted teeth or a fracture.
d. Where the jaw is thin, or weak, or where the 3rd molar is close to the
lower border.
e. Where the position and relationship of the upper 3rd molar cannot be
judged adequately by clinical examination.
jf. To exclude latent disease elsewhere in the jaws.

Radiological Assessment
Assessment in relation to the surgical removal of lower 3rd molars means
estimating how much work will need to be done at the operation and what
technical difficulties will need to be overcome. When the results of the
radiological assessment are added to those of the clinical assessment the
operator should have a clear idea of the problems to be faced and the
sequence and extent of the surgical procedures necessary to remove the
tooth. All facets of the proposed operation should be mentally anticipated.
The following features should be considered.

1. The Orientation of the Tooth

Lower 3rd molars may be mesio-angularly, vertically or disto-angularly
inclined, horizontal or ectopic. Horizontal teeth may lie at various depths
such as with the crown opposite the crown, or the neck, or the roots of the
2nd molar. Most are orientated in line with the dental arch with the crown
forwards but some lie transverse to the arch. Whether the crown faces
lingually or buccally should be determined by an occlusal radiograph.
Ectopic teeth may be found in many unusual situations from the coronoid
notch to the lower border of the ramus. The basic extraction movements are
determined by the orientation of the tooth, but may be modified by tooth
depth, root formation and bone density.
JIS
 ORAL SURGERY PART s

Mesio-angular teeth are first tilted distally by mesial elevation until the
mesial surface of the 3rd molar is inclined upwards to clear the distal aspect
of the 2nd. Buccal elevation is then applied to drive the tooth upwards,
forward and lingually out of the socket.
Horizontally impacted teeth which are mesially facing are moved in a
similar fashion except that the initial upwards and distal tilting movement
needs to rotate the tooth through a greater angle. Where the lingual plate has
been split off by the split bone technique, after mesial elevation to loosen the
tooth, it is rolled out lingually by buccal application of an elevator. This
technique can be applied to both mesio-angular and_ horizontal
impactions.
Buccolingually orientated teeth are not difficult to uncover on their
superior and buccal aspects. The problem often is to find a point of
application for an elevator with a satisfactory fulcrum. It may be necessary
to remove bone from around the tooth until a curved elevator can be
introduced under the crown to raise the tooth from its socket.
Vertically orientated teeth require only slight distal tilting to release
frictional contact with the 2nd molar followed by an upwards and lingual
extraction movement produced by buccal elevation, provided the investing
bone has been adequately removed of course to permit such movements.
Disto-angularly impacted teeth are first tilted distally by elevation
applied to the mesial surface to release frictional contact with the 2nd molar
as before. However, the mesial bulbosity of the 3rd molar must be displaced
backwards and then upwards from under the convex distal surface of the
2nd molar in those cases where the impacted tooth lies below the general
level of the occlusal plane. The second movement again results from buccal
application of an elevator, but with the fulcrum of the elevator opposite the
distal cusp of the 3rd molar. The crown of the 3rd molar is raised upwards
and forwards so that the slope of the crown below the mesial contact point of
the 3rd molar slides over the distal contact point of the 2nd molar. Further
consideration will be given to the primary disimpacting and extracting tooth
movements in relation to root shape and provision for a path of
removal.

2. The Depth of the Tooth

An assessment of the depth ofthe tooth indicates the amount of bone which
must be removed to uncover the tooth. Depth is measured first from the
alveolar crest to the level of the greatest diameter of the crown, and
secondly from the neck of the tooth to the greatest diameter of the root if the
latter is bulbous. The level ofthe crest of the alveolar bone is indicated by a
line which joins the surface of the retromolar fossa to the crest of the
interdental septum, between the 2nd and Ist molars in a gentle, concave
curve. The crest of the retromolar bone is marked in a periapical radiograph
by the apex of the triangle between the bone surface and the top of the
follicular space distal to the crown. Bone is usually removed to uncover the

56
 UNERUPTED AND IMPACTED TEETH

tooth completely to just below the greatest diameter of the crown and the
socket widened by a guttering process down to the greatest diameter of a
bulbous root.

3. The Degree of Impaction of the Tooth

This together with root shape indicates whether tooth division is optional as
a means of facilitating the extraction of the tooth and so reducing bone
removal, or whether it is obligatory.
Disto-angular and vertical teeth are usually impacted against the soft
tissues and bone only. The soft tissues are simply incised to permit a
favourably impacted tooth to be delivered. The major problem is usually
access distolingual to impacting bone which has to be removed to free the
greatest diameter of the crown.
Mesio-angular and mesially facing horizontal teeth are impacted against
the 2nd molar. In general such teeth must be tilted upwards, rotating them
about a point close to the apex of a single-rooted tooth or the distal apex of a
two-rooted tooth until the mesial surface of the 3rd molar will clear the
crown of the 2nd as it is ejected from its socket. To test whether this can be
permitted by bone removal alone a line is drawn from the apex of the distal
root of the 3rd molar to the tip of itsmesial cusp. With this line as radius an
arc ofa circle is described. If this passes clear of the image of the crown of
the 2nd molar elevation after simple bone removal is likely to be successful.
If the arc cuts the image of the crown of the 2nd molar, tooth division will be
essential if this mode of elevation is used.
With the split bone technique a varying amount of distal and lingual bone
is split away. Elevation of the tooth is by application of force to the cervical
enamel just under the crown of the tooth and from the buccal side. The tooth
rotates about the apices and is displaced lingually and upwards. If a good
occlusal radiograph can be obtained the likely success of this manoeuvre
can be tested because this time the radius of the arc of movement joins the
lingual edge of the distal root apex to the tip of the mesiobuccal cusp. If the
mesiobuccal cusp will clear the tooth in front as the tooth rotates lingually,
simple elevation will be successful; if not tooth division will be required.
The types of tooth division will be considered under surgical technique.

4. Root Shape
This may be either favourable or unfavourable. Roots may be unfavourable
in that their curvature opposes the initial distal tilting movement which most
impacted teeth require. If either one or both roots curve mesially this distal
tilting is prevented. Bulbous roots are obviously unfavourable and the
socket must be widened down to the bulbosity to permit the root’s
extraction. On the other hand, the bone around large bulbous roots may be
thin, particularly lingually, and easily split away. Conversely, thin spindly
roots, especially those of three-rooted teeth, are often in thick bone and
easily fractured. Where there are two or more roots they may either
ea
 ORAL ‘SURGERY SPART Si

converge or diverge, locking the tooth into the bone and this again is
unfavourable and often demands tooth division.

5. Bone Removal to Form a Path of Elevation

Bone has to be removed to provide space into which the tooth can be tilted in
preparation for the application of a force dislocating it from the socket. This
is usually space distal to the tooth. The tooth is mentally tilted in this
fashion in relation to the radiographic image so that the amount of bone
which must be removed can be judged. If the roots of the tooth curve distally
the initial tilting movement is favoured, but this root curvature may now
oppose an upwards movement with a lingual and forward component such
as follows buccal elevation. When the upwards extracting movement still
has distal component imposed upon it by the root shape, further bone
removal distal to the tooth will be required or tooth division. The
relationship of the mandibular canal as it curves downwards through the
bone to the site of distal bone removal should be noted to avoid damage to
the nerve if a substantial amount of distal bone is to be removed.

6. Bone Removal to Permit Application of Elevators

Usually a channel must be created down to the follicular space beneath the
mesial surface of the crown, at the amelo-cemental junction. Ifthe follicular
space is narrow it must be widened to accommodate the elevator blade. The
relationship of the elevator’s point of access on the mesial surface of the
tooth to the inferior dental canal should be considered, particularly in the
case of horizontal teeth.
Another common point of application is buccally at the bifurcation of a
two-rooted tooth or under the buccal bulbosity of the crown of a single-
rooted one. Normally a deep pit is driven down to the point of application so
as to leave a shoulder of buccal bone at a higher level which will form the
fulcrum for the elevating movement.

7. Bone Density
This affects the ease with which bone may be removed. It may be assessed
by noticing the thickness and number of the medullary trabeculae. The
thickness of the mandibular cortex at the lower border will also give some
indication of the density to be expected in the external oblique ridge, as will
the relative radiopacity of the latter in a periapical film, given a standard
exposure. Bone in negroes and patients brought up in tropical areas with
high levels of fluoride in the drinking water also tends to be harder to
cut.

8. The Relationship to the Inferior Dental Canal

This has been touched upon during the discussion of bone removal.
Consideration must also be given to its relationship to the roots of the 3rd
molar. If the canal is below the apex it is not at risk. If it is at the apex it may

58
 UNERUPTED AND IMPACTED TEETH

be damaged by mesially applied elevation which forces the apex down if

bone removal has been inadequate. This is particularly true if the apex is
bifid and grooved by the neurovascular bundle. Splitting the tooth
longitudinally with an osteotome also may ‘concuss’ the nerve and produce
a neuropraxia.
If the nerve is above the level of the apex it is usually buccal to the root
unless the crown is lingually inclined so that the root lies buccally. A
buccally placed nerve is at risk from buccal bone removal particularly
during the formation of a point of application for an elevator or by a lingual
extraction movement of the crown which forces the root laterally.
Conversely, buccal movement of the crown may force the root against a
lingually situated nerve. It is of course neurovascular bundles which either
deeply groove or penetrate one or both roots which are most at risk. A
marked radiolucency of the image of the canal where it crosses the root
implies loss of dentine at that point. If the white lines which mark the upper
and lower boundary of the canal are also missing as the canal crosses the
tooth this too implies grooving and often deep grooving or perforation of the
root because the greatest diameter of the canal is involved. The same may
be predicted if the image of the root is narrowed where it crosses the
canal.
Equally disturbing is narrowing of the image of the canal at this point.
Another feature which suggests either deep grooving or perforation of the
root is when the canal is looped upwards by the tooth. The implication is
that the neurovascular bundle has been pulled upwards at that point as the
tooth has attempted to erupt. In some instances the neurovascular bundle is
embraced between the mesial root and an additional lingual root, which are
fused at the apices. Because there is no reduction in thickness of the roots
there will be no radiolucent mark and no radiographic evidence of the
complication.

To Remove or Not to Remove

The first consideration is whether the 3rd molar has been, or is currently,
involved in a disease process. Pericoronitis or food packing between the
crown of the impacted tooth and the 2nd molar with the sequel of caries of
either one or both of these teeth is common in young adults. In later life
caries, periodontal disease or suppuration around a buried wisdom tooth
are the more frequent states of affairs. Sometimes orthodontists want the
3rd molars removed if they feel that during their eruption imbrication ofthe
anterior teeth will reappear. However, a causal relationship between incisor
imbrication and 3rd molar eruption has never been firmly established.
Occasionally there arises a late follicular or keratocyst. More rarely there
may be an ameloblastoma present, but then the problem is not just the
removal of the impacted 3rd molar but the excision of the neoplasm. The
involvement of the 3rd molar by any disease is a clear indication for its
surgical removal.
59
 ORAL SURGERY, PART 1

The more difficult decision involves the prophylactic removal of

impacted mandibular 3rd molars. The reasons for removal of these teeth in
late adolescence or early adult life is because the surgery involved is
significantly easier at that time. In the past, in pre-antibiotic days of course,
a spreading infection from a lower 3rd molar was not infrequently life
threatening. This provided a strong incentive for the prophylactic removal
of lower wisdom teeth. Prompt treatment with antibiotics has reduced the
severity of these infections and a life threatening situation is now rare and
the removal of symptomless lower 3rd molars for the younger patient is
largely a matter of convenience. The surgery may be undertaken by choice
at a time when there is the least disturbance to either study or career.
Pericoronitis is undoubtedly relatively common in teenagers and young
adults so that the argument that the removal of partly erupted wisdom teeth
will avoid this problem is valid. If the patient has reached the late twenties
but has not experienced an attack, the chances that he or she will do so seem
substantially reduced. Caries and periodontal pocketing, particularly
affecting the 2nd molar, remain a risk, but fresh specific indications for the
extraction of impacted wisdom teeth tend not to arise unless and until the
other cheek teeth have been lost and the patient becomes a denture wearer.
Then resorption of alveolar bone uncovers previously buried teeth and
makes partly erupted ones more prominent. If they are covered by a
denture, suppurative pericoronal infection or gross caries is common. The
prospect that this might happen with the likelihood of tedious, lengthy
surgery in an elderly patient is another reason for the prophylactic removal
of these teeth. If they are still present such teeth must be removed when the
other posterior teeth in that quadrant are extracted. On the other hand there
is a natural reluctance for patients to agree to surgery to deal with a
condition which is not troubling them. Furthermore, the dental surgeon
must balance the possible advantages of prophylactic surgery against the
discomforts which the patient will suffer and the possible risks of
complications.

Surgical Technique—General Considerations

For general anaesthesia the patients require preoperative medical assess-
ment as to their suitability for this type of anaesthesia and at least a
haemoglobin estimation and urinalysis. Other investigations such as a chest
X-ray and sickle test, etc., will also be considered. Day-stay general
anaesthesia is only appropriate for straightforward surgery with minimal
anticipated morbidity and good social circumstances for immediate after-
care.
It is normal to remove the teeth on one side at a time under local
anaesthesia but in suitable patients, experienced operators can remove all
four wisdom teeth during the same session, especially if intravenous
sedation is employed. Without sedation around 45 minutes of surgery
under local anaesthesia is as much as most patients find tolerable. One and

60
 UNERUPTED AND IMPACTED TEETH

a half cartridges (3 ml) of 3 per cent prilocaine with 0-03 i.u. felypressin
should be used for each mandibular molar. Use of this solution permits
better post-surgery clot formation and is not followed by reactionary
haemorrhage as vasoconstriction wears off.
The lips, all retractors and the shanks of elevators should be lubricated
with vaseline gel to prevent abrasion. Some operators have a preference for
1 per cent hydrocortisone cream. In general the operator stands on the right
of the patient to remove the teeth on the right side and on the left to remove
the ones on the left side. The soft tissues are stretched up over the anterior
border of the ascending ramus and the incision started behind the 3rd molar
and out towards the external oblique ridge. As the 3rd molar alveolar
process overhangs the submandibular fossa, medial to the line of the ramus
of the mandible, the incision line does not run straight backwards from the
2nd molar but is deflected laterally over the bone towards the external
oblique ridge. The scalpel divides only mucosa and sub-mucosa at the
commencement of the incision but cuts down onto bone distal to the
position of the 3rd molar. The incision is then carried forward to the 2nd
molar, over the crown of the wisdom tooth and through the gum flap. The
interdental papilla distal to the 2nd molar is divided, then the incision is
carried round the gingival margin of the 2nd molar up to the mesial cusp on
the buccal side and down towards the sulcus through attached gingiva only.
For a deeply buried tooth the papilla mesial to the second also is included in
the flap.
A right-handed operator finds it more comfortable to make the incision
from behind forward on the right side and from before backwards on the left.
Where the 3rd molar is partly erupted the incision is made in two parts, the
line of the incision being broken by the opening in the gum flap.
A periosteal elevator is inserted in the mesial relieving incision down to
bone and the flap reflected distally to include the papilla between the 2nd
and 3rd molars. By lifting the mucoperiosteum in a tunnel lateral to the 3rd
molar the attachment of the follicle to the underside of the flap edge is
displayed and cut with scalpel or scissors following which elevation of the
buccal flap can be completed. The attachments of the underside of the
lingual flap to the follicular or gubernacular tissues over the crown ofthe 3rd
molar and at its distal margin are divided with a scalpel, being cautious not
to pass the blade too far lingually.
Where relatively little bone needs to be removed the anterior vertical
relieving incision is omitted and an envelope flap reflected (Fig. 4.1).
Although it is not so easy to insert the periosteal elevator under the
periosteum and reflect the buccal tissues, closure of the wound is easier and
soft tissue healing more rapid.
A periosteal elevator is next introduced under the lingual flap, just behind
the 3rd molar and the periosteum raised first in a distal direction until the
firm attachment of the pterygomandibular ligament has been released.
Elevation continues from this point lingually being particularly careful to
61
 ORAL SURGERY, PART 1

Fig. 4.1. The upper diagram shows an envelope flap incision for [8. Depending
upon the depth it may be finished at one or other of the two arrows anteriorly.
The lower diagram shows the incisions for two-sided flaps. Either a short or a
long relieving incision may be used, again depending upon the depth.

keep between the periosteum and the bone until the instrument tip drops
over the internal oblique ridge. The tissues will then strip forwards to raise
the whole lingual flap. This stripping movement should be performed firmly
but carefully or the lingual nerve will be bruised. Retractors are placed to
hold back both buccal and lingual flaps and, on the lingual side, positioned
subperiostally to protect the lingual nerve.
Bone may be removed with either burs or chisels. Burs rather than chisels
should be used when the patient is receiving a local anaesthetic with or
without sedation or in older patients with brittle bone and at any age where
the external and internal oblique ridges lie forward so that the investing
bone is thick.
Bone removal is commenced with a No. 10 rose-head bur and starting at
the distolingual corner, being careful of course to keep a retractor between
the bur and the lingual nerve. The distal bone is removed next, being sure to
cut right up to the surface of the distal root. Bone removal is continued on
the buccal side, developing the cut into a semicircular trough and deepening

62
 UNERUPTED AND IMPACTED TEETH

it with a No. 6 rose-head down to the bifurcation of the roots laterally, and
mesially to provide an application point for an elevator.
In general chisels may be used where the patient is young and the bone
has a distinct grain, provided both internal and external oblique ridges lie
well back so that the investing bone is thin.
When chisels are used the order of the procedure depends upon the
amount of 3rd molar crown which is visible. If there is a substantial amount
of bone covering the wisdom tooth so that the position of the distal aspect of
the crown is not visible, bone is removed first on the buccal side. If the
occlusal surface of the 3rd molar is clearly seen the lingual split is
performed first.
The removal of buccal bone proceeds as follows (Fig. 4.2). Two vertical
stop cuts are established, one at the mesial limit of bone removal which is
made right into the follicular space, and the other at the distal limit, which is
made to a similar depth, but because of its position may not end in the
follicular space. The vertical extent of the anterior cut is usually 7 mm and
therefore a5 mm chisel is chosen. The bevel faces distally towards the bone
which is to be removed. The 5 mm chisel is then rotated through 90° and a
corner of the blade is engaged in the lower end of the anterior cut to start a
third cut, joining the previous two. The bevel faces upwards and the shaft of
the chisel is at 45° to the buccal side of the body of the mandible. As the
chisel is tapped in it is also moved distally and the buccal bone split away
from the anterior stop cut backwards. A crack will propagate backwards,
ahead of the chisel edge. As soon as the split reaches the posterior stop cut
the chisel is turned over, so that the bevel faces downwards and backwards.
By rotating the chisel about its long axis and swinging the handle laterally
the cut can be continued into the stop cut and across the back of the tooth.
These cuts expose the crown of the tooth.
In preparation for the removal of the lingual plate both lingual and buccal
retractors are adjusted to expose the bone distal to the 3rd molar. A chisel is
placed so that its edge lies just to the lingual of the lateral ridge outlining the
retromolar triangle of bone. The bevel of the chisel faces lingually and the
edge lies diagonally across the jaw from the distobuccal corner of the 3rd
molar to the lingual side 3-4 mm more posterior. The posterior corner of the
blade should just reach the lingual surface. By increasing the angulation of
the chisel the depth of the cut will be increased, and therefore the amount of
lingual plate which will split away. The assistant must ensure that the
lingual tissues and particularly the lingual nerve are adequately protected.
The chisel is tapped into the bone across the back of the wisdom tooth
cutting off the bone which forms the posterior rim to the two-sided balcony
of bone which contains the tooth. When the blade is just short of the lingual
side the lingual plate will often split off and move lingually. If not a twist of
the chisel will complete the split. The actual edge of the chisel should not
penetrate right through to the lingual side.
At this point the lingual plate will be hinging on the anterior end, where
63
 ORAL SURGERY, PART 1

Fig. 4.2. The split lingual bone technique for

removal of lower 3rd molars. a,
After surgical exposure of the site anterior and
posterior vertical stop cuts are
made. These are joined by a horizontal cut
which removes the buccal bone. b,
The chisel is positioned parallel to the externa
l oblique ridge (dashed line), just
to the lingual of the buccal side of the retromo
lar triangle and driven through the
bone to separate off the lingual plate. c,
The lingual plate is levered up and
removed. A straight elevator is tilting the
tooth distally and lingually. d, An
elevator applied buccally delivers the tooth.

64
 UNERUPTED AND IMPACTED TEETH

the bone is thinned by the mesial root of the 3rd molar or the bulbosity of a
horizontal tooth’s crown. A curved Warwick James’ elevator is inserted
into the split and the plate levered upwards, disrupting the hinge. With great
care the separated plate is withdrawn with toothed Fickling’s forceps,
protecting the lingual tissues as the curved, thin, knife-like posterior margin
is brought out of the wound. The blade of the curved elevator is passed
under the origin of the mylohyoid muscle from the lingual aspect of the piece
of bone and the muscle detached, freeing the lingual plate completely.
Removal of this piece of bone should expose both the distal and the lingual
side of the tooth. Some vertical or disto-angular teeth are surrounded by a
wide saucer of bone on the lingual edge which cannot be visualised or split
off until the crown has been removed. Occasionally a large section of
lingual plate and cortex may be split off running back towards the lingula. If
it is possible to elevate the tooth without removal of this large piece of bone,
it should be left attached to the soft tissues and allowed to heal. Failure to
position the chisel at 45° across the long axis of the jaw is one cause of this
occurrence.
Now it may be necessary to remove V-shaped wedges of bone mesio-
buccally with a narrow 3 mm chisel to provide access for elevators. Often
the use of chisels and burs can be combined to provide for the most effective
removal of investing bone. One contraindication to the use of the split bone
technique even in young patients is the presence of a very thick lingual plate
beside a buccally inclined tooth. With adequate reflection of the soft tissues
the situation will be obvious and the bone should be removed with a No. 4 or
6 rose-head bur.
The basic extraction movements depend upon the orientation of the tooth
and were considered during assessment. The indications for tooth division
have also been discussed. Splitting off the distal third of the crown with an
osteotome will often permit a disto-angular tooth with distally curving roots
to be removed without excessive bone removal (Fig. 4.3). Splitting off the
mesial third will not disimpact a mesio-angular tooth as the fragments tend
to impact together and the smaller fragment, being wedge-shaped, cannot
be removed first (Fig. 4.4).
If a two-rooted tooth is eased a little in its socket it may be split
longitudinally between the roots. Provided the root shape is favourable the
two fragments may be elevated separately, freeing a tooth which is
impacted in a mesio-angular or horizontal position. Splitting a tooth
requires a sharp rather than a hard blow with a mallet and a high quality
hard steel or tungsten carbide edged osteotome. For the inexperienced,
division with a fissure bur avoids the risk of a fractured jaw.
If only the distal root shape is unfavourable the tooth may be delivered by
inserting a tapered tungsten carbide fissure bur into the bifurcation, cutting
upwards a little and then distally to separate the distal root. A tap with an
osteotome across the transverse fissure of the crown will split off the distal
half of the crown so that the mesial half of the tooth can be tumbled over the
65
 ORAL SURGERY. PART 1

Fig. 4.3. Removal of a disto-angular 3rd molar. a, The crown is uncovered and
the distal part split off with an osteotome. b, This permits access to the distal
bone, previously hidden by the bulbous distal part of the crown. Sufficient distal
bone is removed to permit tilting of the 3rd molar. The bone between the
recurved roots is drilled away. c, A straight elevator is applied mesially to tilt the
3rd molar clear of the 2nd. d, Buccal application of an elevator drives the tooth
upwards and forwards out of the socket.

Tas JOR Se
rn
(6

Fig. 4.4. Removal of mesio-angular Ig. a, Bone is removed below the greatest
diameter of the crown and below the mesial convexity to make a point of
application for a straight elevator. b, Bone is removed distally to permit the tooth
to be tilted through a sufficient angle to clear{7. c, It is elevated distally and then
upwards first by mesial application of a straight Warwick James’ elevator and
then buccal application of a curved one.

66
 UNERUPTED AND IMPACTED TEETH

pees

Fig. 4.5. Removal of a mesio-angular 3rd molar with recurved roots by section
of the distal root.

distal root (Fig. 4.5). It is usually a simple matter to elevate the remaining
distal root forward into the empty space created by the removal of the
crown.
Dividing the tooth in its long axis between the roots will disimpact a mild
mesio-angular or horizontal impacted wisdom because after the removal of
the distal portion the centre of rotation of the mesial half of the crown is
altered (Fig. 4.6). The mesial cusp now describes an arc around the mesial
root apex and often will move clear of the tooth in front.
If the degree of tooth impaction is severe or if both roots are curved
unfavourably the whole crown must be removed and the roots separated at
the bifurcation with a bur (Fig. 4.7). This is particularly important if tooth
fragments wedge together as soon as elevation is attempted due to the root
curvature.
Tungsten carbide tapering fissure burs in an air drill are best for the
separation of whole crowns. The cut should be made through the thin
cervical enamel, but at a level that will leave enough of the cervix for the
application of elevators. The cut should gradually approach a little closer to
the occlusal surface as it travels towards the lower aspect of the impacted
tooth. This will avoid the creation of a fragment which cannot be levered out
of the space. The cut should provide sufficient space that the occlusal
fragment can be collapsed backwards away from contact with the 2nd
molar. In making this cut if the bur penetrates completely through to the
lingual side of the crown it may also penetrate the lingual plate as the lower
part of the cut is made, putting the lingual nerve at risk unless it is well
protected by a Howarth periosteal elevator. If the bur emerges completely
at the bottom end of the cut and is not controlled as the softer bone is entered
67
 KE He
ORAL SURGERY, PART 1

GE x6
Fig. 4.6. Removal of a horizontal 3rd molar. a, Bone is removed to expose the
crown. With later mesial elevation it would rotate about the distal apex, but the
mesial cusp would not clear the distal surface of |7. b, The tooth is divided
longitudinally between the roots. The angle needed to tilt the distal half clear of
the 2nd molar is determined and appropriate bone removed distally. c, The
distal half is elevated out. d, The mesial half will now rotate about the mesial
apex and clear the distal surface of |7.

the distal root of the 2nd molar or the inferior dental nerve may be
damaged.
On the other hand, if the cut does not penetrate to these surfaces and the
crown is cracked off a wedge of enamel may split away from the neck of the
tooth with the crown, so locking it in place. These problems can be avoided
by splitting off the top half of the sectioned crown with an osteotome placed
against the buccal aspect of the transverse fissure after two-thirds of the cut
has been made. Then the remaining part can be cut through with better
visibility.
Socket toilet should follow the completion of the extraction. The socket is
irrigated with sterile normal saline, taking particular care to aspirate away
all bone and tooth debris from beneath the periosteum under the buccal flap
and the cut surface of the cancellous bone. If bone or tooth debris is left in
the crevice between the periosteum and the buccal bone an abscess will
form there three to four weeks later, perhaps with a sinus in the buccal
sulcus and exuberant granulation tissue. Any sharp points or edges to the
socket especially on the lingual side should be nibbled smooth with bone
nibblers. If they are left they may penetrate the flap and irritate the patient’s
tongue until sequestrated.
68
 UNERUPTED AND IMPACTED TEETH

1 TY Fig. 4.7. Removal of a deep, horizontal 3rd molar. a, The crown is uncovered
and a mesial application point for an elevator established, clear of the
mandibular nerve. b, The crown is partly divided and the distal half split off and
removed. c, This gives better access and visibility for the section of the mesial
half of the crown. Create a wedge, narrow below, so that the fragments can be
elevated out. d, The roots are separated and elevated out one at a time.

Suture of the flap requires some care and should be delayed until all
bleeding is controlled. An envelope flap simply requires a suture between
buccal and lingual flaps distal to the 2nd molar. A two-sided flap ending
midway along the 2nd molar can be closed in a similar fashion, but the
suture should penetrate the lingual flap close behind the 2nd molar and the
buccal flap further distally. This is because the buccal flap retracts distally.
Special note should be taken of the collar of gingival margin which fits
against the distobuccal corner of the 2nd molar. It is easy to pick this up by
mistake and suture it across the 3rd molar socket depriving the 2nd molar of
the masticatory mucosa which should form the gingival margin at this point.
Where the flap extends to the papilla between the Ist and 2nd molar both
this and the sulcus incision will need suturing to retain the flap in place. If
the wound can be closed with a single stitch any ooze will leak out from the
buccal sulcus incision. Tight suturing prevents the drainage of ooze which
then finds its way into the buccal space creating a haematoma. The loop of
the stitch should be large enough to facilitate its removal. Sutures should be
removed at around seven days postoperatively.
69
 ORALASURGERY sek ARIS

Complications
Some degree of pain and swelling is normal and the natural consequence of
the surgery required to remove the 3rd molar. The more extensive the
surgery the more the discomfort. A gentle surgical technique, gentle soft
tissue retraction, care in selecting the method of bone removal, the use of
sharp burs and chisels and the use of elevators with minimum force and only
after proper disimpaction of the tooth or tooth fragments will minimise both
swelling and postoperative discomfort. The use of substantial force to
elevate a tooth crushes the bone of the fulcrum which can lead to
postoperative pain and may be a factor in the production of a dry socket.
While a careful surgical technique and the use of prophylactic antibiotics
reduces the incidence of dry socket following the excision of impacted third
molars they do not eliminate the complication, even where the extraction
has not been unduly difficult. Sympathetic treatment is required.
Some operators favour the use of 10 mg of dexamethasone intravenously
with the anaesthetic induction agent (or orally if using local analgesia)
followed by 10 mg the following day. This will reduce the swelling and pain
but not trismus without any impaired healing or other complications and
may be appropriate where substantial swelling is anticipated. Doses of
10 mg of dexamethasone produce a temporary suppression of circulating
cortisol which recovers within three days. However, again no complica-
tions have been noted (Al Haag et al., 1985). The same trial showed 15
minutes of ultrasound immediately and 24 hours postoperatively to be
almost as effective in the reduction of postoperative morbidity.
Anaesthesia of either the lingual, mylohyoid or the inferior dental nerves
is another common complication. Often the anaesthesia is due to
neuropraxia and lasts only a few days to a few weeks.
There are a number of ways in which these nerves are at risk. Attention to
the details of surgical technique will help to reduce the incidence of more
lasting damage.
The lingual nerve is at risk:

a. From a periosteal elevator raising the lingual flap: the flap is often
tough and patience combined with division of the attachment of the follicle
to the underside of the flap will reduce the force used and the risk of bruising
the nerve.
b. From lingual flap retractors: prolonged retraction of the lingual nerve
with the other lingual tissues results in a neuropraxia even while it protects
the nerve from more serious damage. Care must be taken to see that the
retractor is between the nerve and the bone. It is easy to insert the retractor
too far lingually and not under the periosteum.
c. From instruments used to both cut and grasp the lingual bone and from
the lingual plate itself if the split bone technique is used.
d. From a suture which may under-run the nerve if a large bite of lingual
flap is taken.

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 UNERUPTED AND IMPACTED TEETH

The inferior dental nerve is at risk:

a. During the removal of distal bone, particularly for deep disto-angular
teeth.
b. During division of the crown of a horizontal tooth, particularly if it lies
low in the jaw.
c. During the splitting of a tooth with an osteotome if the nerve is in
contact with the root of the tooth.
d. During the mesial application of an elevator for a mesio-angular tooth
where the nerve lies at the apex.
e. Where the nerve grooves or perforates the root of the tooth the risk of
crushing or dividing the nerve is high. If the risk is anticipated it can be
reduced by careful surgery but not eliminated.
A suppurative infection of the socket with localised osteomyelitis or
fracture of the mandible, particularly where a deeply placed tooth has been
tackled, are rare complications which arise from time to time.
Fracture may occur during removal of a deeply buried tooth or later when
the patient starts to chew again. In the former case immobilization is
recommended, if necessary with the addition of a transosseous wire. With
late undisplaced fractures a soft diet, antibiotics and careful supervision
may be sufficient.
It is often claimed that periodontal pocketing down the distal aspect of a
2nd molar is a late complication of 3rd molar surgery, particularly where a
horizontal tooth has been removed. In this context the preoperative extent
of masticatory mucosa buccal to the 2nd molar is probably more important
than any damage to the cementum on the distal root of the 2nd molar or
infection in the socket. Incorrect approximation of the tissues when they are
sutured may result in the adhesion of sulcus tissue to the buccal gingival
margin of the 2nd molar, replacing masticatory mucoperiosteum at the
gingival margin and eliminating the buccal sulcus.
Persistent infection of a socket extending beyond the period normal for a
dry socket suggests either the presence of a foreign body such as a fragment
of enamel, or localized osteomyelitis, or, if there is redness and swelling of
the overlying face, actinomycosis.
Finally patients should be warned preoperatively of the discomfort and
swelling to be expected, and of any likely complications, without causing
unnecessary apprehension.

THE REMOVAL OF IMPACTED MAXILLARY

THIRD MOLARS
Partly erupted maxillary 3rd molars are often difficult to keep clean,
particularly if they are buccally inclined when they also tend to bite into the
cheek. Over-erupted unopposed upper 3rd molars tend to traumatize the
7A
 ORAL SURGERY, PART 1

lower retromolar tissues. All such non-functional teeth should be

removed.
Completely unerupted upper 3rd molars can be associated with follicular
or keratocyst formation but rarely cause trouble with infection and, even
when partly erupted, pericoronitis is much less common than with lower 3rd
molars. The risk of resorption of the 2nd molar roots is very rare in the case
of lower 3rd molars but occurs from time to time with upper ones.
Unerupted wisdom teeth are usually removed when the other posterior
teeth are extracted and as a preparation for the provision of dentures, or if
the patient is to be given a general anaesthetic for the removal of the lower
3rd molars, unless they are difficult and accidental damage to the 2nd
molars or some other complication such as fracture of the tuberosity is a
risk. Fully erupted teeth which are in the line of the arch may be retained
even if they are functionless when the need for a distal abutment for a
prosthesis is anticipated.
Unerupted upper 3rd molars are best shown by rotational tomographic
films. Oblique lateral jaw films also provide a good representation of their
position. While periapical films produce a more detailed image they are
often unsatisfactory because of the angle of projection.

Surgical Technique
To remove an unerupted upper 3rd molar an incision is made diagonally
across the tuberosity from its distopalatal aspect to the distobuccal corner
of the 2nd molar and on in almost the same line up into the buccal sulcus. In
most cases if a broad Coupland’s chisel is introduced under the flap at the
distobuccal corner of the 2nd molar it can be used to elevate, not only the
mucoperiosteal flap, but also to dilate the coronal space around the crown
of the unerupted tooth. If the bone is thin it can be pushed aside to form an
osteomucosal flap. It is important to free the palatal cusps from the palatal
tissues in the same way. A straight Warwick James’ elevator is inserted into
the follicular space and worked upwards mesial to the neck ofthe 3rd molar,
following which the tooth can be elevated out. A curved Warwick James’
elevator can be hooked into the same situation to disimpact a mesio-
angularly impacted tooth and deflect it laterally out of the socket. The
opposite forefinger is used to receive the tooth as it emerges into the buccal
sulcus to prevent its loss into the pharynx.
More formal bone removal may be required to prepare the tooth for
elevation. If this is so the incision for the flap is extended around the upper
2nd molar to its mesial aspect and the mesial papilla included before it is
taken up into the sulcus. This provides a flap which can be retracted
adequately to enable the operator to see to remove the necessary bone.
Normally the answer to unexpected surgical difficulties is to improve
access and vision to the maximum. However, access is rarely easy to a high
impacted upper 3rd molar and inexperienced operators should avoid
embarking upon tricky surgical procedures.
AZ
 UNERUPTED AND IMPACTED TEETH

After the removal of the tooth the wound is irrigated in the usual way and
any loose fragments of bone are removed. Unless the extended flap has
been needed no suture is required.

Complications
1. Excessive bleeding which usually arises from the sulcus incision and
may require prolonged compression or suture.
2. Haematoma formation may be dramatic with periorbital oedema but
is of no consequence.
3. An oro-antral fistula may arise after elevation, but it invariably heals
satisfactorily if the wound is sutured.
4. Displacement of the wisdom tooth into the antrum will require
removal through a Caldwell—Luc antrostomy which can be carried out
by extending the incision horizontally forwards in the sulcus (see
Chapter 9).
The tooth is occasionally displaced distally into the infratemporal fossa
lateral to the pterygoid plates. Here a careful experienced hand with good
tissue retraction is required to remove it. Should it seem irretrievable the
operator should leave the tooth until localizing radiographs and help can be
obtained.
5. Fracture of the tuberosity may occur especially if the roots are
hypercementosed. It is usually advisable to dissect out the fractured
alveolus and tooth and close the wound primarily. Small tuberosity
fragments are difficult to splint, and due to premature occlusal contact of the
contained tooth cause considerable discomfort.

THE IMPACTED MAXILLARY CANINE

Upper canines more frequently fail to erupt than lower ones. In both cases
malposition of the unerupted tooth is common and in some circumstances
the tooth lies a substantial distance from its normal path of eruption. Failure
of both upper canines to erupt properly is also a frequent occurrence.
Maxillary canines start their development at a higher level than and erupt
after the adjacent teeth. With a greater distance to travel through the bone to
its normal position in the arch there is an increased chance of deflection
from its path. Also in a crowded arch, the additional space required for the
canine may be taken up by the Ist premolar by the time that it is due to
erupt. There are many other suggested causes of malposition of upper
canines, most of which are not convincing or apply only in occasional
circumstances. These include: disturbances of the axis of the tooth germ,
scar tissue in the path of eruption, failure of the root of the deciduous
predecessor to resorb, ankylosis of the deciduous predecessor and the
congenital absence of the lateral incisors, the roots of which may act as a
guiding influence for the canines. Rarely a maxillary canine is congenitally
absent or it is transposed with the adjacent lateral incisor or premolar or it
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 ORAL SURGERY, PART 1

fails to erupt as part of an abnormality which results in the failure of several

or many teeth to erupt.
It is wise to monitor the position and development of the maxillary
canines from the age of nine onwards as part of a general assessment of the
development of the adult dentition. If this is done, many future problems
can be avoided. Certainly if by the age of 13 the upper canines have failed to
erupt their position should be investigated. The attitude of the patient and
the parents to the problem, and the patient’s standard of oral hygiene should
be assessed and noted. The opinion of an orthodontist is required to
determine whether the tooth can be brought into a functional position. The
adjacent teeth should be examined for caries and tested for vitality. The
presence of a non-vital lateral incisor or heavily filled first molar might
appreciably alter the treatment.

Clinical Examination
The canine may be partially erupted or there may be an obvious bulge on
either the buccal aspect of the alveolar process or in the palate, which
denotes its position. A palatal impaction is more common than buccal, but
one can be deceived into assuming a palatal bulge is the crown of the tooth
when it may well be a local bone thickening. Furthermore bilateral
impactions are not necessarily symmetrical. Palpation of the maxilla
through the labiobuccal sulcus may also reveal the crown of the tooth to be
high in the maxilla and adjacent to the floor of the nose. Occasionally the
lateral incisor may be proclined due to the presence of the canine crown
lying labial to the root. Palatal inclination of the lateral can be caused by a
palatally placed canine which is impacted against the apical part of its root.
Rarely the root of a palatal canine may be felt on the buccal aspect as a
small knob high on the side of the maxilla above the premolars. If there is no
clinical evidence of an unerupted canine it may be lying within the alveolar
process in the line of the arch.

Radiological Examination
Careful radiological assessment of the unerupted canine is required before
deciding upon treatment because, unlike a wisdom tooth, it may be possible
to uncover the tooth to permit its eruption into the arch. The position of the
canine can be determined from a choice of occlusal, periapical, rotational
tomographic and lateral skull radiographs. The periapical radiograph
provides a detailed picture of the tooth and its surroundings and is helpful
for demonstrating the degree of root formation of the canine, apical
curvature, the existence of any root resorption affecting the adjacent lateral
incisor and the presence of an associated cyst. The vertex occlusal
projection which produces an axial view of the incisors provides
buccopalatal localization of the canine and determines its relationship to
the standing teeth. The same view will also reveal any rotation of the tooth
about its long axis. The parallax method which uses two periapical films of

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the canine taken from different positions or a periapical and a standard

occlusal will also establish whether the crown is lying buccally or palatally
to the arch.
From the first periapical view, the relationship of the canine crown to the
adjacent incisor root is noted, and compared with this relationship on a
second periapical film taken when the tube has been displaced distally and
re-angulated mesially to centre on the film.
If the canine appears to move away, i.e. distally, from the incisor root and
in the same direction as the displacement of the tube, the canine lies
palatally. Should it appear to move mesially, increasing its overlap of the
incisor, the crown lies buccally to the arch and if there is no obvious change,
the crown probably lies wedged in the arch between the adjacent teeth. The
clinician should also assess the position of the root relative to the premolar
roots in case the canine lies across the arch, with the crown on one side and
the root on the other.
For surgical purposes periapical and vertex occlusal films alone will
often suffice, but rotational tomographic radiographs (e.g. OPG) are
advantageous for demonstrating the vertical angulation of the tooth and its
height above the alveolar margin. In a lateral sinus view, or cephalometric
lateral skull projection, if the image of the crown of the canine overlaps the
incisors this usually indicates that the canine is labial, whereas if the tooth is
behind the incisors it is either positioned in the line of the arch or is palatally
situated. This view is also used for assessing the height and inclination of
the buried tooth. A postero-anterior (PA) projection will provide
information about the angulation of the tooth in the coronal plane, the
proximity of the crown to the sagittal plane, and the relative position of the
canine to the roots of the incisors, premolars, nasal floor and antrum.
Periapical radiographs should be taken even when the canine is partially
erupted, because marked curvature of the apex not infrequently occurs
although the extraction may seem straightforward. Apical hooking should
be suspected if the end of the canine root appears blunted, or indistinct as it
is likely that the long axis of the curved tip is coincident with the path of the
X-ray beam.

Reasons for Removing Unerupted Canines

Many completely buried canines give no trouble and often there is no
reason to remove them. Indeed the surgical removal of unerupted canines,
both upper and lower, carries an element of risk for the adjacent teeth and
needs substantial care. They need removal:
a. Before the fitting of full or partial dentures, but it is also prudent to
remove them before the construction of a bridge in that part of the dental
arch.
b. To permit the orthodontic alignment of other anterior teeth.
c. Where there is resorption of the root of an adjacent lateral or central
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 ORAL SURGERY, PART 1

incisor. If resorption is noticed in time, it may be arrested by removal of the

unerupted canine. If resorption is marked, exposure of the canine and
removal of the lateral should be considered.
d. Where a follicular cyst has developed.
Infection of buried canines is uncommon until the patient is edentulous
and wearing dentures.

Surgical Technique
In the presence of standing adjacent teeth it is obvious that if the canine is
situated buccally a buccal incision should be made and, if it is impacted in
the palate a palatal approach is required (Figs. 4.8 and 4.9). When,

Fig. 4.8. Fig. 4.9.

Fig. 4.8. Removal of labial canines. Above. A three-sided flap is raised and the
thin bone over the crown and neck of the tooth removed. Following this the tooth
is elevated out. Below. A three-sided flap from premolar to premolar is raised to
expose bilateral high labial canines. The crown and cervical third of the root is
uncovered. The neck is cut across with a thick fissure bur and the crown divided
longitudinally with a thin one. It is best not to uncover the tip or to cut through to
the tip. The crown is split apart and the fragments removed. Next the root is
elevated out.

Fig. 4.9. Removal of palatal canines. Right side. A favourably placed and
curved canine can be uncovered and elevated straight out. Left side. If the crown
is tight against the incisor roots it is best separated by an oblique cut from the
root. This permits it to tilt out away from the standing teeth. The root can be
elevated into the crown space.

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 UNERUPTED AND IMPACTED TEETH

however, the unerupted canine is lying directly over the teeth in the arch,
both labial and palatal flaps should be reflected from the beginning. It is also
essential to expose the tooth from both palatal and buccal aspects when the
long axis of the unerupted canine lies across the arch with the root on one
side and the crown on the other and the root passing either above, or
between, the roots of the standing adjacent teeth.
In the edentulous patient one incision made along the crest of the ridge
will permit access from both aspects. Incisions in the palate should never be
made directly over the buried tooth. If the sutured edges of the flap rest over
a socket the suture line may break down, and in the case of a palatal socket
this occasionally leads to the formation of an oroantral or oronasal
fistula.

Extraction by the Buccal Approach

If the teeth are standing a horizontal incision is made around their gingival
margins. It is then taken into the buccal sulcus at each end in a gentle curve
for a distance of about half an inch. The flap is designed so that a complete
interdental papilla is left at each corner (Fig. 4.8). After the flap has been
raised a bony bulge may be visible or palpable indicating the site of the
unerupted tooth or even a portion of its crown may be seen. Occasionally,
however, there is no clinical indication of the exact position of the tooth.
Sufficient overlying bone is removed therefore with either a chisel or a bur
over the site of the buried canine to uncover its crown. Provided that the root
formation is favourable and the canine not impacted against an adjacent
standing tooth, it should be feasible to deliver it by application of a curved
Warwick James’ elevator. If, unfortunately, the root configuration prevents
simple elevation, the root should be exposed over a good part of its length
before further force is applied. If delivery of the canine still cannot be
effected, the tooth must be sectioned at its neck with a bur and the two
fragments teased out separately.
In a number of cases the bulge in the buccal sulcus represents the apex of
the canine which may be hooked, and under these circumstances the crown
will be found on the palatal aspect of the arch. If the coronal part of the tooth
is then uncovered, it may be possible to apply sufficient force to the root on
the buccal side to push the entire tooth through the palatal socket. If this
cannot be accomplished because of a sharp apical curvature, the apex is cut
off and removed buccally following which a sharp tap delivered with a
straight elevator and a mallet to the flat end of the root will deliver the tooth
palatally.
After the canine has been extracted, the wound is cleaned by gentle
irrigation with warm, sterile, normal saline and the flap is sutured back into
position. The follicular tissues need not be avulsed unless virtually
detached. If left in situ they help to protect the roots of the adjacent teeth
and never result in cyst formation. Care must be taken to ensure that
bleeding has ceased before suturing, otherwise there is a risk of haematoma
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 ORAL SURGERY, PART 1

formation beneath the flap. Haemostasis can be achieved by firm pressure

with a gauze swab. :
Sutures are passed through the palatal half of the interdental papilla,
between the teeth from the palatal side, through the buccal half of the papilla
and back beneath the contact point and tied palatally. This avoids the
unnecessary and unsightly row of knots and suture ends visible between the
teeth on the buccal side. Improved flap apposition can also be achieved by
using a vertical mattress suture, again commencing the suture from the
palatal side. Each interdental papilla should be sutured back into place. To
ensure accurate apposition a suture is placed initially through the single
papilla at each end of the incision line. Then the buccal extension is closed
before the remaining papillae are sutured. When inserting sutures at the
buccal extremities it will be found technically easier to pass the needle
through the flap first and then into the tissue on the other side of the wound
which should be elevated from the bone for about 2 mm from the edge.
Attempts to suture in the converse direction may lead to a tearing out of
the stitch or inversion of the wound edges. If the sutures will not pass
between the teeth a bite is taken with the needle through the palatal
mucoperiosteum adjacent to the interdental space and then the suture
material is eased down between the teeth after which the needle is passed
through the buccal half of the papilla and the suture completed.

Extraction by the Palatal Approach

The length of the palatal incision will, of course, depend upon whether one
or two impacted canines are to be removed. In the edentulous case the
incision as stated is made along the crest of the alveolar ridge. If two canines
require extraction the incision line runs in the gingival crevice from the Ist
molar region on one side to a similar position on the opposite side, but if
only a single canine is to be removed the incision need extend only from the
1st molar region on the side to be operated upon to the canine region on the
opposite side (Fig. 4.9). The mucoperiosteal flap is raised with a curved
Warwick James’ elevator or Howarth periosteal elevator working from
each side towards the midline. When detaching mucoperiosteal flaps from
around the teeth it is a mistake to prise away the flap from within the
gingival sulcus because it will be damaged causing interference with
gingival reattachment. Therefore, in order to lift the palatal flap as
atraumatically as possible a palatal papilla is lifted from between the
premolar teeth and a curved Warwick James’ elevator or Ward’s periosteal
elevator introduced beneath its base. As the blade of the instrument, with its
convexity facing the undersurface of the flap, is advanced, the muco-
periosteal tissues will peel away from the necks of the teeth. When
necessary the neurovascular bundle passing through the incisive foramen
should be divided with a sharp scalpel close to the bone. Clamping is
unnecessary, for the small vessels do not bleed much and haemorrhage can
be arrested easily by applying firm pressure with a gauze swab. The

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 UNERUPTED AND IMPACTED TEETH

attachment of the flap to the median suture is reflected with care as the
mucoperiosteum is thin in this area. The flap is retracted away from the
operation site by an assistant using a Lack’s retractor.
Once the palatal mucoperiosteal flap has been raised, the crown of the
tooth—with or without its follicular sac—may be immediately visible.
Sometimes, however, a bulge is present on the palate and there is a thin
layer of bone overlying the crown. This can be shaved off quickly and
cleanly by using a sharp chisel with hand pressure only. Once the neck is
uncovered the general orientation of the tooth is then apparent.
The removal of bone around a canine in the edentulous individual is
straightforward because of the absence of adjacent teeth. If, however, the
unerupted canine is lying in close proximity to standing teeth, bone removal
must be restricted to the distal and palatal aspects of the tooth. This
approach will reduce the risk of damage to the roots of adjacent incisors or
premolars, but some temporary loss of support of these teeth may be
inevitable, after the canine has been removed, if the socket is adjacent to
their roots.
When a canine is completely buried a portion of bone overlying the
suspected position of the tooth is removed with a chisel or bur and the
outline of the crown is uncovered. Once the lie of the tooth is ascertained,
bone is taken away with either a mallet and chisel or with a
No. 6 rose-head bur, ensuring that the roots of any standing teeth are left
undamaged and their supporting bone is retained. Not only is it essential to
expose the crown of the tooth, including the maximum convexity and the
incisal tip, but often it is necessary to free the coronal part of the root of its
immediate investing bone by the ‘guttering’ technique. If the canine has a
favourable root shape and is not tooth-impacted, it should now be easy to
deliver it. A sharp, hook shaped, apical curve will prevent delivery by
palatal bone removal alone. Forceful elevation will then snap the apex off
and attempts to retrieve it via the socket can result in its displacement into
antrum or nose. Sharply angled apices like this result when the dentine
papilla of the developing root impinges against the underside of the
periosteum. Such an apex may raise a distinct knob on the surface of the
bone high over the premolar teeth.
Alternatively, radiographs may reveal it to be in the angle between the
antrum and the nasal fossa. If the apex can be uncovered through a buccal
flap and amputated the remainder of the tooth can be pushed through
towards the palate.
When it is judged that an adequate amount of bone has been removed
from around a buried canine, very gentle leverage with a curved Warwick
James’ elevator should be applied to the appropriate surface (Fig. 4.9).
Which one will depend upon whether the root is straight or curved. If there
is a responsive movement from the tooth, it should be eased out of the
socket, but if resistance is encountered more bone should be drilled away.
During elevation it is a wise precaution to apply the fingers of the left hand
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to the buccal surfaces of standing incisors or premolars to support them and

ensure that they do not move. Often delivery of the canine can be expedited
by using two curved Warwick James’ elevators simultaneously—one on
each side of the tooth—with a double lifting action. Occasionally it is
possible to grasp the canine with forceps and extract it with a rotary
motion.
Sometimes the crown of the canine is deeply impacted against the roots of
adjacent erupted teeth which may show evidence of progressive resorption.
Any attempt to elevate the intact canine is likely to cause movement of, and
damage to, these adjoining teeth. In such circumstances the crown should
be cut off with a bur at right angles to the long axis of the tooth then it can be
displaced away from the adjacent teeth and into the space created by the bur
cut and lifted from the wound (Fig. 4.9). Once the crown is removed there is
usually adequate room for the root to be brought forward and elevated.
Where it is difficult to free the mesial and distal bulbosities of the crown a
further vertical cut through the crown will permit the parts to collapse
inwards. Once this has happened it can be removed.
When the root of the canine lies across the alveolar process between the
roots of standing teeth, its apical prominence may be felt high in the buccal
sulcus, and in this case both buccal and palatal flaps are raised. After
exposing the apex on the buccal aspect and uncovering the crown in the
palate, an attempt is made to deliver the whole tooth palatally by applying
pressure to the apex. Where the root of the canine is curved the tooth may
be loosened, the crown amputated and removed from the palatal aspect and
the root pushed through into the coronal part of the socket.
After the impacted canine has been extracted, loose remnants of the
dental follicle should be removed from the socket with a pair of toothed
Ficklings forceps. The follicle should be left where it covers the root of an
adjacent tooth, particularly if the latter is resorbed. After smoothing the
bone edges the socket is irrigated with warm sterile normal saline to clear
away any tiny fragments of bone or tooth debris.
It is important to ensure complete haemostasis before suturing the soft
tissues, in order to prevent a haematoma accumulating beneath the palatal
mucoperiosteal flap, as this may become infected. The flap should be
correctly repositioned and moulded tightly against the palatal vault with
firm pressure from the operator’s fingers. Each interdental papilla is then
accurately sewn back into place with the suture knots as stated on the
palatal aspect. A 22 mm half-circle cutting needle is inserted squarely
through the base of each papilla. If the needle is not positioned in this
manner but is introduced at an angle there is a tendency for the suture to tear
out.
After piercing the palatal papilla the needle is passed between the teeth so
that it emerges through the corresponding buccal interdental papilla, about
3 mm from its tip. Some difficulty may be experienced in driving a needle
between the teeth of young patients whose interdental crests of bone extend

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to the full height. However, a slim pattern modern eyeless needle will
usually pass through even under these circumstances. A similar problem
arises in patients who possess a gross irregularity of the anterior teeth.
Where it is found impossible to slip the needle directly between the teeth in
the conventional fashion, the suture is first passed through the palatal
papilla and then eased down gradually between the contact points into the
gingival embrasure before rotating the needle through the buccal papilla.
On the rare occasions that suture material cannot be drawn past a tight
contact point into the interdental space, a suitable compromise is to pass the
suture through both the palatal and buccal papillae leaving the intervening
portion resting above the contact point between the approximal surfaces of
the two crowns.
If it has been necessary to raise a buccal flap in addition to the palatal
one, suturing is performed in exactly the same manner, each corresponding
palatal and buccal papilla being sewn together. A thin acrylic palatal plate,
held in place by cribs on the Ist molars, will prevent the formation of a
haematoma beneath the palatal mucosa.

Alternative Methods of Treatment of the Unerupted Canine

1. Leave in Situ
If the canine is asymptomatic and its extraction might cause loosening of, or
damage to, the adjoining erupted teeth, there is a strong case for leaving it
alone. But such a policy depends upon the absence of infection, abnormal
and progressive widening of the follicular space, resorption of adjacent
teeth, or irregularity of the anterior teeth which the patient wishes corrected
by orthodontic treatment. The patient should be kept under annual review
to verify that these complications have not arisen. If the deciduous canine
remains in situ, its doubtful long-term retention must be stressed to the
patient, although a few may remain functional throughout life. With
crowding of the permanent teeth, extraction of the deciduous canine may
relieve the situation, and aposition of the Ist premolar and lateral incisor
can be acceptable from the aesthetic viewpoint, particularly if the lateral
incisor has a large crown, and the palatal cusp of the first premolar can be
ground to increase its resemblance to a canine.

2. Surgical Exposure
Before an attempt is made to assist the eruption of a malposed and
unerupted canine into a functional position certain criteria must be fulfilled,
namely:
a. That there is adequate room in the arch to accommodate the
tooth;
b. That the potential path of eruption is unobstructed;
c. That when eruption is completed the apex of the tooth will be near to
the normal position in all planes;
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d. That exposure of the crown of the tooth can be carried out as close as
possible to the time at which normal eruption would occur.
The initial stage of the operation is to reflect the mucoperiosteum and
trim away the bone overlying the tooth to expose the greatest coronal
diameter, the incisal edge and the cingulum. Care must be taken to avoid
damage to both the unerupted tooth and the adjacent standing teeth, so,
preferably, bone should be removed by using a chisel with hand pressure
only, but in late adolescence the use of burs may be necessary. Before
replacing the palatal flap a window is excised in it corresponding to the bony
cavity containing the canine crown. The flap is then sutured as usual and a
pack of Whitebread’s varnish on ribbon gauze or Coe-Pak should be
pressed firmly into the bony defect so as to cover the exposed crown. This
should be held in position with sutures and left in situ for 2-3 weeks to
prevent granulation tissue and mucosa from overgrowing the denuded
crown. After removal of the pack the progress of eruption should be
observed at frequent intervals.
Following eruption of the tooth, orthodontic treatment may be required
to guide it into a good position in the arch. Sometimes orthodontic traction
is arranged at the time of surgery. If this policy is followed it is important
that the force applied to the tooth should be a gentle one. Traction to bring
the tooth downwards towards its correct position in the arch is likely to be at
an angle to the long axis of a displaced and unerupted tooth. This will tend to
concentrate the force at a fulcrum in the surrounding bone. If this happens
localized resorption of the tooth and bone deposition may result in
ankylosis which will permanently prevent eruption. The simplest technique
now available is the acid etched cementation of an orthodontic bracket to
the crown which may be performed at or after the operation.
In the case of the unerupted buccally placed canine the tooth may lie in
the sulcus tissues. An opening created through these tissues to expose a
tooth crown will soon close when the pack is removed. Furthermore if the
tooth erupted into an area of non-keratinized mucosa its gingival margin
attachment will be poor. Therefore a buccal flap must be raised including
the attached mucoperiosteum. After carefully exposing the crown the flap
margin is sutured above the crown and the bare area below covered with a
pack. With care the follicle can be raised from the surface of the crown and
the flap margin sutured to it.

3. Transplantation and Surgical Repositioning

The success rate with transplantation is highest for unerupted teeth which
still have open apices because of the possibility of revascularization, and
may be seven years or longer. It is essential to establish that there is
sufficient space to accommodate the canine crown. This can be estimated
with fine dividers using the contralateral canine as a guide. Minimal space
deficiency may be overcome by grinding of the crown, but otherwise
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 UNERUPTED AND IMPACTED TEETH

orthodontic therapy may be required to move the buccal teeth distally.

Another problem encountered in late adolescence is over-eruption of the
lower canine against the retained deciduous canine. This can only be
treated by grinding of the incisal edge with a diamond.
The canine should be extracted carefully and transferred to the surgically
prepared socket in the dental arch with the minimum of delay. It is
preferable that the root surface should not be touched either with
instruments or fingers as the viability of the cementum and periodontal
membrane remnants will determine the success of the transplant. Should
the new socket not be ready when the tooth has been delivered the latter is
stored in the patient’s own serum, or under the flap in order to keep the root
moist. Root filling is not attempted so as to reduce handling of the tooth and
apicectomy is unwise. An acrylic dummy can be prepared with the aid of an
extracted tooth and after consideration of the patient’s radiographs. This
should be used to guide the preparation of the new socket, and to reduce the
degree to which the canine itself is handled. The transplanted tooth should
be splinted in its new position for a month after the operation.
In the technique of surgical repositioning, the displaced tooth is not
extracted but rotated or tilted about its apex. It is usually undertaken where
the tooth is fully erupted, but where the crown is out of the line of the arch.
However, there must be adequate space for the canine in its correct
position. Substantial skill is required to remove bone between the canine
and the desired position in the alveolar process, without damage to the root
of the canine. There must also be a good reason why normal orthodontic
means are not used to reposition the tooth.

THE IMPACTED LOWER CANINE

Lower canines are impacted less frequently than upper ones, and they are
usually buccally placed with the crown either fully or partially exposed.
Some lie beneath the roots of adjacent standing teeth and with the crown
positioned near the midline. A few are vertical and lingual to the
incisors.
For orthodontic and aesthetic reasons it is often necessary to remove the
partially or fully erupted but malposed tooth and this can be achieved by
elevation with a suitable elevator or sometimes by simple extraction with
specially designed forceps having one narrow blade which enables the tooth
to be grasped without damaging or moving adjacent teeth. If the tooth is
erupted but entirely buccal to the arch it can be grasped mesiodistally with a
pair of upper premolar forceps. Should such measures fail to deliver the
canine, buccal bone is removed, which will enable the extraction to be
accomplished successfully.
The surgical problem is more complicated in the case of the unerupted
canine deep to the apices of the standing incisors. These teeth should be
localised radiographically with some care. A rotational tomographic film or
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a periapical film, an occlusal film taken with the central ray directed
accurately along the long axis of the lower incisors and a tangential view of
the chin are all essential to permit their full assessment. The deeply
embedded buccal impaction can be removed after raising a buccal
mucoperiosteal flap, if necessary degloving the chin, and excising the bone
covering the canine until the tooth is freed sufficiently for force to be
applied. Although lingual impactions can be treated in the same way via a
lingual approach, access is far from easy and there is a strong case for
leaving these teeth in situ unless associated with a pathological process.
The patient should be reviewed annually. Removal is simple in later years if
the individual is endentulous but unnecessary until then if no clinical
disturbance is being caused.
Rarely a buried lower canine lies across the arch with the crown either
buccally or lingually placed, and this may necessitate a dual buccal and
lingual approach with perhaps the sectioning of the tooth and separate
delivery of the fragments.

THE IMPACTED LOWER PREMOLAR

Failure of eruption of mandibular premolars is the result of lack of space,
gross malposition, or retention of the deciduous predecessor. The 2nd
premolar is most commonly affected due to the drifting forwards of the Ist
permanent molar after early loss of the 2nd deciduous molar. Impacted
lower premolars may be positioned lingually, lie in a vertical position within
the arch or rarely, buccally. Occasionally they lie horizontally below the
apices of the molars. The crown of the tooth may be fully exposed, partially
erupted, or completely embedded.
If the tooth is unerupted, but in a superficial situation, a bulge may
identify the position of the crown. Sometimes the more deeply buried
premolar can be palpated lingually.
Radiographs are always necessary to determine the position of the
premolar and its relationship to the roots of the standing teeth. An intraoral
periapical and either a rotational tomographic or an oblique lateral jaw
radiograph are the best views, together with an occlusal film to demonstrate
the buccolingual position. In young patients the opinion of an orthodontist
should be sought before making the irrevocable decision to extract the
tooth, particularly if the Ist molar is heavily filled or grossly carious.
The reasons for the removal of partially erupted teeth are to eliminate a
stagnational area or food trap and to prevent periodontal disease and
caries.
If the crown of the tooth is largely erupted and presents lingually or
buccally to the adjacent standing teeth, it is often possible to deliver the
tooth with forceps. For instanding premolars the ideal pair of forceps is the
upper roots pattern (Read’s 76N). The instrument is applied from the
opposite side of the mouth and rotated so that the beaks are directed

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downwards so as to seize the tooth mesiodistally or buccolingually. If a

satisfactory purchase cannot be obtained immediately with the forceps, the
judicious removal of a little investing bone may allow the tooth to be gripped
firmly and delivered by rotatory or rocking movements. Slightly less
accessible teeth may be delivered by expanding the bone on the lingual
aspect of the root with a Coupland’s chisel or by creating a narrow trough
around the lingual aspect of the tooth by running a No. 4 rose-head bur
backwards and forwards around the periodontal membrane. A Warwick
James’ straight elevator is passed through the interdental space between the
adjacent teeth from the buccal aspect until its end engages on the lower part
of the crown. A gentle tap or two on the end of the instrument will push the
tooth out.
When the tooth is partially or completely impacted in the arch its crown
will be wedged between the Ist premolar and Ist molar in the case of the
malposed 2nd premolar, or between the canine and 2nd premolar in the
case of the Ist premolar. Therefore, any leverage on the impacted tooth will
put the adjoining teeth at risk. In such circumstances a buccal flap should be
raised of adequate length to ensure good access. It should embrace at least
one standing tooth on each side of the impaction together with a complete
interdental papilla at each end. Adequate working space will diminish the
risk of injury to the mental nerve. If, in fact, the tooth is seen to be in close
relationship to the mental foramen, the patient should be warned
preoperatively that temporary impairment of labial sensation may
complicate the extraction. In retracting a flap in the vicinity of the nerve,
undue tension should be avoided. The nerve should be identified and
protected from trauma by the blunt wide end of a Howarth’s periosteal
elevator or a retractor while drilling or chiselling is in progress.
Buccal bone should be removed with either a chisel or a bur to uncover
the cervical half of the root of the impacted premolar. The crown is then
sectioned with a No. 4 fissure bur. To avoid damage to the adjacent teeth
the fissure bur is sunk into the centre of the tooth at the amelocemental
junction and driven through from the buccal to the lingual aspect. Having
transfixed the tooth the bur is then taken mesially and distally with a
sweeping stroke until the crown is just separated at its margin with the root.
Once divided the crown is then displaced vertically downwards with an
elevator into the space created by the No. 4 fissure bur, following which it
can be delivered buccally. Next the root is elevated from its socket, the bone
edges smoothed, and the flap repositioned and sutured into place.
A similar technique is employed to remove a premolar impacted lingually
or buccally which resists an initial attempt to deliver it following simple
removal of the lingual or buccal plate covering the crown. Sometimes the
tooth is instanding and deeply embedded with the root lying buccally. In
such cases the surgical approach is predominantly from the buccal but an
incision along the crest of the ridge on the lingual aspect is necessary to
uncover the crown and permit removal of the overlying bone. The impacted
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 ORAL SURGERY,’ PART!

tooth should be sectioned, the crown delivered lingually and the root
buccally.
However, in assessing difficult teeth serious consideration should be
given to leaving them alone as tooth damage, fracture of the jaw and
persistent deep infrabony pockets are possible sequelae. Impacted
unerupted premolars which are present in an otherwise edentulous
mandible are usually deeply placed and the jaw is often thin. If in such
circumstances extraction is required, it is prudent to use a drill rather than a
chisel. With a No. 8 rose-head bur, the immediate investing bone should be
cut away from around the tooth to form a channel, preserving as much
buccal and lingual plate as possible. Next, curved Warwick James’
elevators are inserted into the gutter and applied at suitable points along the
long axis of the root. With gentle rotation it should be possible to elevate the
tooth up and out. Premolars with mesially or distally inclined apices may
require separation of the crown from the roots before effective elevation can
take place. Then the entire wound and socket should be cleared of debris
and the flap replaced.

THE IMPACTED MAXILLARY PREMOLAR

An upper premolar is usually impacted with its crown palatally, but
occasionally the tooth is lodged in the arch, obstructed by adjoining teeth or
even by a submerged primary tooth. The crown may be wholly exposed,
partially erupted or completely buried. If a sufficient amount of the coronal
surface is uncovered, the tooth may yield to a simple forceps extraction or to
elevation with a Coupland chisel which is forced into the socket and then
levered against the root. These straightforward methods are more likely to
be successful when the root is conical and the patient young. The majority
of impacted premolars can be delivered only after adopting a planned
surgical procedure involving the removal of palatal bone. To achieve
suitable access for working on a palatal impaction an incision extending
round the gingival margins from the 2nd molar to lateral incisor is
necessary. The bone overlying the crown and neck of the tooth can be
excised with mallet and chisel or gouge, or with burs, and further removal of
the wall of the socket will expose the greater part of the root and allow an
effective extruding force to be applied.
If, however, the crown is wedged between erupted standing teeth in the
arch it is necessary to use a buccal exposure, to section the tooth with a bur,
and dislodge the crown downwards and then outwards. Subsequent delivery
of the root portion can be accomplished readily unless an apical hook is
present. In the latter case drilling to a higher level alongside the root is
usually necessary before the dilacerated apex can be teased out along a
curved path. Naturally care should be exercised during the use of a bur for
either tooth exposure or tooth division to avoid damage to neighbouring

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teeth. Where the impacted premolar lies across the line of the arch both
buccal and palatal flaps should be used.

IMPACTED FIRST AND SECOND MOLARS

First and 2nd molars are sometimes impacted, but it is usually a
comparatively simple matter to raise a buccal flap, remove bone and carry
out vertical section of the tooth in order to facilitate its extraction. First
molars are sometimes found vertically placed near the lower border of the
mandible. In tackling these it must be remembered that the mandibular
nerve is likely to cross the tooth buccal to its neck.
Exceptionally, the Ist, 2nd and 3rd molars are all impacted. It is
impossible to catalogue all the possible combinations and variations of such
impactions, but in practice such multi-impactions are not unduly difficult to
remove. Following a careful study of the radiographs, common sense
dictates which tooth should be removed first, usually the mesial of two, or
the middle of three impactions. Following the removal of the first tooth,
extraction of the remaining teeth is usually comparatively simple.
Where multiple molar impactions are found in young patients it is unwise
to leave the teeth to correct themselves as the impacted state usually
worsens. A careful estimate is made of which tooth needs to be removed to
release the rest and allow eruption.

THE BURIED DECIDUOUS MOLAR

Occasionally a deciduous molar is retained in either the upper or the lower
jaw, and is usually ankylosed. As the permanent teeth on each side of it
erupt, they appear to stimulate periradicular alveolar bone growth, leaving
the ankylosed molar completely or partially buried in the alveolar process
and tightly wedged between the adjacent teeth. It is impossible to remove
such teeth with forceps, even when part of the crown is visible, without
fragmentation or damaging the adjacent permanent teeth. A buccal flap
should be raised and the buccal aspect of the crown of the deciduous tooth
uncovered. Even then it may be difficult to elevate and the crown of the
tooth should be sectioned vertically through the centre, after which the
anterior fragment can be elevated mesially.

SUPERNUMERARIES
Supernumeraries are principally found in the premaxillary region and are
often small and peg-shaped, a type exemplified by the mesiodens which
appears in the midline between, and frequently palatal to, the central
incisors. Mesiodens may lie horizontally, or adopt an inverted position.
Occasionally they are responsible for a dentigerous cyst. Supplemental
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teeth which have the size and shape of normal teeth may also develop in the
upper anterior region, commonly in relationship to the lateral incisor.
Supernumeraries may be single or multiple, unilateral or bilateral, and are a
common cause of failure of eruption, rotation, spacing or malposition of one
or more permanent maxillary incisors. The normal incisors seem to be most
often displaced in a labiolingual direction. Removal of the supernumerary
tooth frequently allows the abnormally placed incisor to erupt, or revert to
its natural position in the arch, but orthodontic assistance may be necessary
fully to correct the misalignment or malposition.
The premolar and molar areas are also sites in which supernumerary
teeth may develop and in addition to the conical and supplemental varieties,
other types may be present in these locations, such as teeth of conventional
shape but smaller or larger in size than a normal tooth. Multicusped
patterns or gross caricatures of the normal may be seen. An extra tooth in
the upper 2nd or 3rd molar region is designated a paramolar if it is
positioned buccally to the permanent tooth. It is often small and conical and
can be fused to the adjoining molar. Fourth molars (distomolars) situated in
the upper jaw may be either conical or molariform in shape. Their precise
location may be either directly distal or distopalatal to the maxillary third
molar. Mandibular 4th molars are usually about the same size as normal
3rd molars. A supplemental lower premolar may be difficult to distinguish
from the adjacent teeth of the normal series.
Accurate localization is facilitated by taking intraoral radiographs from
different angles. Periapical films will demonstrate tooth shape, the
immediate surrounding, the presence of additional supernumeraries, and
the vertical relationships of low supernumeraries. The principle of parallax
can be applied to determine the buccopalatal relationship of the super-
numerary to the adjacent teeth, but the vertex occlusal projection often
provides the surgeon with more certain information in the maxilla.
For high maxillary supernumeraries additional views are helpful, namely
PA jaws and lateral sinuses projections, because they demonstrate the
proximity of the supernumerary to the nose. It is also useful to complete the
radiographic study with a tangential view if the deciduous dentition is still in
situ, as this view makes clear the relative positions of the erupted and
unerupted teeth, particularly when the supernumerary is buccally placed.
Supernumerary teeth should be extracted only when their presence is
responsible for the failure of eruption or malalignment of permanent teeth,
or if they are the cause of other abnormalities. Remember that a small
proportion of supernumeraries in the anterior palate are inverted, that is, the
crown is directed towards the nose. Caution is necessary in recommending
the surgical removal of an inverted palatally placed supernumerary which is
situated close to the roots of the central incisors high in the maxilla and
adjacent to the nasal floor. The roots of the supernumerary and the central
incisors may be adjacent to one another and also difficult to differentiate
from the surrounding bone, so that injury to the root of a permanent tooth

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may occur. If treatment is not indicated for a supernumerary, periodic

radiological review is recommended.
The best time for the extraction of supernumeraries preventing the
eruption of upper incisors is around six to seven years of age, when both
central and lateral incisors are well formed, and it is unlikely that a
permanent tooth will be elevated out in error. In addition, the super-
numerary itself is sufficiently well developed to be easily identifiable and
there is still a reasonable likelihood of the eruption of an upper central
incisor.
For supernumeraries in the anterior maxillary region the surgical
approach will depend upon accurate preoperative assessment, but in the
majority of cases a palatal mucoperiosteal flap is reflected after making a
gingival incision around the necks of the standing teeth from the 2nd
premolar region on one side to the corresponding tooth on the opposite side.
Usually a pyramidal labial flap need only involve the central interdental
papilla for mesiodens, or from canine to canine for those in the central
incisor area.
Relatively inaccessible teeth are approached from both aspects. Often
bone removal can be carried out with a sharp chisel or gouge applied with
hand pressure only, and limited to that immediately overlying the
supernumerary. Once freed, the tooth can be turned out with a cumine
scaler. During the operation unerupted permanent incisors need to be
identified before uncovering the supernumerary, but, as a general rule,
surgery is confined to delivery of the supernumerary, and exposure of the
normal teeth if high is delayed in the hope that they will erupt naturally. If
subsequently they fail to do so a pack is placed after exposure as with the
unerupted canine. After adequate debridement and haemostasis the flap is
returned to its original position and interrupted sutures inserted. With
children plain catgut eliminates the need for removal which many fear.
Primary closure is normally followed by uneventful healing and antibiotic
prophylaxis is less important than in the case of lower third molar
surgery.
In the case of supernumerary upper premolars and molars, periapical,
rotational tomographic and occlusal films will supply all the relevant
information, such as their relationship to adjoining standing teeth and their
proximity to the maxillary sinus and tuberosity. Surgical access will usually
be from the buccal aspect using a suitably designed flap modelled on that
used for exposure of the upper 3rd molar.

DILACERATED INCISORS
Trauma to the upper deciduous incisors in childhood occasionally damages
the underlying permanent incisor tooth germ, especially at the stage when
only the crown is calcified, i.e. about 2-3 years. Further root development
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takes place at an angle to the crown producing a bent tooth which cannot
erupt.
Occasionally exposure and ingenious orthodontic traction may bring
such teeth into occlusion but usually they are best removed early so that the
space may either be filled with the lateral incisor which ultimately can be
crowned, or maintained for a partial denture or bridge.
Whenever unerupted permanent teeth have to be removed for pathological
or orthodontic reasons it is absolutely essential:
a. To have the best possible radiographic assessment of the area,
and
b. To identify carefully each of the unerupted developing teeth so that
the wrong one is not removed.

SUGGESTED READING
Al Haag M., Coghlan K., Christmas P. et al. (1985) Br. J. Oral Surg. 23,
17-23.
Andreason J. O. and Hjorting-Hansen E. (1966) Replantation of teeth I. Acta
Odontol. Scand..24, 266-286.
Andreason J. O. and Hjorting-Hansen E. (1966) Replantation of teeth II. Acta
Odontol. Scand. 24, 289-305.
Bowdler-Henry C. (1969) Excision of the developing mandibular third molar by
lateral treparation. Br. Dent. J. 127, 111-118.
Brown I. D. (1981) Some further observations on submerging deciduous molars.
Br. J. Orthodont. 8, 99-72.
Cook R. M. (1972) The current status of autogenous transplantation as applied to
the maxillary canine. Int. Dent. J. 22, 286-300.
Di Biase D. D. (1969) Mid-line supernumeraries and eruption of the central
incisors. Dent. Prac. 20, 35-40.
Di Biase D. D. (1971) Mucous membrane and delayed eruption. Dent. Prac. 21,
241-250.
Guralnick W. C. and Laskin D. M. (1980) NIH Concensus Development.
Conference for removal of third molars. J. Oral Surg. 38, 235-236.
Howe G. L. (1958) Tooth removal from lingual pouch. Br. Dent. J. 104,
283-284.
Kural J. (1981) Infra occlusion of primary molars: An epidemiological and familial
study. Community Dent. Oral Epidemiol. 9, 94-102.
MacGregor A. J. (1985) The Impacted Lower Wisdom Tooth. Oxford, New York
and Toronto: Oxford University Press.
McKay C. (1978) The unerupted maxillary canine. An assessment of the role of
surgery in 2,500 treated cases. Br. Dent. J. 145, 207-210.
Mortis C., Karabonta I. and Laparidis N. (1978) Extraction of impacted
mandibular wisdom teeth in the presence of acute infection. Int. J. Oral Surg. 7,
541-548.
Rood J. P. (1983) Degrees of injury to the inferior alveolar nerve sustained during
the removal of impacted mandibular third molars by the lingual split technique.
Br. J. Oral Surg. 21, 103-106.

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Rud J. (1970) Removal of impacted lower third molars with acute pericoronitis and
necrotising gingivitis. Br. J. Oral Surg. 7, 153-159.
Rud. J. (1983) Third molar surgery: relationship of root to mandibular canal and
injures to the dental nerve. Tandlaegebladet. 87, 619-531.
Seward G. R. (1954) Notes on dental radiography Parts II, III and IV. Dent. Prac.
IV, 247-253, 312-319, 355-361.
Seward G. R. (1963a) Radiology in general dental practice VII: Radiography of
lower third molars. Br. Dent. J. 115, 7-9.
Seward G. R. (1963b) Radiology in general dental practice VIII: Assessment of
lower third molars. Br. Dent. J. 115, 45-51.

91
 CHAPTER 5

SURGICAL PREPARATION OF THE MOUTH

FOR DENTURES

Most patients tolerate the transition from a natural to an artificial dentition

with reasonable ease, provided teeth are extracted and dentures constructed
with skill and care. Every effort should be made at the time of extraction to
conserve the remaining alveolar bone and masticatory mucosa so that,
when healing is complete, the best possible foundation is created for the
subsequent prosthesis. Anticipation of prosthodontic problems may allow
their solution by surgical means at the time of extractions. Though more
limited in extent, the surgical aspects of preparation for partial dentures are
otherwise similar to those for complete dentures.

PROSTHODONTIC CONSIDERATIONS AT THE

TIME OF EXTRACTION
Careful clinical examination of the teeth must precede the extractions and a
record should be made of their appearance and shade, the relationship of the
dental arches and the height of the lower third of the face. The size, shape
and relationship of the future edentulous areas and any adverse bony or soft
tissue irregularities should also be noted.
Radiographic examination of the teeth and jaws will greatly assist
anticipation of surgical difficulties and complications. Rotational tomo-
graphs are particularly convenient for this purpose but more detailed intra-
oral radiographs should be obtained of any suspicious areas. Obviously,
teeth should be extracted with minimum trauma and all debris removed
from the extraction wounds.
Not all fractured roots need be removed. The disadvantage to the patient
produced by destroying part of the future denture support must be weighed
against the symptoms likely to arise from retention of a root fragment. As a
general rule, fragments which are less than one-third of the original root
length may be left in situ unless they were infected or have been loosened
during the extraction process and would therefore become separated
foreign bodies.
Rocking movements to expand the tooth sockets create a number of
vertical fractures in the labiobuccal and linguopalatal plates and displace
the intervening fragments outwards. These must be compressed back into
place as they can result in sharp margins which will have to be removed
surgically at a later date.

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Small pieces of alveolar bone are often fractured off or extracted with the
teeth and the sharp edges of any such defects can be trimmed conservatively
with rongeurs. However an alveolar bone file allows just enough bone to be
removed to leave a ridge which feels smooth when palpated through the
overlying soft tissue. The thick gingival mucoperiosteum should be retained
as far as possible, even if lacerated, since this tissue will eventually bear the
load from a denture more successfully than the thin mucosa of the sulcus.
Indeed it is the extent of the masticatory mucoperiosteum rather than the
residual alveolar bone which defines the functional denture bearing area.
Generous bone removal at this stage, although producing a smooth ridge in
the short term, will probably lead to a significant reduction in bulk in the
longer term. As some degree of resorption is unavoidable, extensive
surgical destruction must be avoided as excessive resorption can follow
surgical interference.
The gingival tissues should be replaced so as to cover any substantial
areas of exposed bone after extraction, but complicated re-arrangement is
usually unnecessary. Suturing the gingival margins of the sockets will hold
them in place while healing takes place, helps to arrest bleeding, and also
retains the shape of the compressed sockets. Sutures are best placed across
the sockets midway between the interdental papillae. The interdental
papillae and the crests of the interdental septa create a series of
prominences along the ridges which, if recorded on the inner aspect of
temporary dentures and impressed through them by mastication on the
healing ridges, will become permanent. Irregularities are smoothed out
whilst healing and natural resorption take place before permanent dentures
are fitted. Smoothing the inside of the temporary dentures rather than the
ridges helps to avoid this problem without loss of alveolar bone. Smoothing
the interdental septa with a bone file and dividing the interdental papillae
and interdigitating them as the sockets are sewn up, using a continuous plain
or blanket suture, can also reduce the ridged effect.

IMMEDIATE DENTURES
When a complete clearance of the natural teeth is to be carried out, the
provision of immediate replacement dentures should be considered to avoid
both social and functional embarrassment to the patient. There are two
ways of doing this, depending on the convenience to the patient and the
preference of the operator.

1. Two-stage Immediate Denture Replacement

All remaining posterior teeth may be extracted and partial dentures
constructed, fitted and worn until the initial healing of the ridges is
complete. These dentures may be worn for some months, relined, and then
used as the basis for full dentures, which are inserted following removal of
the anterior teeth in a second stage. This method introduces the patient to
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denture wearing gradually and helps preserve the natural functional jaw
relationship.
In the past, either the additional anterior artificial teeth were ‘socketed’,
i.e. made with root-like prominences on the fitting surface, or the bulk of the
upper alveolar process was reduced to provide room for a labial flange. The
immediate aesthetic result of socketing the anterior teeth was very good, but
unless the fitting surface was minimally contoured, permanent indentations
in the ridges were created. On the other hand, alveolectomy of the upper
alveolar ridge removing the outer cortical plate and much of the outer walls
of the sockets promoted a destructive degree of resorption.
It is best to cover the untrimmed ridges with thin acrylic flanges and to
reline these as soon as shrinkage occurs, following which the prominence of
the flanges can be reduced. Where the alveolar process is bulky, the incisors
may be ‘socket fitted’ to merely fit within the gingival margin.
In those cases in which the upper anterior teeth are proclined and the
alveolar process is both prominent and unusually undercut, the less
destructive technique of inter-septal alveolotomy may be employed to
reshape the ridge. In this technique the interdental septa are removed with
burs or straight bone shears and the labial cortical plate is fractured
inwards. The bone shears are inserted across the septum into each
neighbouring pair of sockets in turn and closed so as to cut through both
the bony interdental septum and the soft tissue interdental papilla
simultaneously. They are inserted first from the labial and then from the
palatal direction and the blade points pushed as far apically as possible. In
this way, a narrow wedge of bone and soft tissue is severed and removed
without raising the soft tissues. A vertical cut is made with the bone shears
or a narrow fissure bur through the labial plate distal to the canine socket
cutting from inside the socket outwards. When these cuts have been
completed, the entire labial cortical plate is fractured inwards at its base by
firm finger pressure. It is best to squeeze the alveolar process between the
fingers and thumbs of both hands while grasping it in a swab. In some
patients it may be necessary to drive a flat chisel into the sockets, bevel
facing palatally, to create a horizontal split across the buccal plate,
particularly through the buttress of the anterior nasal spine. A continuous
blanket suture approximates the gingival margins and maintains the new
position of the labial bone. By this means, a reduction in labial bulk is
obtained, but the cortical plate is preserved and resorption should not be
excessive. It is often convenient to excise the upper labial frenum at the
same time so that the provision of a notch for it in the denture flange
is unnecessary and a point of weakness in the finished denture is
eliminated.

2. One-stage Immediate Denture Replacement

The dentures are constructed from casts of full upper and lower impressions
that have been taken carefully to ensure that the maximum denture-bearing

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 SURGICAL PREPARATION OF THE MOUTH FOR DENTURES

area is included, and that muscle attachments and sulcus form are precisely
recorded. The lingual sulci and tuberosity regions are often neglected. With
an accurate squash bite the models are mounted on an articulator and teeth
removed for denture construction. It is important that the dentures should
be fully flanged to facilitate an early reline with a tissue conditioner. The
flanges must not be overextended otherwise painful ulceration will occur.
Similarly undercut areas should be relieved, especially the maxillary canine
eminences.
The teeth are removed as described, preserving but smoothing the
alveolar ridge and loosely suturing the gingiva.
The dentures are fitted immediately and checked for margin pressure
points which must be trimmed.
Most patients adapt well to wearing the dentures continuously for the first
two weeks, but removing them whenever possible for cleansing both the
mouth and dentures.
Careful review will avoid pressure ulceration and loss of retention can be
readily corrected with a soft tissue conditioner lining at about 4 weeks post-
extraction and which may require repeating before a hard acrylic reline at
4-6 months.
In the first few months after the provision of full dentures, the occurrence
of small pressure ulcers is not uncommon, but these can usually be induced
to heal by relieving the fitting surface of the denture. Sometimes, however,
small spikes or spurs may become prominent as initial remodelling of the
bone occurs and these require trimming. Sequestration of small fragments
may also happen and, where possible, these should be allowed to separate
naturally since over-enthusiastic surgery may perpetuate the problem and
lead to further loss of bone. Where there are multiple areas of discomfort,
the dentures should be relined and the use of a semi-soft tissue conditioner
material may be an invaluable intermediate stage. All immediate dentures
have to be regarded as temporary appliances and conventional relining or
replacement should be arranged after six to twelve months.

PROBLEMS PRESENTING IN ESTABLISHED

DENTURE WEARERS
Surgery can only be considered when faults in denture design have been
eliminated as a cause of the problem. Whilst most patients adapt well to the
edentulous state and can wear properly constructed dentures without
discomfort, there remains a minority who never do. This persistent denture
intolerance is the basis of repeated complaints for many of which an
obvious cause cannot be identified, and is usually a psychogenic oral
dysaethesia (see p. 327). Every effort must be made to avoid unnecessary
surgery even in the face of persistent patient pressure, as complaints about
the results of the operation will simply be added to complaints about the
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dentures and will not cure the patient’s unhappiness. There are, however, a
number of irregularities of the denture-bearing areas which can be identified
and relieved with great benefit to denture comfort.
An adequate radiographic examination is essential for accurate diagnosis
in edentulous patients, as, in addition to buried teeth and roots which are
relatively common, other unsuspected pathological changes may be
discovered. However, great care must be taken to ensure that what is found
can be related to the patient’s complaints.

RETAINED ROOTS, UNERUPTED FEETH

AND PATHOLOGICAL LESIONS
Retained roots are unlikely to be a source of symptoms unless they become
superficially placed due to resorption of the surrounding alveolar bone.
Pressure of the denture over such a root may initially cause only discomfort,
but eventually ulceration occurs and infection with oral micro-organisms
follows immediately. Exactly the same process may occur in relation to an
unerupted tooth and, in both cases, extraction is indicated. This should be
accomplished by as conservative an approach as possible, involving only
the minimum removal of bone.
A sinus is often present which leads directly to the root. In some selected
cases, larger roots, suitably aligned, such as those of lower canines, can be
exposed, root-filled and restored so as to provide useful partial support for a
denture. This approach seems to avoid the amount of ridge resorption which
occurs following extraction and is said to enhance the subjective load
bearing capacity of the patient.
Burrowing resorption is sometimes seen in buried teeth and radio-
graphically resembles caries of the crown. This condition may be
associated with pain and can be a rare indication for the removal of an
uninfected and deeply buried tooth.
The presence of pathological lesions such as cysts or tumours in the
edentulous jaws dictates the need for appropriate treatment, and although
prosthetic considerations are secondary, they should not be ignored, so that
the operative technique should be modified so as to retain the best possible
denture foundation.

IRREGULARITIES OF DENTURE-BEARING TISSUES

Comfortable denture wearing may be impeded by a variety of bony or soft
tissue anomalies.

Bony Irregularities and Prominences, Knife-edge Ridges

Irregular resorption may lead to the presence of bony prominences which
tend to be covered by thin mucosa and on which the denture fitting surface
bears heavily and causes discomfort. Such irregular resorption is much less

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common when provision of dentures is delayed for a few months after

extractions or where the ridge is carefully prepared for immediate
replacement.
If adjustment of the denture fitting surface does not provide relief the
troublesome areas are treated by raising a soft tissue flap and reducing the
prominent bone with a bone file or an acrylic bur. However, avoid removing
too much bone with the latter.
The same approach may be used to eliminate inconvenient bony
undercuts or to smooth knife-edge ridges. In either case, the flap must be
raised with care to avoid tearing, and bone removal should be minimal,
particularly in the case of knife-edge ridges.
It must be stressed that every attempt should be made to overcome this
kind of problem by adjustments to the dentures before resorting to surgery
since the results of surgery may be disappointing. It is possible that the
subperiosteal injection of particulate hydroxylapatite may provide a better
solution to undercut and knife-edged ridges than reduction of the existing
bone.

Fibrous Ridges
Flabby fibrous tissue provides a poor foundation for a stable denture and
may be reduced in bulk surgically. This problem occurs most commonly in
the upper anterior region when a full upper denture is opposed by natural
lower anterior teeth. In such cases, consideration should be given to
extraction of the lower anterior teeth as well as trimming the ridge. There is
no identifiable plane of cleavage between the mucosa and the fibrous tissue
so that a V-section fillet has to be removed and the wound edges sutured
together.
It should be noted that this approach to the problem reduces the extent of
the masticatory mucosa and the area of the denture bearing surface. A
procedure similar to an apical repositioned flap as used in periodontology
can provide a better solution in some patients, and again there are reports of
success using particulate hydroxylapatite to augment the resorbing
ridge.
Rarely, patients are seen with gross generalized fibrous enlargement of
the alveolar ridges, a condition akin to hereditary fibromatosis gingivae.
The surgical treatment of such cases follows the same principles, and may
be done as follows.
a. Reflect a masticatory mucosa flap by dissecting parallel to the surface
with a sharp blade, then excising the underlying fibrous tissue with the
periosteum. The mucosal flap is then gently sutured back over the bare
area.
b. Gross enlargments are pared away to produce the desired contour,
with particular care to control the resulting haemorrhage. This can usually
be achieved by application of a Whitehead’s varnish dressing to the new
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 ORAL SURGERY, PART 1

surface, carried on a specially constructed plate or denture. Skin grafting is

not indicated, but mucosa may be used. The mucosal epithelium is sliced off
first to form thin mucosal grafts. The slivers of tissue are accumulated on a
piece of tulle gras and kept moist with a sterile swab soaked in saline until
the end of the operation. The plate is lined with gutta percha and an
impression taken of the operation site after the fibrous ridge has been
surgically reduced. The mucosal grafts supported on the tulle gras are then
placed in the mould and applied to the operated area.

Frenal and Fibrous Bands

The presence of a prominent labial frenum in the upper anterior region, or
less commonly in the lower anterior region, may produce problems in
denture construction or may cause displacement of a denture where
adequate retention is difficult to achieve. Fibrous bands running from the
ridge across the buccal sulcus to the cheek regions produce similar
difficulties, and, in either case, allowance for these structures prevents
adequate peripheral extension of the buccal flange of the denture. The
problems are worst when the frenum or band is attached at or near the crest
of the ridge because the deep notch in the labial flange also weakens the
denture so that a fracture may occur under masticatory stress. (For excision
see following sections.)

Frenectomy
Excision of the labial frenum is a small procedure which can be done
conveniently under local anaesthesia. If a second assistant is available this
is beneficial as the upper lip can be held everted by a finger and thumb of
both hands. Sometimes there is a brisk ooze and this also can be controlled
by the assistant compressing the labial artery. The outline of the incision
should be determined before the local anaesthetic is injected as this tends to
balloon the tissues and distort them. A V—Y procedure is best for reducing
the height of attachment of the frenum.
An incision is made on either side of the attachment of the frenum to the
alveolar process and close to the frenum so that, once it is detached the bare
area is as narrow as possible. The two incisions meet near the crest of the
ridge and the apex of the frenum is then picked up, either by a skin hook or a
stitch and is dissected off the periosteum with a scalpel.
The periosteum between the edges of the wound in the attached gingivae
is incised down to bone and the mucoperiosteum lifted from the bone with a
periosteal elevator for at least 0-5 cm on either side. The scalpel can be used
to undermine the edges of the incisions in the sulcus in a plane over the
surface of the periosteum.
A 4/0 absorbable suture is used to close the incision. The first stitch is
inserted in one side of the wound towards the top of the sulcus. The edge of
the mucosa is everted with a skin hook and the needle picks up the

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periosteum under the edge. The stitch is passed from side to side through the
apex of the freed frenum, through the periosteum under the other edge of the
wound and then through the mucosa. As the stitch is tied the apex of the
triangular shaped dissected frenum is re-located at the top of the sulcus and
the wound closed at this point. Interrupted sutures approximate the
mucoperiosteum over the labial aspect of the ridge as close as it will go. A
single suture in either arm of the Y on the lip side of the reconstructed
frenum is usually sufficient.

Excision of Fibrous Bands

A similar technique to that just described for the correction of overlarge
frena has been used for the elimination of fibrous bands. However, there is
usually a significant difference between the shape of the fibrous bands,
found in the premolar or molar region, and the labial frena.
The ‘fibrous’ bands are in effect folds of sulcus mucosa which arise from a
broad base on the cheek side of the sulcus. Incisions on either side of an
upper labial frenum lie close together and almost parallel to one another.
Incisions made on either side of a fibrous band diverge to separate a
substantial triangle of mucosa. When this is advanced into the fornix of the
sulcus a triangular defect is left which stretches up into a deficiency in the
masticatory mucosa. Undermining the mucosa adjacent to the defect and
closing it does not repair the lack of alveolar mucoperiosteum and
subsequent scar contraction in the mobile mucosa raises a fresh band across
the sulcus.
At first sight a Z-plasty appears to be a more rational plastic procedure
with which to deal with these bands as it can be used to break webs and
bands elsewhere in the body. An incision is made along the length of the
band and then two others, one of which runs from the ridge end down into
the sulcus and the other on the other side of the band from the cheek end,
again down into the sulcus. Two triangular flaps are formed; one is used to
cover the defect on the alveolar aspect, and the other that on the cheek
aspect with a suture line which now lies at the bottom of the sulcus at right
angles to the original band.
Unfortunately the repair on the alveolar aspect is still composed of sulcus
mucosa with its mobile loose connective tissue submucosa, and the breach
in the masticatory mucosa is not dealt with. Scar contraction will re-
establish the fold.
If the periphery of the denture bearing area is to be improved the
masticatory mucosa must be advanced down towards the sulcus at the same
time as the mucosal band is re-attached. This may be done by a rotation flap
of ridge mucoperiosteum which creates a new defect on the palatal aspect of
the ridge surrounded by masticatory mucosa and which will heal by
secondary intention with a similar mucosa, or by free palatal mucosal grafts
applied to the denuded periosteum.
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Excision of the Lingual Frenum

Short lingual frenum or tongue-tie is a congenital condition which
occasionally causes the patient considerable inconvenience. Apart from
being unable to protrude the tongue, the patient’s main disability is the
inability to clear away food which has become lodged in the roof of the
palate or in the labiobuccal sulci. A few patients develop a lisp and
occasionally if the frenum is attached to the gingival margin it may cause
recession of the gingiva around the lower incisor teeth or a diastema. In the
edentulous patient, a tongue-tie interferes with the stability of the lower
denture by causing its displacement every time the tongue moves.
The anterior part of the tongue is tilted upwards first on one side of the
frenum and then the other and a local anaesthetic solution is injected into
the under surface of the tongue close to the sides of the frenum so as to avoid
the ranine veins. Further solution is injected into the floor of the mouth on
either side. When anaesthesia has been achieved a stitch is passed through
the tip of the tongue and the frenum divided with scissors close to the under
side of the tongue. As this is done the tip can be elevated and the wound
stretched into a diamond shape. Sometimes there is a knob of fibrous tissue
in the anterior border of the separated frenum. If this is so it is best excised.
The lateral margins of the diamond are undermined with fine, blunt tipped
scissors, being careful not to damage the ranine veins or the submandibular
duct papillae. Two short lateral incisions may be made, one % of the way
down from the top of the stretched incision on one side and the other 4 of the
way up from the bottom on the other. This permits further elongation of the
wound, and its closure as a Z-plasty by interrupted 4/0 absorbable sutures
(Fig. 5.1). Particular care must be taken to ensure good haemostasis or a
large haematoma will develop in the floor of the mouth, which if it becomes
infected will lead to scarring and recreation of a tongue-tie.

Enlarged Maxillary Tuberosities

Enlargements of the tuberosity may be fibrous, bony or both, and may
extend buccally, palatally, vertically, or in any combination of these planes.
Lateral bulbous tuberosities with very deep undercuts will interfere with the
fit of the upper denture and also lead to its displacement due to impingement
of the coronoid process against the buccal flange of the denture when the
mandible is opened or moved laterally. This can also cause pain in the soft
tissues overlying the coronoid process. Excessive height of the tuberosity
may reduce the inter-alveolar space to such an extent that there is
inadequate room for the lower denture.

Bony Enlargements of the Tuberosity

Enlargements of the tuberosity, which are predominantly bony, and which
do not contain an extension of the maxillary sinus, should be reduced to a
satisfactory size with rongeurs, chisels, or bone burs. The tuberosity is

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Fig. 5.1. Excision of short lingual frenum and tongue-tie. a, The preoperative
state. b, The tip of the tongue is picked up and the frenum divided close to the
under side of the tongue. The wound opens up as shown. c, The scarred and
lumpy part of the lower end ofthe frenum is excised. Two short lateral incisions
are made as shown, avoiding the sublingual veins. d, The wound is closed as a
Z-plasty.

approached through an incision straight along the crest of the ridge

extending from the posterior aspect of the tuberosity to the first molar
region. After the bone has been reduced, the two mucoperiosteal flaps
should be approximated, and any excess soft tissue trimmed off of one or
both of the flaps, taking care not to reduce the extent of the masticatory
mucosa on the lateral side and therefore the sulcus depth. The wound is then
closed.
Preoperative radiographs are essential before reduction of enlarged
tuberosities to demonstrate the proportion of bone and soft tissue and the
extent of the maxillary sinus within them. Where the mucoperiosteum is of
normal thickness and the enlarged tuberosity composed of thin bone over an
extensive extension of the antrum reduction in size is more difficult. The
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RY ge Aken #

mucoperiosteum is reflected to enable the operator to cut through the bone

in the mid line of the ridge with a rose-head bur and then to cut out triangular
sections on either side to leave interdigitating triangular segments. The
antral mucosa on them should not be disturbed. They are in-fractured with
greenstick fractures and the mucoperiosteum trimmed and sutured, making
sure that there is a slight excess to give a tight suture line.

Fibrous Enlargements of the Tuberosity

Fibrous enlargements may be either firm or mobile and the latter type
makes the construction of a satisfactory denture particularly difficult as the
soft tissues can be displaced when impressions are taken.
An incision can be made along the crest of the ridge and then flaps raised
with a scalpel, cutting them to the normal thickness of the ridge mucosa.
The excess tissue is filleted out from under the flaps and then an ellipse
removed from the edges of the flaps until they meet edge to edge and do
not overlap. This technique removes both a lateral and a vertical excess
(Hig) 2):

Fig. 5.2. Diagram showing reduction of fibrous enlargement of the tuberosity.

The mucosa is raised by undercutting the flaps, being careful to preserve a blood
supply to the flap by conserving an adequate thickness of flap, particularly
palatally. The excess fibrous tissue is excised, the flaps trimmed to length and
sutured.

Firm fibrous enlargements are best trimmed by paring them down with a
scalpel. An acrylic base plate is prepared preoperatively. The epithelium is
trimmed off first as a free mucosal graft and the pieces assembled on tulle
gras, cut surface upwards. The fibrous tissue is pared to size and an
impression of the new tuberosity taken in black gutta percha using the
prepared base plate. The mucosal grafts on the tulle gras are placed into the
impression and the baseplate reinserted in the mouth (Fig. 5.3). It may be
retained by two bone screws driven outwards from the palatal aspect into
the base of the alveolar process. Often retention is adequate without
mechanical fixation. The plate is left undisturbed for 14 days.
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SURGICAL PREPARATION OF THE MOUTH FOR DENTURES

Fig. 5.3. Diagram showing reduction of firm fibrous enlargement of the

tuberosity. The epithelium is removed as thinly as possible to form free patch
grafts and the pieces assembled on petroleum jelly gauze. The excess bulk of
fibrous tissue is trimmed away but not down to bone. The graft is supported in
contact with the raw area by a GP lined acrylic baseplate.

Occasionally a relatively normal tuberosity needs to be reduced in height

where there is insufficient room between the ridges in the 3rd molar region
for both an upper and lower denture.

Tori
Tori are developmental exostoses, found most commonly in the midline of
the hard palate but occasionally on the lingual side of the mandible in the
premolar region. It may be possible to relieve an upper denture in the area
overlying a small torus palatinus, but dentures tend to impinge on the larger
ones and may cause ulceration. In addition, the midline relief may cause a
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point of weakness in the denture and lead to repeated fracture. Horseshoe

shaped dentures without a palate have been used, but are rarely
satisfactory. Sometimes there may be more than one bony mass in the
midline, for when the torus is large it tends to become lobulated. Four
lobules with a ‘hot cross bun’ effect is a common arrangement. Surgical
exposure of this bony prominence may be made by an incision around the
crest of the ridge in the edentulous patient or around the palatal aspect of the
gingival margins when teeth are present. The greater palatine vessels will, of
course, be contained in this large flap when it is raised.
Another surgical approach to the centre of the palate may be made
through a straight incision up the midline (Fig. 5.4). This gives an excellent

ra
(>

eee,
ae
Fig. 5.4. Removal oftorus palatinus. a, Y incision to expose torus. b, Removal
of torus. c, Wound closure.

exposure of a torus palatinus, especially if the anterior end of the incision

near the incisor teeth is made to diverge in the form of aY ora T so avoiding
the neurovascular bundle at the nasopalatine fossa. All incisions must, of
course, be made down to bone so that the flaps raised consist of mucosa and
periosteum. The mucoperiosteum overlying the torus is often thin and may
easily tear during elevation ofthe soft tissues from the exostoses. Similarly,
when excising the bony nodule, the surgeon should realize that the palatal
processes of the maxillae are also thin and that any attempt to remove a
torus composed of compact bone with a chisel may result in a fracture of the
palate and perforation of the nasal floor. In a young patient a small torus

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palatinus may occasionally contain cancellous bone, and this can be

chiselled off quite easily.
Usually, it is wise to remove the exostosis with a drill. A fissure bur
should be employed to section the lesion so that a number of slender pillars
of bone can be individually removed with a chisel. The remaining cut
surface should be smoothed with a large bur. If the torus palatinus has been
approached through an incision along the centre of the palate, it will be
found that on replacing the soft tissue flaps over the palatal vault there is a
surplus of mucoperiosteal tissue due to elimination of the bony mass. The
edge of one of the flaps should be trimmed with a scalpel or scissors until
there is accurate approximation, after which the wound is sutured. The
sutures should be left im situ for seven days, but it will be found that as
patients tend to use their tongues to play with sutures in the centre of the
palate some may be lost earlier.
If the torus has been approached from an incision along the crest of the
ridge or around the palatal gingival margins of the remaining standing teeth,
a bulge in the centre of the flap approximating to the torus will be seen after
the torus has been removed. This excess can be eliminated by removing an
ellipse of soft tissue with a scalpel, after which the wound in the centre of the
plate is sutured. The denture or a previously prepared acrylic plate may be
lined in the centre with gutta percha and used to hold the flaps in close
apposition to the bone surface during healing.
The mandibular torus is situated on the lingual side of the alveolar
process opposite the lower canines and premolars and is usually bilateral.
Occasionally it may extend posteriorly as far as the first molar region. Like
the torus palatinus, the exostosis varies in size from patient to patient and
may be lobulated. Lingual tori need only be excised if they cause pain or
difficulty to denture wearers.
In the edentulous mandible the torus mandibularis may be approached
surgically by an incision of adequate length along the crest of the ridge. If
any teeth are present, the incision is made around their gingival
margins.
Unlike the torus palatinus, the torus mandibularis can be removed easily
with a chisel. The underlying bone is then smoothed with a bone file or large
bone bur and the incision sutured. There is no necessity to tailor the flaps
after the excision of the bony lump, for the bony mass is comparatively
small and the surplus soft tissue is therefore minimal (Fig. 5.5).

Prominent Bony Attachments for Muscles

When gross resorption of the edentulous alveolar ridges occurs, the
processes of the mandible to which muscles are attached, and which
therefore retain a functional stimulus, do not atrophy, and tend to become
relatively prominent. Dentures may impinge on these areas causing pain
and ulceration, and the activity of the muscles themselves may have a
displacing effect on the margin of the prosthesis. The muscles involved are
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Fig. 5.5. Removal of torus mandibularis. a, Torus. b, Removal of torus. c,

Wound closure.

the mylohyoid, which is attached to a ridge on the lingual side of the molar
region, the genial muscles, attached to the genial tubercles on the lingual
side in the midline, and the mentalis muscles, attached just beneath the
sulcus on the labial side on either side of the midline.

Mylohyoid Ridge Resection

The surgical approach to the area is made through an incision of adequate
length along the crest of the ridge and this incision usually extends from
canine to the 3rd molar region where it is angled laterally onto the external
oblique ridge to avoid the lingual nerve. The position of the lingual and
mylohyoid nerves should be borne in mind continuously while working in
the 3rd molar region.
The mucoperiosteal flap is elevated lingually with a Howarth’s periosteal
elevator, care being taken not to disturb the tissue on the buccal side of the
incision. The mylohyoid ridge and its attached muscle are exposed and the
flap held back lingually with a Lack’s retractor. A chisel is positioned with
its cutting edge against the base of the thin ridge where it joins the body of
the mandible and a light tap with a hammer is sufficient to detach it. The
separated fragment or portions of mylohyoid ridge are pulled away from the
body of the mandible by contraction of the mylohyoid muscle and they are
then gripped by Fickling’s forceps.
At this stage it is sometimes helpful if the assistant presses upwards in the

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 SURGICAL PREPARATION OF THE MOUTH FOR DENTURES

Fig. 5.6. Mylohyoid ridge resection. a, Prominent mylohyoid. b, Removal of

ridge and 0-6 cm of mylohyoid muscle. c, Wound closure.

submandibular region to raise the detached piece of ridge so that it can be

more easily grasped. Gentle traction on the Fickling’s forceps is used to pull
the severed ridge and attached muscle upwards out of the wound. The
mylohyoid muscle, which is only about 3 mm thick, is then divided close to
its ridge attachment, using long curved Mayo or MclIndoe scissors.
After separation of the ridge fragment, the main mass of the mylohyoid
muscle contracts back into the floor of the mouth. Any residual sharp bony
edges at the site of the ridge are eliminated with a large pear-shaped bone
bur. Only when the lingual aspect of the mandible feels quite smooth to the
touch is the wound closed. Before suturing, the area is gently irrigated with
warm Saline solution to remove bone debris. Any bleeding points should be
controlled by diathermy coagulation (Fig. 5.6).
A vacuum drain may be inserted on each side. The introducer is passed
firmly against the lingual surface of the mandible anterior to the sub-
mandibular gland and out through the skin of the neck. The drain end is
drawn through and the perforated part cut to a length to fit in the sublingual
space. The mucosa is closed with a continuous suture to make a leak proof
suture line and the neck end of the drains attached to sterile vacuum bottles.
It is advisable to prescribe a course of antibiotic treatment postoperatively
to prevent the development of infection.

Removal of Genial Tubercles

Where there is gross resorption, the genial tubercles form a hook-like
process over which the denture rides and tilts. It has been considered
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unwise to divide both genial muscles and mylohyoid muscles at the same
time as control of the tongue is affected. Fortunately, the intrinsic
musculature prevents this even if the genial muscles are completely
detached.
The surgical approach is straightforward. The incision is best placed
directly over the genial tubercles, in the lingual frenum and at right angles to
the line of the arch in order to avoid tension across the suture line during
movement of the tongue. The incision is made down to bone, and the soft
tissues and muscle attachments stripped off the bony prominence of the
tubercles which can then be removed with rongeurs or a bur as is
convenient. The incision is sutured and a suitably modified denture
inserted.
If necessary the whole of the genial muscle mass can be displaced
downwards. A 2/0 chromic catgut or polyglactin suture is passed with a fine
awl from the buccal sulcus, around the mandible and through the genial
muscles. The suture is removed from the awl, whichis ‘partially’ withdrawn
and then reinserted on the other side of the muscle bellies where the suture is
rethreaded through the awl’s eye. The end is taken back again, through the
muscle and back to the labial side. This embraces the genial muscles in a
mattress suture. The muscles are now detached with stout curved scissors,
cutting close to the bone, and pulled down by the suture to the lower border
of the residual mandible. If necessary the sutures can be removed at
14 days. Artery forceps are applied to the mattress suture below the knots in
the labial sulcus and the suture ends cut off between the knots and the
forceps. One artery forceps is released and the mattress suture pulled
out.
Branches of the sublingual arteries enter the mandible above the genial
tubercles and will be divided as the muscles are cut through. Bleeding from
these and any other muscular vessels must be arrested before the muscle is
pulled down and the wound closed.

Denture-induced Hyperplasia
These lesions develop following the persistent wearing of an ill-fitting
denture. They are usually a consequence ofgross alveolar resorption so that
the denture flanges become relatively over-extended. When first seen, they
are inevitably inflamed and oedematous, so, if the offending denture is
radically relieved, or preferably not worn at all, there will be considerable
shrinkage over a period of 10-14 days. The necessity for excision of the
lesion can be better assessed following this initial phase of resolution.
Lesions are most commonly found in the lower anterior region, but may
occur in relation to any part ofthe periphery of a mobile denture. They often
consist of multiple leaflets of fibrous tissue covered with relatively normal
mucosa. Though they should always be examined histologically when
excised, the incidence of malignant change is surprisingly small.
Each strip of hyperplastic tissue arises from the sulcus tissues by a long

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Fig. 5.7. Removal of localized mass of denture hyperplasia. a, Incision through

mucosa only. b, Undermining edges of defect. c, Wound closure.

thin attachment. In cross section the fibrous mass is usually substantially

wider than the attachment which in the other direction stretches along the
length of one edge. The attachment therefore can be described as a linear
pedicle. Not infrequently the mass is bifid in a longitudinal direction or
there are two masses running parallel to one another and attached close
together. One mass fills the space between the fitting surface of the denture
and the now much reduced ridge while the other overlaps the flange of the
denture.
Single or bifid granulomas can be treated by simple excision through the
linear pedicle. The margins of the wound are undermined with a scalpel and
any residual core of fibrous tissue from the pedicle excised down to the
surface of the periosteum. Usually the wound can be closed without further
loss of depth to the sulcus (Fig. 5.7).
Simple excision of thick fleshy lesions will leave a sizeable mucosal
defect. Undermining the margins of such a deficiency and suturing it will
lead to a loss of sulcus depth and increase the prosthetic difficulties.
An incision can be made on the labial or buccal aspect of the mass and the
mucosa dissected off the surface as a thin layer until the ridge is reached on
the other side of the mass. The fibrous core of the hyperplastic tissue is
excised down to the periosteum and the flap of mucosa sutured to cover the
defect. The blood supply to the mucosal flap will be too tenuous for it to
survive as a flap if it has been removed in a sufficiently thin layer to permit
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adequate excision of the fibrous core. It should be regarded as mucosal graft

which is attached along one edge. A previously fabricated acrylic plate is
lined with gutta percha at the site of the excision and held in place with
circumferential or per alveolar wires as appropriate. The pressure will
prevent haematoma formation under the mucosa and permit it to attach as a
raft.
: In some patients there are multiple rows of granulomatous masses so that
their individual excision is quite impractical. The entire complex will need
to be excised and the resultant defect grafted with a split skin (Thiersch)
graft.

Alveolar Ridge Remodelling

Following extraction of the teeth, bone is formed within the healing sockets
and subsequently undergoes remodelling until there is little or no
radiographic evidence of their former presence. Remodelling resorption
also affects the entire alveolar process to produce, after some six to eight
months, relatively stable ridges of even contour, but reduced bulk compared
with the immediate postextraction alveolar processes. Further slow
resorption continues thereafter which varies in rate between subjects. In
some patients barely detectable changes result over many years. In others,
within five or ten years all the original alveolar process has gone and in
some, basal bone is also lost. Indeed the body of the mandible may be
reduced to pencil thinness.
Comparatively little is known about the factors which govern the rate of
this long-term remodelling and less about ways of preventing it. It is
probable that masticatory forces acting on mucosal borne dentures are one
cause of alveolar bone loss, hence one of the reasons for interest in
overdentures. Not only do studs and copings added to the root-filled roots
aid retention and the stability of the denture, but some of the masticatory
force is transmitted naturally to the alveolar bone via the periodontal
membranes of the supporting roots. Indeed, it may be sufficient to root-fill
the roots and smooth off the cut surface, bevelling the margins. Special oral
hygiene measures are necessary in all cases to ensure the health of the
gingival margin and to prevent caries of the root end.
Atrophy of the alveolar bone is seen radiographically where posterior
teeth in one jaw are unopposed either by natural teeth or dentures, but this is
expressed as a loss of medullary bone trabeculae below and between the
tooth roots. There is a thinning of the lamina dura but the crests of the
interdental septa and the buccal and lingual cortical bone appears to be
largely unaffected.
During the initial remodelling of the edentulous ridge sometimes a
bulkiness is left at one point which will be found to surround a retained root.
This has led to the suggestion that the deliberate retention of roots
containing vital pulp tissue might help to preserve the size of the alveolar
process and perhaps reduce long-term bone resorption. The pulps of the

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teeth must be healthy so tooth loss must be necessary for periodontal

disease. The teeth must not exhibit excessive mobility and about half the
original socket depth must remain. Single prominent teeth are not suitable
as the denture is likely to rub on the resultant bulbosity. A reverse bevel
incision is made to remove epithelium lining the pockets and buccal and
lingual flaps reflected, those buccally to well below the level of the sulcus.
Infected granulation tissue and any calculus deposits are carefully curetted
away and the tooth crowns amputated with a water cooled bur. The root
ends are reduced to below the level of the alveolar crests and bevelled
towards the buccal and lingual aspects without damage to the socket walls.
The periosteum is divided under the labial and buccal flaps well below the
sulcus to permit easy advancement of the mucosa to cover the sockets and
to permit tension free suture with a fine continuous monofilament suture
material.
Success depends upon primary healing and failure follows exposure of
the root ends and infection of their pulps. The evidence from observation of
accidentally retained roots suggests that the presence of deeply buried
fragments does not affect ridge remodelling and that with time a proportion
of larger roots are likely to be uncovered as a result of slow bone resorption,
necessitating their extraction. It seems unlikely that this technique will have
more than an occasional application.
Also promising is the insertion of non-porous hydroxylapatite cones in
extraction sockets. These resist resorption, but bone will be deposited on
their surface so that they can be incorporated in the healed alveolar bone.
Incomplete closure of the sockets does not necessarily lead to failure as
they can be covered by granulation tissue at any defects in the suture line. In
experimental animals bone will grow over the cones. Trials in humans are in
progress in American universities and it will be interesting to see if retention
of alveolar ridge bulk results in the long term.

Sulcus Deepening
As the alveolar ridges shrink over the years there is not only a loss of bone
height but a reduction in area of the masticatory mucosa. The decrease in
denture bearing surface increases the potential pressure to which it is
subject during mastication leading to pain and probably also to a further loss
of supporting bone. Although the sulcus tissues are mobile, movements of
the jaws and facial muscles will still displace the periphery of an
overextended denture. Also, once the ridges have lost their height, the
displacing forces generated in the sulcus tissues and by mastication result in
great denture instability and a succession of frictional ulcers.
Where there is bone below the sulcus which could form additional
support for a denture, a sulcus deepening procedure can improve denture
stability and comfort. If this additional bone is to be made available it must
be covered by amucosa which is firmly and immovably attached to the bone
surface. Various attempts have been made to excise the loose submucosa
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 ORAL SURGERY, PART 1

from beneath the sulcus tissues and to press the mucous membrane into firm
contact with the periosteum so that they become united. These techniques
employ closed and open submucosal dissections utilizing compression base
plates to hold the mucous membrane down onto the periosteum.
Alternatively, flaps are advanced into the sulcus leaving the exposed
periosteum to granulate and heal by secondary epithelialization. Regret-
tably they rarely lead to a permanent gain in sulcus depth. Over the months
the sulcus tissues contract back to their previous position. The most reliable
technique is to line the extended sulcus depth with a split skin (Thiersch)
graft taken from a non-hairy part of the arm or leg. These too contract quite
markedly if they are not kept stretched for at least three months, by which
time a permanent gain in sulcus depth can be assured. The best results are
therefore achieved by deliberately over extending the new sulcus, but not to
the extent of damaging the mental nerves, or the origins of the depressor
labii inferiors or depressor anguli oris because an unnatural lack of lower lip
movement will result. Nor should the new sulcus reach too far on to the
point of the chin where the bulk of a denture flange becomes unsightly.
Base plates lined with black gutta percha are prepared preoperatively on
models cast from overextended impressions. The dissection is carried out
so that the graft-buccal mucosal junction, which scars, will sit over the
denture flange assisting retention. Care must be taken not to damage the
periosteum which will need to be incised around the mental nerves. If the
nerves are very superficial it may be necessary to prepare to groove in the
underlying bone to set them below the surface.
After the dissection the black gutta percha is heated in hot water and
moulded into the depths of the new unlined sulcus. After cooling in situ the
base plate is carefully removed, dried and sprayed with an acrylic adhesive
such as nobecutaine and the split skin graft draped over the buccal
periphery and undersurface. The graft is then gently inserted on this acrylic
and gutta percha mould and the plates are wired in place for 10-14 days.
After removal and the trimming off of the excess skin they are reinserted to
keep the grafts stretched.
Dentures should be made before the operation and the flanges modified
with a tissue conditioner to fit the new sulcus. They replace the temporary
plates and should be worn day and night for 3 months until the skin grafts
are reasonably stable. They are of course removed after each meal, cleaned
and immediately reinserted. Once the grafts have matured and softened,
acrylic flanges are added to replace the tissue conditioner and they are left
out each night in the usual way. The technique also works well for the
maxilla where the dissection is much simpler.
The best form of free graft is undoubtedly palatal mucosa which can be
removed in strips, cut off as thin as possible and assembled on tulle gras.
Small spaces between the pieces will epithelialize over. Such grafts are
applied as described on gutta percha lined plates. This method results in
fresh masticatory mucosa which is stable and does not shrink.

Di
 SURGICAL PREPARATION OF THE MOUTH FOR DENTURES

Unfortunately the amount of graft which can be harvested from a palate is

limited so that extensive sulcus deepening procedures cannot be grafted in
this way. The denuded palatal mucosa is protected with a plate and a
suitable dressing until it has re-epithelialized.

Lowering of the Floor of the Mouth and Vestibuloplasty

This procedure, as described by MacIntosh and Obwegeser in 1967, in
effect combines the benefits of a mylohyoid ridge resection and a lower
buccal sulcus deepening procedure with a split skin graft. Ten millilitres of a
1:240000 solution of adrenaline in saline is injected into one side of the
floor of the mouth so as to distend the tissues and separate the tissue planes.
An additional 10 ml of sterile normal saline can be injected if required once
vasoconstriction has occurred.
An incision is made at the attachment of the lingual mucosa to the inner
aspect of the ridge from the 2nd molar region to the midline. A swab rolled
onto a sponge holder is pressed against the underside of the tongue to open
up the wound. With gentle touches of a knife the connective tissue is
separated from the periosteum.
Once the lingual nerve has been identified the mucosal incision can be
extended backwards and then laterally over the retromolar region. The
lower end of the superior constrictor is separated from the mandible so as to
free the nerve. The sponge holder is moved deeper into the wound and the
attachment of the mylohyoid muscle to the mandible is separated from the
bone with scalpel and scissors. Remodelling of a sharp mylohyoid ridge
follows detachment of the muscle. A few of the upper fibres of the
genioglossus may be divided also.
After the buccal sulcus has been infiltrated with vasoconstrictor the
incison is continued on the buccal side at the junction of the attached and
sulcus mucosa. The buccinator is detached in the same way as the
mylohyoid, taking care to identify and preserve the mental nerve. To avoid
a floppy lower lip separation of the origins of the depressor muscles should
be avoided. A similar procedure is completed on the other side.
Four polyglactin sutures are initially inserted into the lingual flap and
both ends are then passed under the mandible with the aid of a
circumferential wire awl, entered through the submandibular skin, and
brought upwards into the buccal flap. Even though resorbable sutures are
used, removal is best and is facilitated with a pull-out black silk suture,
knotted onto each circumferential suture in turn, above the lingual
mucosa.
When the buccal sutures are tied, the two ends from adjacent sutures are
knotted together so as to increase the length of buccal mucosa which takes
the pull of the thread. Soft PVC tubes may also be threaded on to stop them
cutting in. As the sutures are tightened the floor of the mouth and the buccal
mucosa are both drawn down towards the lower border of the mandible.
i
 ORAWES UR GERRY. eb ARSieel

Fig. 5.8. Lowering of the floor of mouth and skin graft. a, (Patient’s left.) The
floor of mouth is incised at the lingual edge of the ridge masticatory mucosa
(patient’s right). The soft tissues are displaced medially off the mylohyoid
muscle, the lingual nerve found and preserved. b, (Patient’s right.) The
mylohyoid muscle is cut, close to the mandible. (Patient’s left.) The entire
mylohyoid is separated and the buccal mucosa incised at the lateral margin of
the ridge mucopelriosteum. Mental nerve and buccinator are uncovered. c, The
mental foramen is extended downwards to lower the nerve. Sutures are passed
through lingual mucosa and muscle, around pull-out sutures. The ends are
passed with circumferential awls under the mandible and through the buccal
mucosa, displacing the buccinator muscle. The ends of adjacent sutures are
threaded through soft rubber tubes and tied.

After the sutures have been tied the two pull-out threads will be tied together
at the front under the tongue (Fig. 5.8).
The ridge remains covered with masticatory mucoperiosteum, but there
is now a bare area of periosteum both buccally and lingually. The areas are
covered with a skin graft applied with a black gutta percha mould on an
acrylic plate, as previously described, and the plate is fastened on with
circumferential wiring. The plate and the sutures are removed at 14 days.
Sometimes removal of a particular suture can prove difficult, hence the use
of resorbable ones. The mould should be washed and replaced until
dentures, which have been previously constructed, can be modified to fit the
new foundation. They should be inserted as soon as possible, preferably the
same day, and worn continuously except when removed for cleaning for
around 4—6 months.

Augmentation of the Bony Ridge

Where atrophy of the alveolar bone is extreme and where there is
additionally loss of basal bone, sulcus extension procedures alone will not

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 SURGICAL PREPARATION OF THE MOUTH FOR DENTURES

help. If the results of some of the techniques of sulcoplasty are poor those of
augmentation of the bony ridges are mostly disappointing.
One of the complications of such extreme atrophy is the bilateral fracture
of the edentulous, pencil thin mandible which results in a severe ‘bucket
handle’ deformity. This can be treated successfully either by Gunnings’
splints and pyriform aperture wires, or if the mandible is thick enough by
miniature (Champey) bone plates applied supraperiostealy along the lower
border of the mandible. The latter technique may be improved by using a
submandibular approach and by inserting cancellous bone chips from the
iliac crest. The use of interosseous wires at the fracture site which require
severe disruption of the periosteum for their insertion, and which lack
rigidity results in a delayed or mal-union.
The successful treatment of such cases with bone grafts along the
mandibular lower border fixed with circumferential wires led to attempts to
increase the thickness and strength of the jaw before fracture had occurred.
Sulcus deepening procedures were added to this technique as a means of
augmenting the foundation for a lower denture. Unfortunately the
additional bone is completely resorbed within a matter of a year or so,
frustrating both objectives.
Bone grafts of split and contoured rib, segments of iliac crest and
medullary chips have also been used to augment and rebuild both the
mandibular and maxillary alveolar ridges. Such techniques require division
of the periosteum beyond the immediate base of the flaps to permit their
advancement and closure of the soft tissues over the grafts. Meticulous
vertical mattress suturing is required because only a one-layered closure is
possible and any leak leads to infection of the grafts. Because the area of
masticatory mucosa is also greatly reduced, sulcoplasties become
necessary, once the grafts have become vascularized, to create the new
bony denture foundation. Unfortunately, once again, much of the height
gained may be lost, often within a period oftwo to three years. On the other
hand, the width of the denture foundation is usually increased permanently.
Indeed, as an alternative approach, the grafts may be added laterally to
increase the width but not the height of the denture foundation.
More recently attempts have been made to increase the height of the bony
ridges by sandwich grafting so that the denture bearing surface is formed by
part of the original mandibular cortex, nourished during the healing process
by a periosteal blood supply through attached mucosa and muscles.
A visor osteotomy has been used in which the mandible is sectioned
vertically between the cortical plates. This is possible for the full depth of
the mandible between the mental foramina, but further back the plane of
section has to be angled medially to avoid the mandibular neurovascular
bundles. The cut therefore emerges on the lingual side between the
mylohyoid ridge and the lower border of the mandible. The lingual fragment
was then raised up still attached to the mucosa and muscles, and the lower
part at the front wired to the upper border of the outer segment. Bone chips
LS
 ORAL SURGERY, PART 1

could be packed around it to increase the bulk. Unfortunately the lingual

fragment was often thin and weak, particularly posteriorly, and the result
did not resist resorption.
A horizontal sandwich osteotomy with a cartilage or bone graft inserted
into the resulting gap will raise the alveolar crest upwards. Again the
closeness of the mandibular bundle to the top of the atrophic mandible
makes it necessary to turn the cut vertically behind the mental nerves.
Hopkins (1982) refined the sandwich osteotomy by unroofing the
inferior dental canal from the mental foramen backwards and freeing the
mandibular neurovascular bundle as far as the ramus. A groove was cut in
the posterior end of the external oblique ridge to accommodate it. This
permitted a 45 ° oblique osteotomy to be made from one molar region to the
other without fear of damage to the nerve. The upper fragment was
supported on substantial blocks of bone and bone chips packed in to fill all
recesses and to give contour to the reconstructed mandible (Fig. 5.9). He
was able to report a 60 per cent residual increase in height after two years
which appeared thereafter to be stable (Hopkins and Sugar,
1982). Unfortunately neural morbidity tends to be high with all these
techniques.
A sulcoplasty is necessary once the osteotomies have united and all
grafts have been incorporated.
Problems with bone graft augmentation of the ridges has prompted
attempts to do so with allografts which would not resorb. Various inert
materials have been implanted into subperiosteal pockets, notably
‘proplast’ sponge and more recently dense hydroxylapatite granules. The
latter can be injected through relatively limited soft tissue wounds into
subperiosteal pockets created over the ridges. The need to undermine
sufficient tissue to get adequate relaxation to elevate the mucosa means that
there is a tendency for the injected granules to migrate sideways until the
healing process restrains them. The material is inert, but crushed
autogenous bone can be mixed with it, which will attach to it and encourage
subperiosteal bone to be deposited upon it. The material resists resorption
so will persist once successfully implanted. The gain in ridge height is often
modest. There would seem to be an application for this material for
undercuts by filling out a concavity rather than excising the overhang and
for eliminating razor sharp ridges. Porous hydroxylapatite blocks forming
segments of a ridge also can be used. The dissection to create a suitable
tunnel is more taxing but they can be used in both jaws and do not migrate
like the granules. It remains to be seen what the outcome will be in the long
term.

PROBLEMS WITH EXTENSIVE PROCEDURES

Those patients who require the more extensive procedures tend to be
elderly. Not only may they have respiratory, cardiovascular or other

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 SURGICAL PREPARATION OF THE MOUTH FOR DENTURES

Fig. 5.9. Hopkins ridge augmentation procedure. a, The grossly resorbed

mandible. b, The mental nerve and mandibular nerve are uncovered by
removing a strip of bone and displaced sideways. c, The jaw is divided vertically
from end to end ofthe ridge. The lingual fragment is raised and wired to the rami
posteriorly. Block bone grafts support it in place and bone chips are packed into
all gaps. Three circumferential wires sandwich the bone grafts in place.

problems which make them poor risk cases for surgery, but old people, even
if fit, recover less rapidly, are more prone to complications and take longer
to achieve full mobility again after an enforced period in bed.
Once patients have had all their teeth extracted they usually believe their
dental problems are over. They rarely envisage trouble with dentures and
certainly not difficulties that cannot be solved solely by prosthetic skills.
1 Ie
 ORAL “SURGERY, PART

The concept of a surgical solution to their problems is not accepted readily

and if a substantial operation is proposed it is quite properly viewed with
concern. There can be no guarantee that even the best of these techniques
will produce a lasting improvement, and with a high risk of permanent
morbidity such as a numb lip, and also because a better foundation for the
dentures does not ensure that the patient can wear them successfully, the
surgeon should be wary of being over-persuasive, however great the urgings
from the patient’s dentist. Furthermore, it is a common experience that
these patients are not tolerant of the discomforts of surgery, and the delay in
healing with grafting procedures can be considerable if complications
arise.

IMPLANT PROCEDURES
Subperiosteal Implants
These have been used now over some thirty years and more is known about
their long-term outlook than for any other implant. The technique for the
use of all implants demands care and attention to detail both in the surgery
and the prosthetics. Subperiosteal implants have a limited place in the
treatment of carefully selected patients who cannot tolerate dentures due to
a lack of anatomical support and inability to gain sufficient muscular
control.

Endosseous Implants
There have been many designs of endosseous implant. The blade implant
has proved reliable especially when acting as an abutment to a bridge
attached to a natural standing tooth. Where more rigid implants support a
fixed prosthesis the elasticity of the mandible when loaded has led to either
separation of the prosthesis/implant interface or loosening of the implant.
They also fail when the load is excessive and not distributed over an
adequate area. An obvious problem is the need for adequate supporting
bone as there are severe anatomical restraints, notably the inferior dental
nerve in the mandible and the maxillary sinuses or nasal cavities in the
maxilla.
The most successful implants to date are the ‘osseous integrated’
implants of Branemark. These screw type, titanium implants are initially
buried beneath the sutured mucosa until bony healing about them is
complete. The submucosal ends are then exposed by removing a disk of
mucosa and precision copings attached. They are only inserted in the
anterior alveolar region so that full arch prostheses are cantilevered
posteriorly.

Staple Implants
Two popular bar-type supports for lower dentures with attachments which
penetrate the mandible have been developed. The Small staple implants

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 SURGICAL PREPARATION OF THE MOUTH FOR DENTURES

consist of a plate which is fixed to the lower border of the mandible between
the mental foramina by a series of round staples. The outermost staples pass
right through the mandible and thimble attachments are fixed to the superior
end. A connecting bar or copings which fit over the thimbles is embedded in
the denture.
The ramus frame implant is a horseshoe-shaped rectangular section bar
which is suspended just clear of the lower ridge mucosa. The two posterior
ends are perforated and fit into 12 mm deep slots cut into the anterior border
of the ramus just above the retromolar region. An anterior vertical strut in
the midline joins the frame onto a short perforated horizontal bar which is
tapped into a deep slot cut between the residual ridge and the mental
eminence. The stability of the implant is dependent upon bone growing
through the perforations. The denture fits over the oral bar. The advantage
of this implant is the ease with which it can be removed should it fail
biologically or with which it may be replaced if it fails mechanically.

ORTHOGNATHIC SURGERY
Skilful prosthodontics can often provide useful dentures for patients with
discrepancies in the relative position of the upper and lower jaw. These
patients have established masticatory habits related to the malrelation of
their natural teeth and can often use such dentures which reproduce this
relationship within the limits of stability. However, in some instances it is
impossible to make dentures which are stable enough for chewing purposes,
although they may be acceptable aesthetically and for speech. Where the
prosthetic problems prove insoluble it may be necessary to produce a more
normal relationship of the alveolar ridges by means of orthognathic
surgery.

SUGGESTED READING
Block M. S. and Kent J. N. (1984) Long-term radiographic evaluation of
hydroxylapatite—augmented mandibular alveolar ridges. J. Maxillofac. Surg.
42, 793-796.
Block M. S. and Kent J. N. (1985) Healing of mandibular ridge augmentations
using hydroxylapatite with and without autogenous bone in dogs. J. Maxillofac.
Surg. 43, 3-7.
Boyne P. J., Rothstein S. S., Cook V., Stutz T. I. and Gummaer K. I. (1982)
Fluorescence microscopy of durapatite implants. Proc. Am. Ins. Oral Biol.
53-57.
Branemark P. I. (1977) Osseointegrated implants in the treatment of the edentulous
jaw. J. Maxillofac. Surg. 42, 793-796.
Cram D., Roberts H. and Baum L. (1972) Ramus endosseous frame implant for use
with patient’s denture. Report of a case. J. Am. Dent. Assoc. 84, 156-158.
Dugan D. J., Getz J. B. and Epker B. N. (1981) Root banking to preserve alveolar
bone: a review and clinical recommendations. J. Am. Dent. Assoc. 103,
737-742.
nS
 ORAL SURGERY, PART 1

Hall H. D. (1971) Vestibuloplasty, mucosal grafts (palatal and buccal). J. Oral

Surg. 29, 786-791.
Harle F. (1975) Visor osteotomy to increase the absolute height of the atrophied
mandible: a preliminary report. J. Maxillofac. Surg. 3, 257-260.
Hopkins R. (1982) A sandwich mandibular osteotomy: a preliminary report. Br. J.
Oral Surg. 20, 155-167.
Lekkas K. (1977) Absolute augmentation of the mandible. Int. J. Oral Surg. 6,
147-151.
MacIntosh R. B. and Obwegeser H. L. (1967) Preprosthetic surgery: a scheme for
its effective employment. J. Oral Surg. 25, 397-413.
Roberts H. D. (1971) Surgical and Laboratory Procedures for the Placement of
the Ramus, Single Tooth and Ramus Frame Implants. Washington: College
Press.
Schettler D. and Holtermann W. (1977) Clinical and experimental results of a
sandwich-technique for mandibular alveolar ridge augmentation. J. Maxillofac.
Surg. 5, 199-204.
Starshak T. J. and Sanders B. (1980) Preprosthetic Oral and Maxillofacial
Surgery. St. Louis, Mosby.
Stoelinga P. J. W. Tideman H., Berger J. S. and De Kooman H. A. (1978)
Interpositional bone graft augmentation of the atrophic mandible. A preliminary
report. J. Oral Surg. 36, 30-32.
Sugar A. and Hopkins R. (1982) A sandwich mandibular osteotomy: a progress
report. Br. J. Oral Surg. 20, 168-174.

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 CHAPTER 6

PYOGENIC INFECTIONS OF THE SOFT TISSUES

ACUTE ALVEOLAR ABSCESS

Some clinicians use the term alveolar abscess as being synonymous with a
periapical abscess, while others would include periodontal or even
pericoronal abscess, so using it in a similar fashion to the lay term ‘gum
boil’.
Acute periapical abscess arises when organisms from an infected
necrotic eo pulp invade the periapical tissues. They usually gain access
9 the periré le r tissues through the apical foramina so that the infection
is ar periapical, but on occasions the infection escapes through an
accessory canal, an endodontic perforation, or an opening in the floor of the
pulp chamber of a primary molar resulting from resorption or a fractured
root. Under these circumstances the abscess develops on the lateral aspect
of the root or at the root furcation. Infection from a split root character-
istically presents as a mid-root sinus or a longitudinal area of resorption
along the lateral border of the root.
The usual causes ofinfective necrosis of the pulp are a carious cavity, or
contamination of a traumatic exposure of the pulp. Sometimes the initial
necrosis is a Sterile process, as when the apical vessels are torn by a blow on
the tooth or following inadvertent chemical or thermal damage to the pulp
during a coronal restoration. The necrotic pulp subsequently becomes
infected via the periodontal lymphatics from the gingival crevice.
Radiographic evidence suggests that the acute abscess is often an
exacerbation of a pre-existing chronic periapical infection and presents
initially as redness and swelling in the sulcus, usually on the outer aspect of
the alveolar process. Then a fluctuant, submucosal swelling develops which
bursts to produce a sinus discharging pus. The condition is invariably
painful until the pus has been released either spontaneously or surgically
(Fig. 6.1).
Acute periodontal abscess arises in the periodontal membrane adjacent
to a periodontal pocket. While in some cases, food impaction or repeated
occlusal trauma appears to be the precipitating factor, often the immediate
cause of the abscess is not apparent. An acute periodontal abscess produces
redness and swelling of the gingival margin, interdental papilla and of the
mucoperiosteum lateral to the tooth. The pain is usually continuous, dull or
throbbing, variable in intensity but rarely as severe as a periapical abscess.
The pus usually discharges via the gingival pocket, but may produce a sinus
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 ORAL SURGERY, PART 1

b
Fig. 6.1. a, ‘Comforter’ caries has destroyed the crowns of these deciduous
upper central incisors. Sinuses in the sulcus over the apices due to chronic
apical abscesses. b, AJ discoloured and pulpless. Mesial caries A|A. The apex
of unresorbed AJ is being pushed out of the sinus in the sulcus by
developing 1| j -

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 PYOGENIC INFECTIONS OF THE SOFT TISSUES

on either the inner or outer aspect of the alveolar process and only rarely
tracks to the skin surface.
A pericoronal abscess arises around the crown of a partially erupted vital
tooth, usually the 3rd molar, and therefore, resembles a periodontal
abscess.
Abscesses may also arise in association with infected cysts, odontomes,
tooth and bone fractures, subperiosteal and endosteal implants and other
foreign bodies. Factors which determine whether an alveolar abscess is
acute or chronic are similar to those affecting abscesses in general, namely
the virulence of the organisms concerned, the general condition of the
patient and the presence or absence of drainage.

Differential Diagnosis
The differential diagnosis between an acute periapical and an acute
periodontal abscess is as follows. With a periapical abscess there is a tooth
or root with necrotic and infected pulp, a swelling over the apex and
possibly a sinus. The tooth is periostitic and later may become mobile. A
periodontal abscess arises in relation to a periodontal pocket and there is a
swelling or sinus in the gingival third of the alveolar process or,
alternatively, a discharge from the pocket. The tooth is both tender to
pressure and mobile at an early stage in the evolution of the condition but
the pulp is usually vital. Periodontal abscesses are uncommon in children
and an acute swelling close to the gingival margin of a primary molar is
usually a periapical abscess.
Just occasionally a periodontal abscess may secondarily infect and
destroy the pulp of the related tooth, or an apical abscess may discharge via
the gingival crevice, but careful consideration of the clinical and
radiographic evidence will usually permit a differentiation to be made.

Bacteriology
Although by ordinary clinical microbiological methods nent
aaa andsother perobie organisms aa be cultured, anae

hme cnen puso for strict anaerobic ee made.

Clinical Course of a Periapical Abscess

The acutely inflamed pulp produces a throbbing pain characteristically
provoked by heat. Occasionally, the pain subsides with pulp necrosis
especially if the infection pursues a chronic course. However, when the
infection spreads into the periapical tissues from the root canal of the tooth,
the periodontal membrane becomes acutely inflamed and swells, raising the
tooth slightly in the socket so that it comes into premature contact with the
opposing tooth when the patient bites. Thus the tooth becomes tender to bite
upon, tender to percussion (periostitic), and moderately mobile as
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 ORAL SURGERY, PART 1

demonstrated by lateral pressure. Pus accumulates in the periapical

marrow spaces where normally it is successfully walled off by a pyogenic
membrane. An intense throbbing pain is experienced at this stage, but relief
occurs immediately if the tooth is extracted and the pus is allowed to drain.
If treatment is delayed, bone resorption permits the pus to penetrate the
overlying cortex and spread out under the periosteum. The character of the
pain changes from throbbing back to a dull ache and there is usually a
marked diminution in its intensity.
While the pus is still confined within the bone a soft, puffy collateral
oedema of the overlying tissues develops and the regional lymph nodes
become enlarged and tender. With the spread of infection through the
cortex, the swelling becomes more marked and the tissues immediately
overlying the pus become firm and tender. Should a spreading cellulitis
supervene, or a suppurative infection of a tissue space result, then an
extensive firm swelling develops and the previously pinkish hue of the
overlying skin deepens to a distinct red colour. It is important to distinguish
between pitting collateral oedema and the firm swelling associated with a
cellulitis or soft tissue abscess, for the former will resolve rapidly without
additional treatment after the drainage of the intrabony pus following
extraction. This is true even for children where collateral oedema can
produce a sizeable swelling. A cellulitis on the other hand requires not only
the extraction of the infected tooth and the drainage of any soft tissue
abscess, but also prompt treatment with antibiotics.

Further Course of the Infection

In the overwhelming majority of cases, the pus burrows laterally through
the adjacent cortical bone rather than disseminates through the cancellous —
bone whichis protected by an inflammatory cell barrier, the py i
membrane. The presence of a previous bone cavity OTs = a
symptomless periapical granuloma which often precedes the acute abscess
and the closeness of the apices of most teeth to the labial or buccal cortex
may facilitate this process. Once the pus enters the soft tissues it tends to be
directed in certain directions by fascial or muscular attachments and
untreated will eventually discharge into the mouth or onto the face or neck.
Early extraction with a course of antibiotic therapy (e.g. metronidazole,
penicillin, etc.) will usually bring about resolution of the infection. Rarely,
and only in circumstances to be described later, is it appropriate to leave
infected teeth in situ until the infection ‘has been brought under control’.
The best method of control of any surgical infection is removal of the cause,
drainage of any pus and antibiotics.
Sometimes it is possible to drain the pus through the apex of an acutely
abscessed tooth by opening into the pulp canal. This is most easily
accomplished in the case of single-rooted teeth such as incisors and canines
and has the obvious advantage of preserving the tooth. If drainage is
effected in this way antibiotics should be given to help control the infection
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 PYOGENIC_INFECTIONS OF THE -SOFT TISSUES

and in all cases drainage via the pulp canal must be accompanied by
incision and drainage of any pus which has accumulated in the adjacent soft
tissues. If, despite these measures, the infection persists, then the tooth
must be extracted.
In the case of a periodontal abscess, it is seldom essential to remove the
tooth to promote drainage unless it is either a bifurcation or trifurcation
abscess. However, simple drainage must be followed by periodontal
surgery to prevent recurrence.

PERICORONAL INFECTION
Pericoronitis is an inflammation of the soft tissues covering the crown of a
partially erupted or unerupted tooth. The condition can only arise in
association with an unerupted tooth if there is a communication between the
crown of the tooth and the oral cavity. A transient inflammation of the
overlying gingiva often occurs immediately preceding full eruption of the
deciduous teeth. However, this rapidly subsides as the tooth erupts further,
and is probably caused by the initial loss of the overlying zone of epithelial
intercellular adhesion and aggravated by chewing on the inflamed
unkeratinized mucosal margin.
Classic pericoronitis is likely to occur when the eruption of the tooth is
impeded or unduly prolonged, usually as a result of malposition or
impaction. It is because of this that pericoronal inflammation is almost
invariably associated with the mandibular 3rd molar and is only seen in a
small number of cases in relation to other impacted teeth such as the upper
3rd molar. Some affected lower wisdom teeth may be in a favourable
position for eruption, and once the infection has been controlled, further
upward movement may take place uneventfully so that a normal gingival
margin is attained. It is, however, logical to consider extracting a lower 3rd
molar which has been responsible for repeated attacks of pericoronitis, even
though the tooth has reached the occlusal plane. Fortunately, deeply buried
teeth are not involved in periocoronal infection and there is rarely
justification for their prophylactic removal. In fact, many patients with
impacted lower 3rd molars remain symptom-free throughout their whole
lifetime.
Another interesting anomaly is that bilateral concurrent pericoronitis is
rare, despite the presence in many young adult mouths of two partially
erupted lower 3rd molars, and when it occurs usually implies a predisposing
condition such as infectious mononucleosis or Vincent’s ulcerative
gingivitis.

Aetiology
The aetiology of the condition is obscure. It has been postulated that food
collects between the crown of the tooth and the overlying gum flap and that
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this constitutes a favourable site for bacterial incubation which, in turn,

causes inflammation of the gum flap.
This may be true, but similar conditions prevail in other individuals with
partially erupted teeth without pericoronitis supervening. Indeed it is
sometimes possible by pressure on the operculum to express, from a
clinically quiescent pericoronal space, a large amount of white material
which is composed of desquamated epithelial cells, decomposed foodstuff,
and dead and living bacteria.
Trauma to the overlying pad of gum from the cusps of an opposing tooth
is an obvious aetiological agent, but in many cases it is difficult to determine
whether the traumatic injury to the intervening soft tissues occurred before
or after the flap became swollen by inflammatory oedema. The virulence of
the bacteria within the pericoronal space must also be an influential factor
and it is now recognized that these organisms are usually anaerobes such as
bacteroides which have assumed a pathogenic role.
Lowering of the host resistance appears to be correlated with the
development of a pericoronitis and many patients have a history of an upper
respiratory tract infection such as acute coryza, pharyngitis, influenza or
infectious mononucleosis. Other systemic illnesses, fatigue and emotional
strain also appear to precipitate the condition.
A practical clinical classification for pericoronitis is to divide it into three
categories: chronic, subacute and acute. This has the virtue of providing
suitable criteria for treatment.
With chronic pericoronitis, the patient is usually asymptomatic except
for the occasional mild discomfort or bad taste due to a discharge of pus
from beneath the gum flap. Treatment is not sought unless the patient
experiences subacute or acute exacerbations.
In subacute pericoronitis most patients experience a well localized dull
pain and the gum pad is swollen, tender and red. Sometimes pus can be seen
oozing from beneath the anterior margin of the gingival flap or it can be
expressed by gentle pressure. There is foetor oris and indentations from the
cusps of the upper 3rd molar may be observed where they impinge on the
pericoronal tissues and the adjacent oedematous buccal mucosa. The
patient may complain of slight discomfort on swallowing and some
difficulty in opening the mouth. The submandibular lymph nodes on the
affected side are enlarged and tender.
Acute pericoronitis presents with a combination of intra- and extraoral
clinical features. The signs are similar to those of subacute pericoronitis
except that facial swelling is common. Limitation of opening may be
marked, pain is throbbing and severe and may interfere with sleep, while the
majority of patients experience discomfort on swallowing. The consti-
tutional upset may be considerable with pyrexia, severe malaise and
anorexia. The regional lymph nodes are tender and enlarged. If untreated
the infection is likely to spread to the adjacent tissue spaces.
Pus from pericoronitis related to a lower 3rd molar may track forwards

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submucosally along the inclined gutter, formed by the body of the mandible
and the attachment of buccinator to the external oblique ridge. The pus will
accumulate in the submucosa beneath the mucosal reflection and point
opposite the Ist and 2nd molar or even the 2nd premolar. This migratory
abscess may eventually discharge spontaneously via an intraoral sinus or,
more rarely, track down to the middle of the lower border of the mandible
just behind the depressor anguli oris muscle where, if it is not incised, it will
burst through the skin. While many pericoronal infections are suppurative,
some are ulcerative. Classical ulcerative pericoronitis is due to a Vincent’s
infection, but acute herpetic gingivostomatitis may start around a lower 3rd
molar, later spreading forwards and backwards onto the fauces and soft
palate.

Treatment
It is important to decide whether the related tooth is likely to achieve full
eruption. Clinical examination and radiography will help to determine this.
Such factors as the age of the patient and a history of previous attacks of
pericoronitis will obviously have to be taken into consideration. Eruption is
unlikely after 25 years of age and several previous attacks would also
suggest extraction to be the best treatment.
1. If there is abscess this must be incised and drained. With antibiotic
cover it may also be convenient to remove the 3rd molar at the same time.
There is no evidence that this will produce osteomyelitis or disseminate the
infection provided that the extraction can be accomplished without bone
surgery.
2. If there is no abscess gentle irrigation of the pericoronal space with
warm normal saline, using a 10 ml syringe and a needle with the point
ground off, helps to dislodge food debris and other material which may have
collected under the gum flap. Irrigation is continued with hot saline mouth
baths over the inflamed area. The patient should be instructed to perform
this ritual at two hourly intervals while at home and during work hours.
3. An antiseptic should be instilled into the pericoronal space. This can
be aqueous povidine iodine or alcoholic tincture of iodine or 1 per cent
gentian violet.
4. If the condition is being aggravated by an upper 3rd molar which
irritates the swollen gum flap when the patient closes, then this should be
relieved either by extracting the upper tooth or by grinding down the
offending cusps if the tooth’s retention is important as an abutment for a
future bridge or prosthesis, or if it is intended to preserve the mandibular 3rd
molar.
5. Antibiotic therapy such as metronidazole 400 mg, 12-hourly,
phenoxymethyl penicillin 500 mg, 6-hourly, or amoxycillin 500 mg,
8-hourly, is indicated for all cases of acute pericoronitis and may be needed
also for the subacute condition if the infection is unlikely to subside quickly
from the use of local measures alone.
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6. Ulcerative pericoronitis due to Vincent’s organisms is treated by

metronidazole 400 mg, 1 2-hourly, supplemented by gentle local measures
as under (2) and (3) above, but extraction of the upper 3rd molar would be
unwise until the infection is under control.

SPREADING INFECTIONS IN THE SOFT TISSUES

An infection spreading in the soft tissues from one of the foci discussed
above may take the form of the following.

1. A Cellulitis
This is a spreading infection of the loose connective tissues. It is
characteristically the result of a streptococcal infection and does not
normally result in the formation of large collections of pus. Antibiotics
usually arrest the spread of the infection and bring about complete
resolution of the condition. However, the presence of pockets of undrained
pus should always be suspected and, if present, dealt with by exploration
and drainage.

2. A Suppurative Infection
Suppurative infections are characteristic of staphylococci, often with
anaerobes such as bacteroides, and may produce large accumulations of
pus which will require immediate drainage.

3. Gangrene
In pre-antibiotic days the pressure within tissue compartments produced by
massive oedema and suppuration in response to fulminating infections
could lead to necrosis of the involved muscles. In particular this was seen in
the case of subtemporalis muscle infection and Ludwig’s angina. Swelling
of this degree is rarely seen these days, but just occasionally infection by
gas-forming organisms and anaerobes occurs which results in muscle
necrosis.

Soft-tissue Infections and their Spread

Infections of the soft tissues around the jaws usually originate from a
periapical infection related to a tooth or root, pericoronal and periodontal
infections, or a secondarily infected cyst or odontome. Occasionally the
infecting organisms enter the soft tissues from a penetrating wound,
especially one with a retained foreign body, following an injection with a
contaminated needle or a furuncle of the overlying skin. In children a
staphylococcal, facial or submandibular cellulitis may arise from tonsillar
or nasal infections or during the eruption of a tooth or following loss of the
deciduous predecessor. Irrespective of the original source of infection, once
it has become established within the soft tissues, its further spread tends to
occur in a uniform fashion.

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 PYOGENIC INFECTIONS OF THE SOFT TISSUES

The routes by which the infection can spread are as follows.

1. By direct continuity through the tissues.
2. By the lymphatics to the regional nodes, and eventually into the
bloodstream. If infection becomes established in lymph nodes, secondary
abscesses may develop. Spread into the tissues from the nodes results in
secondary areas of cellulitis or a tissue space abscess.
3. By the bloodstream. Local thrombophlebitis may rarely propagate
along the veins, entering the cranial cavity via emissary veins to produce
cavernous sinus thrombophlebitis. Organisms or infected emboli may be
Swept away into the bloodstream Sous to bacteraemia, septicaemia and
pyaemia with the development of embolic abscesses.

A number of factors affect the ability of the infection to spread. These are
as follows.
1. The type and virulence of the organism or organisms.
2. A failure to drain accumulations of pus. Pus contains large numbers of
organisms and their toxins and drainage of an abscess usually leads within a
matter of hours to a marked reduction in malaise and a fall in the patient’s
temperature and pulse rate. Furthermore, pus which is increasing in volume
may force its way into adjacent tissue spaces rather than towards the
surface.
3. The state of the patient’s health generally which may be adversely
affected by a virus infection, diabetes, malnutrition or alcoholism.
4. The effectiveness of the patient’s immune mechanism. It takes time
for the body’s immune mechanisms to be mobilized to combat an organism
not previously encountered. In pre-antibiotic days a failure of the white cell
count to rise was of grave significance. While antibiotics now enable
clinicians to attack the organisms directly new circumstances result from
the use of corticosteroids and immunosuppressive drugs which impair the
body’s natural defences. Patients may be encountered who have a rare
congenital defect such as hypogammaglobulinaemia.

The anatomical factors influencing the direction of spread within the

tissues are:

1. The site of the source of the infection, i.e. upper or lower jaw, and the
particular segment of the jaw involved.
2. The point at which the pus escapes from the bone and discharges into
the soft tissues, e.g. labiobucally or linguopalatally.
3. The natural barriers to the spread of pus in the tissues, such as by
layers of fascia or muscle or the jaw bones themselves.
The muscles which commonly play a part in containing infections around
the jaws are the myohyoid, buccinator, masseter, the medial and lateral
pterygoid muscles, the temporalis and the superior constrictor of the
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pharynx. Even the smaller and thinner muscles of facial expression can
play a significant role in determining the direction in which the infection
spreads.
The fascial layers probably play a slightly less important role than the
muscles in influencing the spread of infection through the soft tissues of the
face and neck. One of the problems which arise when discussing the layers
of fascia is that the term is used somewhat imprecisely. Last (1959)
emphasized that, on the one hand, the term is used to describe tough
membranes, such as the investing layer of deep cervical fascia or the
prevertebral fascia, both of which are demonstrable anatomical structures
and can be incised and sutured. But on the other hand, the term is also
applied to thin, delicate sheets of areolar tissue, like the buccopharyngeal
membrane, or such as are normally found covering the surface of many
muscles. From a surgical point of view, therefore, only the investing layer of
cervical fascia, the prevertebral and the pretracheal fascia, the carotid
sheath and the parotid fascia need to be considered in relation to the spread
of infection in the soft tissues of the submandibular region and neck.

sternomastoid and trapezius muscle

external occipital protuberance in a: e eto
the tip of the mastoid process. In the front of the neck it is attached to the
lower border of the mandible from the chin to the angle on each side.
Between the angle of the mandible and tip of the mastoid process the
investing layer splits into two layers. The parotid gland lies between these
two layers which become the parotid fascia. The superficial layer extends
upwards to be attached to the zygomatic arch. In many subjects it extends
forward from the parotid gland to form a thinner sheet which covers the
buccal space laterally. The deep layer of the parotid fascia is attached along
the base of the skull from the tip of the mastoid process as far medially as the
carotid canal where it blends with the carotid sheath.
The lower border of the investing fascia is attached to the spine of the
scapula posteriorly, to the clavicle and sternum, anteriorly and encloses the
trapezius and sternomastoid muscles. The midline is attached to the
suprasternal notch by two layers which split a short distance above it, and
the space between the anterior and posterior insertions is known as ‘Burn’s
space’. The investing layer is also attached to the hyoid bone.

The Prevertebral Fascia

This fascia lies anterior to the prevertebral muscles and extends from the
base of the skull in front of the longus capitis and rectus lateralis downwards
to the longus cervicis muscle at the level of the body of the 3rd thoracic
vertebra. It extends laterally across the scalenus muscles in the floor of the
posterior triangle of the neck.
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The Pretracheal Fascia

Its superior attachment is the hyoid bone at the midline and the oblique line
of the thyroid cartilage more laterally. It splits to enclose the thyroid gland
and laterally it fuses with the front of the carotid sheath deep to the
sternomastoid. Inferiorly it passes behind the innominate veins to blend
with the adventitia of the arch of the aorta. The pretracheal fascia therefore
forms a layer deep to the infrahyoid muscles.

The Carotid Sheath

The carotid sheath is not as dense a fascial sheet as the investing layer but
more a multilayered wrapping of areolar tissue. It is attached to the base of
the skull at the lower end of the tympanic plate and is continued downwards
to the aortic arch. It will be seen that the investing layer, the pretracheal and
the prevertebral layers of cervical fascia run in a vertical direction. Anterior
to the prevertebral fascia there is a space which extends from the base of the
skull to the diaphragm. Its upper part is the retropharyngeal space and this
compartment extends inferiorly behind the oesophagus through the
superior to the posterior mediastinum. An abscess in the lateral pharyngeal
space therefore may extend either laterally to the carotid sheath or medially
into the retropharyngeal space and thus descend into the superior and
posterior mediastinum. Similarly, infection penetrating anterior to the
pretracheal fascia and deep to the strap muscles can extend downwards
through the superior mediastinum into the pericardial space.
It will be seen that the investing layer, the prevertebral, and the
pretracheal layers of fascia potentially permit the spread of infections down
the neck into the thorax. Fortunately nowadays with antibiotic therapy this
is exceedingly rare.

SITES AT WHICH PUS ACCUMULATES

Pus tends to accumulate in specific regions which are referred to as tissue
spaces, none of which are actually spaces until pus has been formed. Some
of these potential spaces are compartments which contain structures such
as the submandibular salivary gland, the buccal pad of fat or groups of
lymph nodes. Normally these are surrounded by loose connective tissue
which is easily stripped back by finger pressure, either at operation in the
living patient, or in the cadaver to produce a cavity. Pus destroys the loose
connective tissue and separates the anatomical boundaries of the
compartment as it increases in volume, so creating an abscess cavity
bounded by muscles, fascia and bone.
Where a muscle is attached to a bone by Sharpey’s fibres, the attachment
is mostly strong and tendinous, but the muscle may be in part attached
mainly to the periosteum so that it and periosteum together are readily
stripped from the surface of the bone. Here again a potential space exists

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deep to the muscle if infection gains access to this plane of cleavage. As pus
forms it elevates the periosteum from the bone to form an abscess cavity
until its spread is limited by the more tendinous part of the muscle.
The narrow interval between muscles also contains a layer of loose
connective tissue which permits independent movement of the layers. Here
again pus can accumulate to produce an anatomically defined cavity.
The important spaces and potential spaces in the vicinity of the jaws are
as follows.

In Relation to the Lower Jaw

Submental space.
Submandibular space.
Sublingual space.
Buccal space.
Submasseteric interval.
Parotid compartment.
Pterygomandibular space.
Lateral pharyngeal space.
COIAARWN=
Peritonsillar fossa.

In Relation to the Upper Jaw r

Within the lip.
Within the canine fossa.
Palatal subperiosteal interval.
Maxillary antrum.
Infratemporal fossa space (this
nApRWN is the upper extremity of the
pterygomandibular space).
a Subtemporalis muscle interval.
It is important when studying these spaces not to become over concerned
with the details of their anatomical boundaries; indeed many of these
compartments intercommunicate. Furthermore, none of the muscular or
fascial barriers are impassable and pus will eventually penetrate them and
reach the overlying skin. However, because pus normally accumulates in
these well-defined areas, its surgical drainage will be facilitated by a
knowledge of the relevant anatomy. In all cases it is necessary to identify
and deal with the source of the infection.

POTENTIALLYGINFECTEDSSPA GES RELATED

TO THE LOWER*IJAW
Submental Space Infections
Surgical Anatomy
The submental space lies between the mylohyoid muscle above and the
investing layer of the deep fascia below and this, in turn, is covered by

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Fig. 6.2. A diagram of the submental space from below. a, The mandible. b, The
anterior belly of the digastric. c, The submental lymph nodes in the submental
space. d, The mylohyoid’muscle.c, The hyoid bone.

platysma muscle, superficial fascia and skin. It is bounded laterally by the

lower border of the mandible and the diverging anterior bellies of the
digastric muscles over which lie the more lateral submental lymph nodes
(Fig. 6.2). The majority of the submental lymph nodes lie within these
boundaries and are embedded in adipose tissue, not loose connective
tissues as is the case with the submandibular nodes. For this reason
submental abscesses tend to be well circumscribed.
The submental space is usually involved secondary to infection of the
submental lymph nodes following lymphatic spread from the lower incisors,
the lower lip, the skin overlying the chin, or from the tip of the tongue and the
anterior part of the floor of the mouth and sublingual tissues.

Signs and Symptoms

The established submental abscess forms a distinct, firm swelling beneath
the chin and the patient experiences considerable discomfort on
swallowing.

Treatment
Satisfactory drainage of a submental abscess can be effected by a
transverse incision through the skin posterior to the crease behind the chin
itself. The abscess is opened with sinus forceps and a drain inserted.

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 ORAL SURGERY, PART 1

Fig. 6.3. Diagram ofthe submandibular space, submandibular gland and lymph
nodes removed. a, Posterior belly of digastric and stylohyoid muscle. 5b,
Anterior belly of digastric. c, Mylohyoid muscle. d, Hyoglossus muscle. e,
Middle constrictor.f,Styloid process and stylohyoid ligament.

Submandibular Space Infections

Surgical Anatomy
The submandibular space is that compartment which lies between the
anterior and posterior bellies of the digastric, and contains the sub-
mandibular salivary gland and the submandibular lymph nodes. The lower
part lies deep to the investing layer of the deep cervical fascia and the upper
part beneath the inferior border of the mandible. Anteriorly it is bounded
above and medially by the mylohyoid muscle which is covered by loose
alveolar tissue and fat. More posteriorly the submandibular space projects
upwards under cover of the medial aspect of the mandible as high as the
mylohyoid ridge. Medially the wall of the compartment is formed by the
hyoglossus muscle. The C-shaped submandibular salivary salivary gland
lies within the submandibular space and provides a route of communication
with the sublingual space around the posterior border of the mylohyoid
muscle (Fig. 6.3). Where the facial artery hooks around the lower border of
the mandible the deep fascia is attached to the bone sufficiently above the
lower border to permit the submandibular lymph nodes to overlap the
mandible.
Infection from the teeth or submandibular gland may pass via the
lymphatics to the submandibular lymph nodes and, as in the case of the
submental space, infection of the submandibular space occurs when the
lymph nodes fail to contain it. Spread of infection from the teeth by direct
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continuity is influenced by the origin of the mylohyoid muscle in relation to

the eye a the apices of he ower us

innervaepert of the mandible aas far back as the third molar tooth. The two
halves of the muscle slope downwards towards each other and the posterior
quarter of each is attached to the anterior surface of the body of the hyoid
bone, while the anterior three quarters of each muscle meet in a midline
raphe which extends from the symphysis menti down to the hyoid bone. The
mylohyoid line lies near the inferior border of the mandible in the
symphysial region and slopes gently upwards as it extends backward
towards the region of the lower 3rd molar tooth. The apices of the roots of
the lower incisors, canines and premolar teeth are, therefore, above the
level of the mylohyoid diaphragm, while the apices of the roots of the molar
teeth lie below the level of its attachment. Apical infection from a lower
molar tooth, particularly the 2nd and 3rd, which happens to penetrate the
thin lingual plate can pass directly into the submandibular space.
It is possible for infection to extend backwards from the submental space
or from the submental lymph nodes via the lymphatics. Similarly infection
may pass from the back of the sublingual space around the deep part of the
submandibular salivary gland into the submandibular space.
It is important in assessing submandibular node enlargement due to
infection to recall that the infection may originate not only from a lesion of
one of the lower posterior teeth, middle third of tongue, or the posterior part
of the floor of the mouth, but also from one of the upper teeth, the cheek,
maxillary sinus or palate. While apical and periodontal abscesses of an
upper tooth or lower posterior tooth are particularly common causes of such
an infection they are not the only ones. In particular a subacute maxillary
sinusitis is easily overlooked.

Signs and Symptoms

An established infection produces a firm swelling in the submandibular
region. Because of the relationship of the submandibular lymph nodes and
the attachment of the deep fascia to the lower border of the mandible, the
swelling bulges over the lower border at the point where the facial artery
crosses it (Figs. 6.4 and 6.5). There is invariably limitation of jaw opening
and the usual systemic signs and symptoms associated with a substantial
infection.
It is worth remembering that secondary deposits of a malignant neoplasm
or alymphoma in lymph nodes of the upper neck may undergo necrosis and
present as a fluctuant swelling. Infiltration of the surrounding tissues by
neoplasm will produce swelling and induration resembling cellulitis, except
that redness of the skin, even if prevent, will not be as great as expected from
an abscess. Nor will there be the degree of tenderness which would be
expected. If the swelling is incised fragments of necrotic tissue will
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 ORAL SURGERY, PART 1

Fig. 6.4. A submandibular space infection secondary to a carious left lower

molar. The way the swelling bulges over the external border of the mandible
because of the position of the submandibular lymph nodes is shown.

Fig. 6.5. Facial and submandibular lymph nodes enlargement and subman-
dibular space infection secondary to an abscess
E] in a child.

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 PYOGENIC INFECTIONS OR-THE SOFD TISSUBS

discharge with the liquified neoplasm. A biopsy will establish the

diagnosis.

Treatment
Drainage of a submandibular abscess is effected through an incision made
parallel with, but 2-3 cm below, the lower border of the mandible using,
where possible, a skin crease. Skin and subcutaneous tissues are incised
and then sinus forceps are pushed through the tough investing deep fascia
towards the lingual side of the mandible to release the pus from the
submandibular space.

Sublingual Space Infections

Infections which discharge into the soft tissues on the lingual side of the
mandible at a point above the origin of the mylohyoid muscle and below the
level of the mucosa of the floor of the mouth pass into the sublingual space.
These infections usually arise from premolar periapical or periodontal
disease or occasionally from the submandibular salivary gland. Periodontal
abscesses of the lower canine or incisors may also infect the sublingual
space, but periapical abscess of these teeth usually discharge labially.

Fig. 6.6. The sublingual space has been opened up by section of the mandible
and mylohyoid. a, Buccinator. b, Superior constrictor. c, Styloglossus. d,
Hyoglossus. e, Genioglossus and, below, the geniohyoid.f,Mylohyoid.g, The
deep part of the submandibular salivary gland and, more anteriorly, the
sublingual salivary glands.

Surgical Anatomy
The sublingual space is a V-shaped trough lying lateral to the muscles ofthe
tongue, including the hyoglossus, the genioglossus and the geniohyoid, and
bounded laterally and inferiorly by the mylohyoid muscle and the lingual
side of the mandible (Fig. 6.6). It is covered superiorly only by the mucous
membrane of the floor of the mouth.

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 ORAL SURGERY, PART 1

The infection is confined, therefore, to the connective tissue which

surrounds the sublingual glands and Wharton’s duct.

Clinical Features
Clinically, a firm, painful swelling is produced on the affected side in the
anterior part of the floor of the mouth which raises the tongue. The
oedematous tissues have a shiny, gelatinous appearance. The patient will
experience pain and discomfort on swallowing, but apart from enlargement
of the submental or submandibular lymph nodes there is little or no external
swelling.
Infections of the sublingual space may discharge into the mouth or pass
anteromedially over the hump of the genial muscles to the sublingual space
on the other side. From the postero-inferior part of the space, infection can
pass around the submandibular gland to enter the submandibular space
(Fig. 6.7), or again spread posteriorly via the tunnel under the superior
constrictor for the styloglossus into the parapharyngeal and pterygoid
spaces. Infection may also spread via the lymphatics to the submental or
submandibular lymph nodes.
The sublingual space is separated from the submental space by the
mylohyoid muscle which forms a complete diaphragm within the floor of
the mouth. As described earlier spread to the submental region occurs most
often as a result of lymphatic spread to the submental lymph nodes.
However, there are also perforating arteries which pass through the
mylohyoid to form anastomoses between the sublingual arteries and the
submandibular arteries which accompany the nerves to the mylohyoid. In
some patients infection can spread through these apertures to the submental
space.

Treatment
When the infection is only moderate in extent, antibiotic therapy combined
with extraction of the responsible tooth, and the intensive use of hot saline
mouthbaths, will promote satisfactory resolution of the condition. If there is
gross swelling an incision to drain the floor of the mouth should be made
lateral to the sublingual plica, as the only important structure at this site is
the sublingual nerve which is deeply placed and unlikely to be damaged.
The other important structures lie medial to the plica and include the
submandibular duct, the sublingual artery and veins and the lingual nerve,
and these should not be put at risk. An incision in the plica itself can result in
a ranula. When both the submental and sublingual spaces contain pus they
can be drained via a skin incision in the submental region, pushing closed
sinus forceps through the mylohyoid muscle. Similarly when the subman-
dibular space is involved a sublingual abscess can be reached and drained
through an incision in the submandibular skin and via the submandibular
space.
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 PYOGENIC INFECTIONS OF THE SOFT TISSUES

Fig. 6.7. Top. A cellulitis of the right sublingual space, spreading across the
midline and originating from septic 5] socket. Bottom. Enlarged submental
lymph nodes secondary to the sublingual cellulitis.

Ludwig’s Angina
Ludwig’s angina is a clinical diagnosis and is the name given to a massive
firm cellulitis affecting simultaneously the submandibular and submental
regions and the sublingual spaces bilaterally (Fig. 6.8).

Aetiology
The complication of Ludwig’s angina usually follows a submandibular
space infection caused by a periapical infection or pericoronitis around the
lower 3rd molar. The infection then spreads to the sublingual space on the
same side, around the deep part of the submandibular gland. From there it
passes to the opposite sublingual space and thence to the contralateral
submandibular region. The submental space is involved by lymphatic
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 ORAL SURGERY, PART 1

Normal Ludwig’s angina

“OD
Fig. 6.8. Diagram to explain Ludwig’s angina. On the left the normal side, on
the right the state of affairs (bilaterally) in Ludwig’s angina. The tongue, a, is
raised by the volume of exudate in b, the cleft between the hyoglossus and
genioglossus for the lingual and sublingual arteries and veins. c, The sublingual
space. d, The submandibular space. Infection in cleft b has direct access to the
laryngeal regions and in the sublingual space through to the pterygoid and lateral
pharyngeal spaces.

spread. This serious condition can also develop in a converse manner, 1.e.
by spread from the sublingual spaces to the submandibular spaces.
From the sublingual spaces the infection may spread backwards in the
substance of the tongue in the cleft between the hypoglossus muscle and the
genioglossus and along the course ofthe sublingual artery. It is by this route
that the infection reaches the region of the epiglottis and so produces
swelling around the laryngeal inlet.
From the submandibular region the spread may rarely extend down-
wards beneath the investing layer of the deep cervical fascia.

Signs and Symptoms

The external clinical appearance of Ludwig’s angina is of a massive firm,
bilateral submandibular swelling which soon extends down the anterior part
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 PYOGENIC INFECTIONS OF THE SOFT TISSUES

Fig. 6.9. Intraoral appearance of Ludwig’s angina. The floor of the mouth is
distended and the tongue forced up against the palate.

of the neck to the clavicles. Intraorally a swelling develops rapidly which

involves the sublingual tissues, distends the floor of the mouth and forces
the tongue up against the palate (Fig. 6.9). In extreme circumstances the
tongue may actually protrude from the mouth.
The patient is very ill with a marked pyrexia. Deglutition and speech are
difficult and progressive dyspnoea is caused by the backward spread of the
infection until, in the untreated case, oedema of the glottis causes a
complete respiratory obstruction. A fatal termination can occur in an
untreated case of Ludwig’s angina within 12-24 hours. In the past this
disease carried a high mortality and even today death is a not uncommon
outcome.

Treatment
Treatment is based on a combination of intensive antibiotic therapy
coupled with surgical drainage and decompression of the fascial spaces.
The immediate intravenous infusion of 500 mg of metronidazole and
500 mg of amoxycillin usually brings about a rapid improvement. This
regime is repeated 8-hourly. (If allergic to penicillin use erythromycin
lactobionate, 600 mg given slowly intravenously every 8 hours or 80 mg
gentamicin intramuscularly.)

Anaesthesia
On no account should a general anaesthetic be given to such patients except
by askilled and experienced anaesthetist. Many fatalities have occurred as
a result of anaesthetizing such patients, particularly when an intravenous
agent has been used for induction. In such cases the patient is only
maintaining the airway by the vigorous use of voluntary muscles in the
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 ORAL SURGERY, PART 1

region of the airway, together with assistance from the accessory muscles of
respiration. If a general anaesthetic is administered this voluntary control
over the airway is lost. Furthermore, as the patient becomes unconscious
there is a massive increase in the oedema and the airway becomes occluded.
If a laryngoscope is used at this stage the pharynx billows inwards like a
bolster and it becomes quite impossible to pass an endotracheal tube. If it is
imperative to give a general anaesthetic to a patient with a severe swelling of
the floor of the mouth, then an endotracheal tube should be passed with the
aid of a fiberoptic laryngoscope while the patient is conscious.
Established cases of Ludwig’s angina can be operated upon under a
combination of local analgesia and intravenous analgesia (not anaesthesia).
It is usually possible to drain the pus after local infiltration of the skin and
subcutaneous tissues overlying both submandibular regions with an
analgesic solution such as 2 per cent lignocaine, with adrenaline.
Additional drainage can be effected through the floor of the mouth. Many
surgeons in the past have preferred drainage through the classic U-shaped
incision beneath the lower jaw which divided not only the skin and
subcutaneous tissues but also the muscles. However, this desperate
measure was only necessary prior to the introduction of antibiotics and the
earlier use of a tracheostomy and is now an obsolete technique.
A nasopharyngeal airway and a tracheostomy set should be kept ready
beside the bed of any case of Ludwig’s angina. The instruments for
performing a tracheostomy should also be immediately available whenever
an operation for drainage is performed. Immediate evaluation of the blood
gases will give an additional indication of the degree of respiratory
obstruction and may indicate the need for a tracheostomy even if the patient
is not obviously in distress.
A tracheostomy should be performed under local anaesthesia as soon as
respiratory obstruction seems likely. Even at this stage the operation will be
taxing. The oedema reaches the clavicles and the tissues are brawny and
inflexible. Thus the trachea is a long way from the surface of the wound and
its identification is made difficult by the amount of haemorrhage from the
inflamed tissues. Aspirating air with a wide bore needle and syringe from
the trachea during the performance of an emergency tracheostomy ensures
that the right structure is incised. A cuffed endotracheal tube may be needed
instead of a tracheostomy tube because of the swelling. If the operation is
delayed until venous congestion and cyanosis appears, the patient’s chest
will by then be heaving, so adding to the difficulty of the surgery. In an
emergency a laryngotomy, opening the cricothyroid membrane, is easier to
perform than a tracheostomy.

Abscess Formation in Relation to the Buccinator Muscle

Surgical Anatomy
The buccinator muscle is a wide, but fairly thin, muscle which forms a
muscular sheet in the cheek. Its line of origin is horseshoe-shaped and runs

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along the base of the upper alveolar process from the level of the upper Ist
molar distally to the tip of the pterygoid hamulus. Posteriorly it takes its
origin from the pterygomandibular raphe which unites the buccinator to the
‘superior constrictor. At the lower end of the raphe it gains an attachment to
the lateral ridge outlining the retromolar triangle. On the mandible, the
attachment of the buccinator muscle follows the external oblique line to the
base of the alveolar process corresponding to the lower Ist molar. The
muscle fibres arising from this horseshoe-shaped line run in a generally
forward direction towards the corner of the mouth where they blend with the
fibres of the orbicularis oris. The fibres of the buccinator arising from the
upper jaw tend to pass downwards and those from the lower jaw upwards
and where these muscle bands cross over at the corner of the mouth the
buccinator is thicker than it is more posteriorly. There is an important band
of horizontal fibres in the inner aspect of the muscle which on contraction
help to maintain the food bolus between the occlusal surfaces of the teeth.
Persistent contraction of these fibres produces a linear thickening of the
buccal mucosa corresponding to the line of occlusal contact.
It is important to remember that the attachment of the buccinator is above
the level of the apices of the lower molars and below those of the upper
molars. The buccinator muscle acts as an effective barrier to the spread of
pus and this is especially true during the early stages of an abscess in the
cheek. The buccopharyngeal fascia is a very delicate affair and probably
plays no part in limiting the spread of infection. Pus which spreads buccally
from any of the upper or lower molar teeth to perforate the outer cortex of
the alveolar process can discharge into the mouth on the oral side of the
origin of the buccinator muscle. Such abscesses are simple to diagnose,
because the swelling is principally in the buccal sulcus beneath the mucosa
and opposite the tooth of origin, while externally the facial swelling is
relatively small, soft and puffy. Sometimes when the intraoral abscess is
large it may reach the occlusal plane and become traumatized, but
eventually it will discharge spontaneously. Evacuation of the pus is readily
achieved by an incision through the overlying mucosa. Pus from periapical
infection of the molar teeth which emerges from the bone above the origin of
the buccinator in the upper jaw, or below its origin in the mandible, will
spread to the outer side of the buccinator partition and give rise to a local
buccal space abscess. Some buccal space infections originate from an
infected facial lymph node.
The Buccal Space
Surgical Anatomy
This potential space is bounded anteromedially by the buccinator muscle,
posteromedially by the masseter overlying the anterior border of the ramus
of the mandible, and it is covered laterally by a forward extension of the
deep fascia from the capsule of the parotid gland and by the platysma
muscle. It is limited below by the attachment of the deep fascia to the
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Fig. 6.10. Diagram showing the buccal space in horizontal section and the
spread of infection from an impacted lower 3rd molar. a, Medial pterygoid
muscle. b, Mandible. c, Masseter. d, Buccal space and the buccal pad offat with
diagonal shading. e, Parotid with parotid fascia extending forwards to cover the
buccal space in conjunction with the platysma muscle.

mandible (Fig. 6.10) and by the depressor anguli oris and above by the
zygomatic process of the maxilla and the zygomaticus minor and major.
The buccal space contains the buccal pad of fat and is therefore
continuous posteriomedially around the fat with the pterygoid space
through the interval between the buccinator and the anterior border of the
coronoid process. The buccal pad of fat, of course, not only fills out
the cheek but wraps around the pterygoid muscles and the temporalis
tendon behind the tuberosity, as it were, to lubricate the masticatory
machinery.
When a lower 3rd molar is exposed surgically blood may escape laterally
due to the detachment of the pterygomandibular raphe and the adjacent
bony origin of the buccinator fibres. This produces a haematoma in the
buccal space. Infection from a pericoronitis of a 3rd molar can follow the
same route to produce a buccal space infection (Fig. 6.11).
If an abscess from a mandibular tooth ultimately discharges on the skin
surface the sinus track may be felt as a cord below the lower buccal sulcus.
The direction of this cord will indicate the tooth of origin.
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 PYOGENIC INFECTIONS OF THE SOFT TISSUES

Fig. 6.11. A buccal space infection secondary to an abscess on a lower Ist

molar. Observe that the swelling is just behind the angle of the mouth and
reaches down to the lower border of the mandible.

Treatment
Drainage is effected by a horizontal incision low down inside the cheek
through which sinus forceps are passed to penetrate the buccinator. The
incision with the scalpel should not be carried through the buccinator in
case the facial artery or branches ofthe facial nerve are divided. It should be
below the parotid papilla to avoid damage to the duct. A soft corrugated
rubber or polypropylene drain is essential to keep the path through the
muscle open. Buccal space abscesses pointing on the face can be incised
and drained through the skin, but it should be possible to drain the majority
intraorally to avoid a scar.

The Submasseteric Abscess

Many anatomists have stated that the muscle consists of three heads with
insertions into the ramus which are separated from each other by bare areas
of bone with a space between the middle and the deep heads, termed the
‘submasseteric space’. This space was thought of as providing a pathway
for infection to pass upwards and backwards from the retromolar fossa
region.
MacDougall (1955) examined the evidence for the submasseteric space
at the bone surface and came to the conclusion that it did not exist. He based
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this observation on the dissection of 141 specimens of the masseter muscle

together with radiological investigations following the injection of a
radiopaque barium sulphate paste into cadavers, but he confirmed that the
masseter muscle consists of three layers fused anteriorly but easily
separated posteriorly. Although he found no submasseteric space at the
bone surface, there was a potential one in the substance of the muscle
between the middle and deep heads, and while the bony insertion is firm
above and below, the intermediate fibres have only a loose attachment. It is
possible therefore for these fibres to be separated from the bone relatively
easily by the accumulation of pus at this site. As surgical exploration in
cases of established submasseteric abscess has confirmed, the pus
accumulates beneath the periosteum and against the bone in this area. One
must assume that it tracks backwards subperiosteally to where it may erode
laterally into the potential space between the muscle bellies.

Aetiology
A submasseteric abscess is by no means common and usually arises from
infection in the lower 3rd molar region. Pericoronitis related to vertical and
disto-angular lower 3rd molars is most likely to lead to a submasseteric
abscess. The presence of the buccinator attachment probably discourages
backward extension of pericoronal pus where the lower 3rd molar crown is
anterior to this muscular barrier. Pus can also reach the submasseteric area
if a periapical abscess from a mandibular molar spreads subperiosteally in a
distal direction.

Clinical Features
In the established submasseteric abscess the external facial swelling is
moderate in size and is confined to the outline of the masseter muscle (Fig.
6.12). The swelling does not usually extend beyond the posterior margin of
the ramus or encroach on the postauricular tissues like an acute parotitis,
although occasionally the postmandibular sulcus may be obscured by
inflammatory oedema. Extension of the abscess inferiorly is also limited by
the firm attachment of the masseter to the lower border of the ramus.
Forward spread of the swelling beyond the anterior border of the ramus is
restricted by the anterior tail of the tendon of temporalis which is inserted
into the anterior border of the ramus. Although the swelling of a
submasseteric abscess is only moderate in extent it is usually acutely tender
and gives rise to an almost complete limitation of mouth opening.
The marked degree of limitation
of opening is an i t
diagnostic
feature and sometimes seems inconsistent with the amount of swelling
present over the lateral aspect of the ramus. The overlying skin is only
reddened in advanced cases and fluctuation cannot be elicited because the
muscle lies between the pus and surface. In longstanding cases consti-
tutional symptoms are minimal, but at the acute stage the systemic reaction
includes pyrexia and malaise.
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Fig. 6.12. Submasseteric abscess. Notice that the swelling does not lift the lobe
of the right ear so is not due to swelling of the parotid.

Owing to the thick covering of the masseter muscle with tendinous

attachments to the posterior and inferior borders of the ramus, the
collection of submasseteric pus is confined against the surface of the ramus
and spontaneous discharge is less likely to take place than with most other
soft tissue abscesses. If the infection is particularly severe pus may
discharge forwards at the anterior border of the ramus, or backwards
immediately behind the angle of the mandible. But, as the point of discharge
is remote from the main accumulation of pus, drainage tends to be
incomplete and a residual pocket is left which gives rise to further
exacerbations at a later date. A chronic submasseteric infection can persist
for years punctuated by recurrent flare-ups. Each acute abscess can be
drained by a skin or mucosal incision or controlled by antibiotics, but
without complete resolution. Spread of the infection into the masseter
muscle itself gives rise to a large multilocular abscess, the drainage of which
is difficult so that treatment may become protracted.
The ramus of the mandible is more dependent upon a blood supply from
the overlying muscle than the body which is to a greater extent supplied by
the mandibular artery. As a result, ischaemic changes may take place in
that part of the bone denuded of periosteum by a submasseteric abscess so
that a low grade osteomyelitis of the lateral cortical plate occurs with
sequestrum formation. The extent of bone destruction depends, of course,
upon the area of bone in contact with pus together with such factors as the
degree of virulence of the organism. Often submasseteric infection leads to
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subperiosteal new bone deposition beneath the periosteum, an important

clue to the diagnosis. Such depositions are likely to be prolific in young
patients in whom the osteogenic potential of the periosteum is high. Layers
of new bone produce a hard swelling over the ramus, which in extreme cases
may be misdiagnosed as a sarcoma. Some so-called cases of “Garre’s
osteomyelitis’ affecting the ramus are probably examples of this
periostitis.

Radiological Examination
Unfortunately, the early, acute submasseteric abscess gives rise to no
radiological abnormalities. Once it occurs, subperiosteal new bone
formation is best demonstrated by a tangential postero-anterior radiograph.
The new bone has an opaque linear or irregular ‘fuzzy’ appearance. After
the infection has been cured the additional bone will gradually remodel until
the ramus eventually reverts to its normal thickness. If a superficial
osteomyelitis supervenes then the affected lateral cortical plate of the ramus
will show evidence of bone destruction with a patchy radiolucency. If
drainage is delayed, sequestrum formation may be seen. Although only the
outer cortex of the ramus is affected by the osteomyelitis, when the jaw is
viewed in an oblique lateral radiograph the entire thickness of the ramus
appears to be involved due to superimposition.

Differential Diagnosis
Basically, swellings affecting four anatomical compartments have to be
distinguished:
1. The masseteric compartment.
2. The buccal space.
3. The parotid compartment.
4. The ramus of the mandible.
1. Swellings involving the masseteric compartment follow the outline of
the masseter muscle. Such swellings include masseteric hypertrophy which
stands out on clenching the teeth and softens on relaxation. Intramuscular
haemangiomas affecting the masseter can also produce an enlargement of
the muscle which varies in size when the muscle is clenched and enlarges on
bending the head below the waist. Sometimes in these cases phleboliths
may be seen in a tangential radiograph and provide a clue to the diagnosis.
Thrombophlebitis of an intramuscular haemangioma must be distinguished
from a submasseteric abscess.
2. The buccal space is anterior to the masseter and the swelling reaches
almost as far forwards as the angle of the mouth. The commonest causes of
buccal space swellings are infection, haematomas and haemangiomas, and
occasionally a lipoma. If thrombosis occurs in a cavernous haemangioma of
the buccal space the patient can present with an acute and painful
enlargement.

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3. Parotid swellings are largely posterior to the masseter and may be due
to obstruction, suppurative infections of the gland or of the related lymph
nodes, mumps and cytomegalovirus infection, Sjogren’s syndrome or a
neoplasm. Classically the swelling extends posteriorly to raise the lobe of
the ear but the anatomical extent may be less easily determined where there
is considerable oedema of the overlying skin and subcutaneous tissues.
An obstruction of the parotid duct will cause intermittent enlargement of
the parotid gland and the patient usually gives a history of exacerbation at
mealtimes. A stone may be demonstrable by plain radiography or
sialography. Acute and subacute suppurative parotitis can be more difficult
to distinguish from submasseteric abscess externally, but in the case of the
former, pus can be expressed from the parotid duct.
Sometimes mumps affects one salivary gland only, or one gland alone
some days before the others are affected. If the parotid gland is affected
again the differential diagnosis can be difficult. However, the parotid
papilla will be reddened and there is usually fever and general malaise
which may either precede or coincide with the glandular enlargement.
Although only one gland may be affected, frequently the other shows
signs of involvement from one to five days later. The submandibular and
sublingual glands are sometimes enlarged and tender. In addition the
breasts, pancreas and testes may be involved. There also will be an
increased serum amylase and a rise in S & V mumps antibodies.
Tumours tend to be circumscribed and non-tender and are often
pleomorphic adenomas. The adenoid cystic carcinoma and malignant ones
may produce a facial palsy.
4. Ramus enlargement is rarely difficult to diagnose as radiographs will
show a developmental, cystic or neoplastic enlargement. Ramus swellings
also move with the mandible as the mouth is opened.

Treatment
In the early stage of submasseteric infection it is occasionally possible to
abort the condition by the removal of the causative tooth and administration
of an antibiotic; benzy] penicillin or metronidazole is usually sufficient. The
established submasseteric abscess must be decompressed by incision and
drainage. The incision is made over the lower part of the anterior border of
the ramus and deepened to bone. Forceps are then passed along the lateral
surface of the ramus downwards and backwards and the loculus of pus is
opened. A specimen is sent to the microbiological laboratory for
examination of a stained direct film, culture and antibiotic sensitivity. The
abscess is usually situated below the level of the incision and not at a point
of dependent drainage, and, therefore, drainage may be inefficient. A Yeats
or corrugated drain should be sewn in to keep the incision open.
The alternative approach, especially when the mouth cannot be opened,
is to make a skin incision behind the angle of the mandible and to open the

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Fig. 6.13. Diagram showing the relationship of the peritonsillar, lateral

a eal and ¢ paces. a, Pterygoid space. b, Peritonsillar space. c,
atera aryngeal sp , Superior constrictor. e, Carotid artery. f Vagus
nerve al ee trunk. g, Internal jugular vein. h, Stylopharyngeus
muscle. 7, Styloglossus muscle. j, Styloid process. k, Stylohyoid muscle. J,
Mastoid process. m, Digastric muscle. n, Parotid gland. 0, External carotid and
posterior facial vein. p, Mandible. g, Facial nerve. r, Inferior dental artery and
nerve. s, Masseter. ¢, Lingual nerve. u, Tails of temporalis tendon. y, Buccinator
muscle. (Partly after Murphy T. R. and Grundy E. M. (1969) Dent. Prac. Dent.
Rec. 16, 41.)

abscess by Hilton’s method. A gloved finger dilates the wound further, after
which a retractor can be inserted and the surface of the mandible tested with
a Howarth’s periosteal elevator for the presence of a sequestrum. Again a
soft corrugated, polyethylene drain should be sewn into the wound. It is left
in position for 24 hours at least and may need to remain 3-4 days if a
recurrent abscess is to be avoided.
Infection of the Pterygomandibular Space
Surgical Anatomy
The pterygomandibular space is a compartment situated between the
medial surface of the ramus of the mandible and the medial pterygoid
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 PYOGENIC INFECTIONS OF THE SOFT TISSUES

muscle. The two heads of the latter arise principally from the medial surface
of the lateral pterygoid plate and the tuberosity of the maxilla. The medial
pterygoid lies at first on the medial surface of the lower part of the lower
head of the lateral pterygoid muscle which it embraces with the aid of the
superficial slip, and then its fibres pass downwards, laterally and backwards
to be inserted by a strong tendinous lamina into the lower and posterior part
of the medial surface of the ramus and angle of the mandible as high as the
mandibular foramen. Between the lateral surface of the medial pterygoid
and the medial surface of the ramus of the mandible run the inferior dental,
mylohyoid and lingual nerves, the maxillary artery and the inferior dental
artery and vein. Posteriorly the lateral pterygoid muscle forms a roof to the
pterygoid space (Fig. 6.20) and just below the lateral pterygoid the
pterygomandibular space potentially communicates with the para-
pharyngeal space (Fig. 6.13).
In practice infections do not usually spread there by this route because of
the parotid gland lying tight against the back of the mandible and the medial
pterygoid muscle. Infection is more likely to extend into the parapharyngeal
space by passing medially around the anterior border of the medial
pterygoid.

Aetiology
Infection in the pterygomandibular space may be introduced by a
contaminated needle used for an inferior dental nerve block injection. It can
also spread to this area from the lower 3rd molar region, especially when
pericoronitis develops around the crown of a lingually inclined disto-
angular tooth. In other instances the infection originates from the upper 3rd
molar or follows a posterior superior dental injection.

Abscess in the Pterygomandibular Space

Even well established infections of the pterygomandibular space do not
cause much swelling of the face and such swelling as is visible involves the
submandibular region and buccal space. However, there is a severe degree
of limitation of opening and dysphagia and on palpation tenderness can be
elicited in the swollen soft tissues medial to the anterior border of the ramus
of the mandible.
Usually the abscess tends to point at the anterior border of the ramus and
drainage can be effected easily by an incision down the anterior border,
after which a pair of sinus forceps can be directed into the plane between the
ramus and the medial pterygoid to enter the space.
Occasionally an infection in this area may spread upwards along the
medial surface of the ramus to produce an abscess in the infratemporal fossa
and beneath the temporalis fascia. It can also pass anteriorly between the
front of the ramus of the mandible and the buccinator into the buccal space,
and antero-inferiorly below the lower border of the superior constrictor
along the styloglossus into the submandibular space. Indeed, if there is
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difficulty in reaching the pus via an incision down the front of the coronoid
process within the mouth, sinus forceps can be passed upwards and
backwards deep to the mandible through an incision in a skin crease in the
submandibular region.
Lateral Pharyngeal (Parapharyngeal) Space Infection
Surgical Anatomy
The lateral or parapharyngeal space, which is also known as the
‘pharyngomaxillary’ space, is a potential cone-shaped space or cleft with its
base uppermost at the base of the skull and its apex at the greater horn of the
hyoid bone. Its medial wall is the superior constrictor muscle with its
covering sheet of buccopharyngeal fascia, together with the styloglossus,
stylopharyngeus and middle constrictor and the lateral wall from above
downwards consists of fascia covering the medial pterygoid, the angle of the
mandible and the submandibular salivary gland. More posteriorly it is
closed laterally by the parotid gland and the posterior belly of the digastric
muscle. The posterior border of the space is the prevertebral fascia and the
upper part of the carotid sheath lies within it.
The boundary walls of the lateral pharyngeal space do not permit easy
communication with the adjacent spaces. Infection passes most easily
between the lateral pharyngeal space and the submandibular space by
tracking along the styloglossus muscle. There is also a weak zone in the
posterior part of the fascia around the submandibular salivary gland, medial
to the stylomandibular ligament, and rupture of a submandibular abscess
through into the parapharyngeal space at this point results in the rapid onset
of respiratory embarrassment.
Some surgeons include a downward continuation of this compartment
around the carotid sheath as far as the thoracic inlet. Thus they would
include the inferior constrictor and oesophagus in the medial wall, the
lateral lobe of the thyroid as an anterior relation, and the sternomastoid and
superior belly of the omohyoid in the lateral wall.

Aetiology
The lateral pharyngeal space may become infected from an abscess
extending backwards from the lower 3rd molar area or more commonly one
passing laterally from a tonsillar abscess. Infection can also spread
backwards into it from a sublingual or submandibular space infection as
described above.
A rare cause of parapharyngeal infection is the surgical displacement of a
lower 3rd molar distally under the lingual flap and backwards into the
lateral pharyngeal space. Similarly a 3rd molar root may be dislodged into it
through a hole in the lingual plate. Displaced teeth or root fragments should
be removed as soon as possible after the accident in order to avoid possible
abscess formation. Following retrieval of the dislodged object, a prophyl-
actic antibiotic should be administered until the risk of infection has passed.
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A five-day course of phenoxymethy] penicillin 500 mg, 6—-hourly, or

metronidazole 400 mg 12—-hourly, would be appropriate.

Signs and Symptoms

The pyrexia and malaise can be considerable in the case of lateral
pharyngeal abscess, more so than with many other infections around the
jaws. Pain on swallowing is extreme and there is some limitation of opening,
but the latter is not severe unless the pterygomandibular space is involved
as well. The tonsil and the lateral pharyngeal wall are pushed towards the
midline, but the soft palate is not greatly disturbed. Usually there is little
swelling ofthe side of the face, but there may be some at the lower border of
the parotid gland and this is probably due to enlargement of the nodes in this
region.
Infection of the lateral pharyngeal space is extremely serious owing to the
intimate relationship of the carotid sheath. Thrombophlebitis of the internal
jugular vein may occur as a complication and if pus in the lateral pharyngeal
space is left undrained for any length of time the common carotid artery may
become eroded with fatal consequence. Inequality of the pupils due to
involvement of the cervical sympathetic can be a warning of such a
disastrous sequel.

Treatment
Early intensive therapy is given with intravenous metronidazole and benzyl
penicillin (or erythromycin, gentamicin or cefuroxime) followed by
drainage. For drainage of such an abscess, an inhalation anaesthetic is
given cautiously by an experienced anaesthetist. The head-down position
must be used, because the abscess may burst as the tube is passed. A sucker
is essential and the ability to pass a nasotracheal tube blind can be a great
asset since visibility with a laryngoscope can be limited by difficulty in
opening the jaws to their maximum. If the patient’s mouth can be opened
wide an intraoral incision medial to the anterior border of the ramus is the
most direct drainage route. If this is not possible a skin incision is made
1 cm below and behind the angle of the mandible and then sinus forceps
followed by a finger are inserted into the space between the submandibular
and parotid glands and passed medial to the mandible and upwards along
the inner aspect of the medial pterygoid muscle into the lateral pharyngeal
space. A drain is inserted in either case.

Peritonsillar Abscess or Quinsy

Surgical Anatomy
A peritonsillar abscess is a localized infection in the connective tissue bed
of the faucial tonsil between it and the superior constrictor muscle. Acute
infection penetrates from the depth of a tonsil crypt or the supratonsillar
fossa, but may occasionally be a complication of acute pericoronitis
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associated with a lower 3rd molar. In the latter case the abscess points near
the lower pole of the tonsil.

Signs and Symptoms

There is acute pain on one side of the throat radiating to the ear. Dysphagia
is experienced and, although the patient finds it difficult to open the mouth,
the actual limitation of opening may not be pronounced. Speech becomes
awkward, especially in bilateral cases, and the peculiar muffled ‘hot potato
in the mouth’ voice is characteristic. Owing to the extreme pain experienced
on attempting to swallow, saliva may run out of the mouth. The patient
looks and feels ill, is anorexic and becomes rapidly dehydrated unless
remedial measures are taken.
The fully developed abscess causes a tense swelling of the anterior pillar
of the fauces, and a bulge of the soft palate on the affected side which in
extreme cases reaches the midline and pushes the uvula downwards and
forwards until it impinges against the opposite tonsil. The inflamed tonsil
may protrude from behind the anterior pillar, but sometimes it is masked by
oedematous tissue which covers it anteriorly. The tongue is coated and
there is marked foetor oris. Oedema may eventually affect the base of the
tongue, epiglottis and aryepiglottic fold. In 3-5 days the mass often
becomes fluctuant and, if allowed to pursue its natural course, finally
ruptures by pointing, usually through the anterior tonsillar pillar. Foul pus
discharges for several days and the symptoms and signs gradually
abate.

Treatment
This involves antibiotics and incision. The abscess is incised using a
guarded knife and sinus forceps which are inserted into the most prominent
part of the soft palate where fluctuation is maximal. A mouth prop should be
used to prevent unexpected closure while the knife is in the mouth. The
opening can be carried out under local analgesia, initially using a lignocaine
spray but reinforced by 2 per cent lignocaine and adrenaline infiltrated into
the mucosa at the site of the incision. If general anaesthesia is used the
anaesthetist must be experienced in this type of case and good suction must
be available to prevent aspiration of the pus. Induction and the passage of
the tube should be with the patient in the head down position, because the
abscess may be ruptured as the anaesthetist attempts to pass the tube.

Differential Diagnosis
Some confusion could possibly arise in the differentiation of pterygo-
mandibular and lateral pharyngeal space infections from a peritonsillar
abscess, especially when either of the former is pointing along the anterior
border of the medial surface of the ramus. Table 6.1 therefore summarizes
the differences between the physical signs produced by these conditions.

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 PYOGENIC INFECTIONS OF THE SOFT TISSUES
Table 6.1 Differential diagnosis

Pterygo-
Space mandibular Lateral pharyngeal Peritonsillar

Anatomy Between mandible Between medial Between superior

and medial pterygoid and superior constrictor and mucous
pterygoid constrictor membrane
Limitation of Extreme Moderate Some
opening:
External swelling Little None None
Swelling in mouth Some over medial A good deal of pillars _ Pillars of fauces and
and throat aspect of anterior of fauces but little most of soft palate
border of ramus of soft palate :

POTENTIALLY INFECTED SPACES RELATED TO

THE UPPER JAW
The Upper Lip
Infections at the base of the upper lip usually occur as a result of an abscess
of the upper incisors or canines. The pus forms on the oral side of the
orbicularis oris muscle and tends to point in the vestibule (Fig. 6.14).

re

Fig. 6.14. Child with acute alveolar abscess on |_1 with oedema ofthe upper lip.
There is a markedly enlarged submandibular lymph node on the same side lying
lateral to the lower border of the mandible.

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 ORAL SURGERY, PART1

Fig. 6.15. An abscess from |2 root pointing in the nostril where it could be
mistaken for a nasal furuncle. Pressure on the end of |2 root caused pus to ooze
out of both the root canal and the sinus in the nose. This clinical picture occurs
rather more often with the upper central incisors.

Because of the bulk of the muscles taking origin beneath the anterior nasal
spine, abscesses from the central incisors point towards the apex of the
lateral incisor. Rarely they will point in the floor of the nose and be mistaken
for a boil of the nose (Fig. 6.15). Infections of the lip on the outer surface of
the orbicularis oris muscle usually occur as a result of a skin infection such
as a furuncle.
Infections in the area of the upper lip including the incisors and canines
may rarely give rise to an orbital cellulitis or a cavernous sinus
thrombophlebitis by passing from the superior labial venus plexus to the
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 PYOGENIC INFECTIONS OF THE SOFT TISSUES

anterior facial vein and then in a retrograde direction via the ophthalmic
veins to the cavernous sinus. This pathway is facilitated by the fact that
these veins have no valves. Cavernous sinus thrombophlebitis used to be a
fatal condition before antibiotic therapy (see later).

Treatment
All abscesses in the region of the upper lip should be treated by a
combination of antibiotic therapy and drainage. Incision of the abscess can
usually be made in the vestibule and the offending tooth is either opened and
drained or extracted.

Differential Diagnosis of Swellings of the Upper Lips

1. Trauma: Any blow on the upper lip can produce a swelling of the
tissues which may be of considerable size. If the upper incisors have been
damaged and the patient is seen a day or two after the injury, it may be
difficult to decide whether infection has supervened. Surgery such as an
apicectomy in the upper incisor region may be followed by substantial local
swelling again raising doubts about the occurrence of postoperative
infection. Either postoperative or post-traumatic oedema will start to
subside after 48 hours whereas the physical signs will worsen if infection is
present.
2a. Hypersensitivity reaction: Allergic swelling of the upper lip may
result from contact with a substance such as a lipstick or toothpaste which
excites an allergic response or arise as a feature of angioedema (Fig. 6.16).
Some part of the swelling following endodontic therapy would appear to be
a hypersensitivity response to opening through the apex of the infected
tooth. The enlarged lip is soft and non-tender and will reduce in size with
antihistamines.
b. Other oedematous swellings: There are a number of uncommon
causes of oedematous swelling of the upper lip including the Merkerson—
Rosenthal syndrome. This syndrome is considered to include a swollen lip,
fissured tongue and facial palsy. Biopsy of the lip will reveal non-caseating
Langhan’s giant cell granulomas which if associated with neuropathy are
likely to be sarcoid, but if associated with granulomatous bowel disease is
then Crohn’s disease.
3. Cysts and neoplasms: Cysts of the jaws can produce a swelling in the
vestibule which extends towards the upper lip and may cause enlargement
of the lip especially if infected. Any odontogenic cyst in the upper incisor
region or a nasopalatine cyst is capable of involving the labial tissue. The
nasolabial cyst which lies against the bone between the ala of the nose and
the upper lip will produce a prominent swelling in the region of the
nasolabial fold. Occasionally a pleomorphic adenoma or muco-epidermoid
carcinoma may arise in the labial tissues. These are usually firm in
consistency, but sometimes a cystic variety is encountered. If a malignant
salivary gland neoplasm involves the overlying skin, it may produce a red
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Fig. 6.16. Angio-oedema. The patient is subject to transient swellings in various

parts of the face similar to the one shown above top. The picture below was
taken 24 hours later.

coloured swelling with prominent dilated small vessels, and should there be
an accumulation of mucus, or necrosis of the centre of the lesion it may
closely resemble a pointing abscess. In all these cases the length of time the
patient has had a swollen lip should correct the erroneous first impression.

The Canine Fossa

A periapical abscess which discharges buccally from an upper canine or
first premolar may lead to an accumulation of pus in the canine fossa, deep
to the muscles of facial expression moving the upper lip (Fig. 6.17).

Surgical Anatomy
If the canine root is relatively short, pus from a periapical abscess will
emerge from the bone below the origin of the levator anguli oris and will
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Fig. 6.17. The canine fossa space. The arrows show the direction the pus will
take from the apex of the canine and from the apices of the premolars. a, Levator
labii superioris alaeque nasi. b, Levator labii superioris arising above the infra-
orbital foramen. c, Levator anguli oris (dotted outline) arising below the
foramen. d, Zygomaticus minor. e, Zygomaticus major. f Buccinator. g,
Orbicularis oris.

tend to point in the upper buccal sulcus, because the buccinator muscle has
no attachment to the bone anterior to the Ist molar.
The levator anguli oris takes origin below the infraorbital foramen and
the levator labii superioris above the foramen and overlaps the anguli oris. If
the pus does not point in the buccal sulcus it tends to travel up the medial
border of the levator anguli oris, deep to the levator labii which it cannot
penetrate. It then emerges between the levator labii superioris and the
levator labii superioris alaeque nasi to point below the medial corner of the
eye.
If the root of the canine is long or the origin of levator anguli relatively
low, pus from a periapical abscess may emerge above the origin of the
levator anguli oris. In these circumstances it can only escape to the surface
between the levator labii superioris and the levator labii superioris alaeque
nasi.

Clinical Appearances
There is considerable oedema of the cheek and upper lip even if the abscess
points in the buccal sulcus. If pus accumulates in the canine fossa then the
nasolabial fold is often obliterated and the swelling of the upper lip produces
a drooping of the angle of the mouth. Oedema of the lower eyelid heralds
pointing of the abscess below the medial corner (Fig. 6.18).
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Fig. 6.18. Swelling of the left cheek and medial corner of the lower eyelid
resulting from an abscess on the upper left canine.

Treatment
There is again an obvious risk of cavernous sinus thrombosis as a
complication of these infections and early effective drainage is important,
but should be carried out without unnecessary trauma. Antibiotics should
always be prescribed.

Differential Diagnosis
Facial swelling due to an abscess from an upper tooth has to be
distinguished from a carbuncle and from acute maxillary sinusitis which
occasionally may cause infra orbital oedema with swelling of the lower
eyelid. Swelling of both lower and upper eyelids may accompany acute
ethmoidal sinusitis which may extend and become an orbital cellulitis.
Acute frontal sinusitis produces oedema of the forehead and involves only
the upper eyelids. Acute nasolacrimal dacryocystitis following stenosis of
the duct can produce an inflammatory swelling below the medial canthus of
the eye, not unlike that produced by a pointing canine abscess, but there will
be redness of the lower conjunctival fornix and probably a purulent exudate
there.

Abscess Involving the Upper Molar Teeth

Abscesses involving the upper molar teeth usually point in the buccal
sulcus, but occasionally pus from a palatal root or a periodontal pocket in
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the trifurcation may point on the palatal side. More rarely pus may
discharge into the maxillary antrum giving rise to an enigmatic acute or
subacute sinusitis. Buccal abscesses from upper molar teeth produce very
little swelling of the face if they discharge below the attachment of the
buccinator. If the pus discharges into the soft tissues above the attachment
of the buccinator to reach the buccal space, a moderate swelling of the
affected side of the cheek occurs. Although this type of abscess can point on
the face below the zygomatic bone, it usually accumulates eventually in the
buccal sulcus, and therefore drainage is carried out through an intraoral
incision.

Subperiosteal Abscess in the Palate

The mucoperiosteum which covers the palate is made up of mucosal and
periosteal layers which are bound together so strongly that they cannot be
separated. It is attached to the periodontal membranes of the surrounding
teeth and to the median suture line. The periosteum is attached to the
underlying bone by Sharpey’s fibres and small blood vessels and their
attachment produces a roughness of the bone surface best seen on a dried
skull. No actual space exists between the mucoperiosteum and the
underlying bone, but the periosteum between the gingival margin and the
midline can be stripped up comparatively easily during surgery and also by
pus when it accumulates between the bone and the periosteum.
Although the attachment to the necks of the teeth is relatively strong, in
the case of long standing infection the pus may eventually lyse the
connective tissue and seep through the gingival crevice alongside a tooth.
Pus rarely tracks across the centre of the palate and usually remains
confined to the side of the focus of infection because of the attachment to the
median suture. As the apex of the lateral incisor is often closer to the palatal
bony surface, this tooth is the most common source of a palatal abscess
followed by a periodontal abscess from a palatal pocket or an apical abscess
from the palatal root of a multirooted tooth.
The many reasons for necrosis of the lateral incisor pulp include: caries,
unlined cavities, blows and fractures, and infection through a develop-
mental cingulum invagination. Abscesses originating from this tooth may
migrate and point as far posteriorly as the soft palate, so that whenever the
source of a palatal abscess is in doubt the lateral incisor must be the prime
suspect and it should be tested for vitality.

Signs and Symptoms

Pus beneath the palatal mucosa produces a circumscribed fluctuant
swelling which is usually confined to one side of the palate. The swelling
may sometimes show little obvious distension of the tissues, but
nevertheless, extends for a considerable distance beneath the thick
mucoperiosteum. There may be little tendency for the abscess to discharge
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Fig. 6.19. A palatal abscess arising from 2| which is carious distopalatally.

spontaneously, although pus may well up at the sides of adjacent teeth if it

has been neglected for a period of time (Fig. 6.19).

Differential Diagnosis
Some painful, tender, fluctuant, palatal swellings are due to infected dental
cysts and this diagnosis should be suspected if the swelling transgresses the
midline. Otherwise the diagnosis of palatal abscess should present no
difficulty, but occasionally a large, fluctuant mucous extravasation cyst or
cystic pleomorphic adenoma or muco-epidermoid carcinoma may cause
confusion, especially if it is in close relation to an obviously infected tooth
or root. Some carcinomas from the maxillary sinus or malignant
lymphomas also present as fluctuant palatal swellings. A gumma of the
palate now rarely seen could also cause confusion in diagnosis.

Treatment
Incision of a palatal abscess should be carried out in an anteroposterior
direction to avoid dividing the greater palatine vessels. The responsible
tooth must be treated at the same time. To prevent the accumulation of a
haematoma in the abscess cavity, which may progress to a further abscess,
the lateral edge of the incision should be gripped with the tips of mosquito
artery forceps. A knife blade is run round the tip, removing a small piece
from the mucosa, and a short length of ribbon gauze drain is tucked loosely
into the cavity and sutured to one edge of the wound for 24 hours. When the
drain is removed there will be a cavity between the mucoperiosteum and the
bone but the tongue will soon press the mucosa back into place.
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Periapical Abscesses in Relation to the Maxillary Sinus

The apices of the roots of many of the upper teeth are in a close relationship
to the floor of the maxillary sinus. The particular ones which are related
vary from patient to patient depending upon the size of the maxillary sinus
and upon the length of the roots. Ones most frequently related are the apices
of the 2nd and Ist molars followed by the 3rd molar, 2nd and Ist premolars
and canine. Despite this, pus from an abscess of one of these teeth usually
discharges onto the alveolar surface, although radiographs often show
mucosal thickening in the overlying antrum. If pus does enter the antrum the
features of an acute sinusitis will follow with facial pain especially on
bending, engorgement of the nasal mucosa with obstruction and a nasal
discharge.
Beware of diagnosing an acute pulpitis in a tooth made periostitic due to
an overlying acute sinusitis. An infected pulpless tooth or a minute
oroantral fistula following an extraction may give rise to a chronic sinusitis
with recurrent subacute episodes which may defy diagnosis. Advanced
periodontal disease may also result in chronic maxillary sinusitis, with
mucosal thickening and sclerosis of the bony floor.

Radiology
The earliest change is thickening of overlying antral mucosa or polyps seen
on a periapical, rotational tomographic or lateral occlusal film. An
empyema produces an opaque sinus with a fluid level best seen in an
occipitomental radiograph, but the opacity may be seen also in a standard
occlusal radiograph.
It is worth noting that a rotational tomographic film will only give a
vertical ‘cut’ of the antrum and is therefore unreliable in providing
information about the state of those parts which lie laterally to the cut.

Treatment
Some discharge of pus will have taken place via the nose and in most cases
extraction of the infected tooth will lead to drainage of the remainder which
has accumulated below the level of the osteum. Provided that the defect in
the antral floor is small and the infection controlled with antibiotics, the
socket should heal normally and seal the fistulous orifice. Even a larger
fistula will often close spontaneously with antibiotics, frequent irrigation
with warm saline and a protective acrylic plate which prevents food debris
entering the sinus. If this is not successful a formal antrostomy through a
Caldwell—Luc approach with removal of polyps, and intranasal antrostomy
and closure of the fistula with a flap will be required.

The Infratemporal Fossa

Surgical Anatomy
The infratemporal fossa space forms the upper extremity of the pterygo-
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 ORAL SURGERY, PART 1

Fig. 6.20. Diagram of the pterygomandibular and infratemporal spaces in

coronal section. a, Intratemporal space. b, Pterygomandibular space. c,
Temporalis muscle. d, Temporal fascia. e, Masseter muscle. f/ Medial
pterygoid muscle. g, Lateral pterygoid muscle (dotted outline); position of the
lateral pterygoid tendon.

mandibular space. It is bounded laterally by the ramus of the mandible, the

temporalis muscle and its tendon, medially by the lateral pterygoid plate
and superiorly by the infratemporal surface of the greater wing of sphenoid.
It contains the origins of the medial and lateral pterygoid muscles and the
lower head of the lateral pterygoid can be said to mark the border between
the pterygomandibular and infratemporal spaces. It is traversed by the
maxillary artery and contains the pterygoid plexus of veins. Pus can extend
upwards under the origin of the temporalis muscle from the lower part ofthe
infratemporal fossa, and also around to the lateral side of the muscle, under
the temporal fascia.
It will be seen that this space is actually continuous in its anterior part
with the upper part of the pterygomandibular space but is separated from it
by the lateral pterygoid muscle posteriorly. Infection usually reaches
the infratemporal space from the upper molars while the pterygo-
mandibular space is more often affected by infection from the lower jaw
(Fig. 6.20).

Clinical Features
Subacute infections due to contaminated needles may follow injections in
the tuberosity area and produce relatively slight physical signs apart from
trismus which must be distinguished from limitation of opening due to a
temporomandibular joint disturbance.
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 PYOGENIC INFECTIONS OF THE SOFT TISSUES

Fig. 6.21. Patient with a severe infratemporal, pterygoid and buccal space
infection which followed an injection in the upper right molar region. There was
anaesthesia of the tongue on the right, but no swelling of the tongue and inability
either to open or close the mouth. The right temporal muscle is bulged to an
extent that the position of the zygomatic bone is marked by a depression.
Temperature was 104 °F with drying and cracking of the lips.

Acute infratemporal fossa infections tend to follow infections of upper

3rd molars, particularly those which are partially erupted, and occasion-
ally from local anaesthetic injections with contaminated needles. The
infection spreads upwards deep to and lateral to the temporalis muscle.
Limitation of opening is marked, as with a pterygomandibular space
infection, but there will be bulging of the temporalis muscle. This may not
be obvious as the muscle and overlying fascia contain it, but the swelling
may be detected as a filling out of the hollow behind the zygomatic process
of the frontal bone (Fig. 6.21).
Pus may also spread upwards beneath the origin of the temporalis muscle
itself almost to the lower temporal line to form a subtemporalis abscess. The
situation is similar to that found with a submasseteric abscess, and in pre-
antibiotic times, if drainage was delayed the temporalis muscle and surface
of the skull would be found to be necrotic. In acute infections the patient is
very ill and has a high temperature.
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 ORAL SURGERY, PART 1

Infections of the infratemporal fossa are always serious owing to the

presence of the pterygoid plexus of veins. Emissary veins connect these
with the cavernous sinus through the sphenoidal emissary foramen (of
Vesalius), the foramen lacerum, foramen spinosum and the foramen ovale.
Infection from the pterygoid plexus can therefore spread to the cavernous
sinus. It can also spread directly through the other foramina in the
infratemporal fossa into the middle cranial fossa. Thus on rare occasions
headache, irritability, photophobia, vomiting and drowsiness will indicate
intracranial infection.

Treatment
Antibiotics must be given promptly. Benzylpencillin 600 mg, 8-hourly,
together with metronidazole 500 mg, 8-hourly, is a suitable intravenous
regime which can be followed by phenoxymethyl penicillin 500 mg, 6-
hourly, and metronidazole 400 mg, 12-hourly, by mouth. Drainage of the
infratemporal fossa can be effected through an incision buccal to the upper
3rd molar following the medial surface of the coronoid and temporalis
upwards and backwards with closed sinus forceps. A soft drain must be
sutured in. In severe cases drainage through an incision at the upper and
posterior edge of the temporalis within the hairline may be necessary also.
The sinus forceps are passed downwards, forwards and medially to the pus.
Again a soft drain is inserted.

Course
Prolonged limitation of opening may follow these infections. In most cases
the range of movement increases in time with the aid of active exercise. If
jaw exercises and manipulation do not seem to increase the opening,
temporalis myotomy or excision of the coronoid process may improve
matters.

Cavernous Sinus Thrombophlebitis

This serious condition becomes recognizable by the appearance of marked
oedema and congestion of the eyelids, and injection and oedema of the
conjunctiva due to impaired venous return. This may develop into a
pulsating exophthalmos where the carotid pulse is transmitted through the
retrobulbar oedema. At this stage ophthalmoplegia is detectable and if the
retina can be visualized, papilloedema with multiple retinal haemorrhages
will be seen. Untreated the thrombophlebitis will spread to the opposite side
giving rise to bilateral signs.
Cavernous sinus thrombophlebitis will require energetic antibiotic
therapy and heparinization to prevent extension of the thrombosis;
however, a neurosurgical consultation is essential as a matter of great
urgency.
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 PYOGENIC INFECTIONS OF THE SOFT TISSUES

THE USE OF HEAT IN THE TREATMENT OF

SOFT-TISSUE ABSCESSES
Poultices were applied to extensive infections of the soft tissues in pre-
antibiotic days in order to induce local vasodilatation by means of their heat
and the rubifacient substances which they contained. It was hoped that the
increased blood supply would help the tissues overcome the infection. In
the case of suppurative infections they appeared to hasten suppuration and
encourage the pus to point under the poultice where it could be readily
drained.
Poultices probably increase the spread of a cellulitis. Furthermore, if
poultices are applied after pus has formed beneath the deep fascia, the
increased oedema and exudate which they induce could worsen the
patient’s condition. Incisions for drainage are often delayed by this
practice. Consequently the application of heat externally to infections of the
floor of the mouth and neck has come to be regarded as a bad measure, and
with the establishment of effective antibiotic treatment and early and
efficient drainage has virtually disappeared. Hot salt water mouth baths still
provide comfort and to a degree improve oral hygiene but, like poultices,
probably have only a small therapeutic effect. If a cellulitis does not resolve
rapidly with antibiotic treatment, but the disappearance of constitutional
signs and symptoms suggests that the causative organisms are sensitive,
then ensure that there is no undrained pus somewhere which has been
overlooked.

THE SURGICAL DRAINAGE OF ABSCESSES

Successful surgical drainage of an abscess depends upon a knowledge ofthe
applied anatomy of the part and therefore an understanding of the probable
location of the accumulation of pus in the tissues, together with good
surgical judgement concerning the proper time to instigate drainage. It is
most important to recognize when pus has formed and to drain it at once. If
the incision is carried out too early little or no pus is found, but this is no
longer considered harmful to the patient. On the other hand, if incision is
delayed until an abscess from a deep space presents as a fluctuant swelling
then the pus may invade hitherto uninfected tissue spaces, or discharge
spontaneously and produce a disfiguring external scar. Unfortunately the
value of antibiotics may encourage surgeons to delay unnecessarily incision
and drainage.
Immediate incision and drainage are required:
1. Where there are signs of pus beneath the deep fascia:
a. Alocalized dusky redness appearing in the general redness of the
firm swelling;
b. A localized area of tenderness over the centre of the swelling;
c. Pitting oedema in the middle of a previously firm swelling;
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 ORALYSURGERYS PARE

d. A sharp rise in the temperature, particularly if the patient is

having antibiotics.
2. Where the involved compartment is inaccessible, such as the
pterygomandibular and lateral pharyngeal spaces, and in the case of
submasseteric and infratemporal fossa infections where it may be
impossible to elicit the classic signs of suppuration. If pus is left in these
situations tissue necrosis may supervene. Therefore a lack of local
improvement with adequate doses of antibiotics, a recurrence of pyrexia or
a sudden increase in temperature and severe limitation of opening are some
of the indications for drainage of these sites.
3. With Ludwig’s angina and other serious and rapidly evolving
infections of the floor of the mouth and upper neck, immediate incision and
drainage of the relevant tissue compartments is essential. However, early
extraction of causative teeth and the use of metronidazole to eliminate
anaerobes including bacteroides has greatly reduced the incidence of these
cases.
Patients under treatment for acute inflammatory soft-tissue swellings
should be seen daily. In a proportion of cases the infection will be halted and
the swelling will subside as a result of the administration of antibiotics and
the extraction of the causative tooth. In others the signs of suppuration or
the need for incision as discussed above will become apparent. Patients
with infections causing substantial swelling of the floor of the mouth or side
of the pharynx need admission to hospital so that early incision and
drainage can be instituted and more frequent observation of their progress
made possible. Patients with dangerous or rapidly progressive infections
should be under constance surveillance, preferably in an intensive care unit,
for the onset of respiratory difficulty and impeding obstruction can take
place with surprising rapidity.
With prolonged antibiotic treatment some modest-sized abscesses may
be virtually sterilized, but this does not lead to a satisfactory outcome. At
best the pus is walled offto produce a pultaceous mass, but an accumulation
which can still be drained. Later invading macrophages and granulation
tissue will convert the whole into a tumour-like mass called an ‘antibioticoma’.
Aspiration of pus with a wide bore needle and syringe is one way to obtain a
specimen from which obligate anaerobic organisms may be cultured. Small
superficial abscesses may be drained in this way and of course this is easy to
carry out with an abscess in the buccal sulcus. However, without free
continuous drainage, as achieved by incision, the abscess may refill within
24-48 hours. This is certain to happen if the tooth causing the infection has
not been effectively dealt with. Where an abscess points beneath the skin as
a red shiny swelling in a conspicuous position aspiration may be tried as a
means of avoiding the scar of an incision, but such an abscess often heals
with puckering and subcutaneous scarring so that the aesthetic benefit is
marginal. Treatment of any scar should be delayed for at least 6 months
because a slow improvement will occur.
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 PYOGENIC INFECTIONS OF THE SOFT TISSUES

Prompt drainage when pus forms avoids the temptation to prolong

antibiotic treatment perhaps with exotic and potentially toxic drugs and
reduces the opportunities for the emergence of resistant strains.
Success in the treatment of a cellulitis becomes apparent with a fall in the
patient’s temperature, a reduction in malaise and toxaemia, the relief of
pain and a decrease in the swelling. The first sign of such a decrease is often
the appearance of fine wrinkles in the overlying skin where previously it was
tense, red and shiny.

Technique of Incision and Drainage

Incisions for the drainage of pus vary according to the location and may be
made in either the skin of the neck or face or in the mucosa of the mouth.
Abscesses in the sulcus are just under the surface with no structures of
importance in between and the incision is made with a scalpel straight
through into the abscess cavity.
In general incisions are placed over the point of maximum fluctuation, or
over the most direct route to the pus, so that dependent drainage is achieved.
However, this is not always essential as the tissues will contact around an
abscess and push the pus out even if the opening is at the top. Indeed, it is
common experience that pus will even well up the root canals of the lower
incisors when they are opened to drain a periapical abscess. Since there are
no structures of consequence in the subcutaneous tissues the incision may
be made boldly through the skin and into the subcutaneous tissues.
The siting of the incision is guided by the direction of Langer’s lines and
the skin creases. Once this incision has been made the scalpel is discarded
because if pus has not been found at this depth further deepening of the
wound is achieved with sinus or artery forceps to avoid damage to important
underlying structures. Closed forceps are pushed through the deep facia and
advanced to the pus. In a man the investing layer of cervical fascia can be
quite tough and a controlled effort may be required to penetrate it.
Pus will discharge up the sides of the forceps as soon as the abscess cavity
is entered, whereupon the forceps are opened in a direction parallel to
adjacent important structures. The hinges of the sinus forceps must be
external to the wound or the path through the tissues will not be stretched
and enlarged by the movement of the forceps blades. Where the patient is
very thin, it must be remembered that the subcutaneous tissue will contain
little fat, and even with oedema, therefore, the distance to the platysma will
be small. In such subjects particular care must be taken to incise no deeper
than the subcutaneous fat to avoid inadvertent damage to the mandibular
branch of the facial nerve.
Some pus should be collected in a specimen tube or on a bacteriological
swab, and sent for a stained direct film to provide immediate information,
and for culture for further identification and to determine the antibiotic
sensitivity of the organisms. Swabs should be taken to the microbiologist
straight away so that they do not dry out as the organisms will often die and
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 ORAL SURGERY, PART 1

a false negative culture result. Where specimens have to be sent a distance

to the laboratory the microbiologist will provide bottles of transport
medium. Obligate anaerobes will not be recovered unless special culture
techniques are used, so a failure to note their presence in a routine
laboratory report does not mean that such organisms are not contributing to
the infection.
After a large abscess cavity has been adequately opened, the surgeon
should insert a gloved finger into the space and explore its extent. This
confirms that the whole abscess cavity has been drained and that no
additional loculi of pus remain. Gentle probing with the finger will break
down the walls of any loculi and allow the pus enclosed within them to be
evacuated.
A soft ‘Yeats’ or corrugated drain is then inserted using the sinus forceps
to carry the end into the depths of the cavity and the part external to the
wound is sutured to one edge of the incision. A sterile safety pin has been
traditionally used to prevent the drain being lost in the wound but this is
unlikely in the facial region. The drain is left until little pus accumulates in a
dressing left for 24 hours. Long drains should be shortened for a further 24
hours before final removal. Adhesive wound closure strips may be used to
approximate the skin edges at this stage to improve the appearance of the
final scar.
With intraoral abscesses, the operation may be performed in miniature
and mosquito artery forceps used instead of sinus forceps. In some
situations in the mouth medicated ribbon gauze soaked in Whitehead’s
varnish may be adequate as a drain and more comfortable than a soft plastic
one. All intraoral drains must be anchored with a stitch to prevent them
being swallowed or aspirated.
Occasionally where a large cavity exists it may be better to suture a soft
plastic tube or quill into the dead space and irrigate it 4-hourly with half
strength hypochlorite solution (Eusol or Milton’s) until the effluent
becomes clear. Drainage may continue in between irrigations into a small
collecting bag sealed to the skin surrounding the incision wound. Usually
within 3—4 days it is possible to remove the tube and replace it with half inch
ribbon gauze again soaked with hypochlorite solution, but changed four
times daily until the wound closed. This classic technique is particularly
important when resistant microbes have been reported and should be used
in conjunction with a simple antibiotic regime such as metronidazole.

SINUS FORMATION
The majority of abscesses will burst spontaneously if they are neglected for
a sufficient period of time. However, this is an undesirable occurrence
especially when the abscess discharges through the skin, for not only may
the sinus appear in a location unfavourable for drainage, but the resulting
scar is always puckered, thickened, and depressed and more obvious than in
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 PYOGENIC INFECTIONS OF THE SOFT TISSUES

Fig. 6.22. A submental sinus resulting from a chronic abscess on 1]. The
anterior teeth have been fractured as a result of a fall and 1| is dark brown in
colour and pulpless.

cases where elective surgical incison and drainage has been carried out.
Furthermore, the sinus will become chronic unless the original source of
infection is removed and it will be subject to exacerbations and remissions
with attempts at healing during the quiescent phase. When these sinuses are
sited on the face or neck their appearance is quite characteristic and a focus
of infection such as a buried tooth or root must be sought and eliminated.
(Fig. 6.22.) Not infrequently a lack of understanding of dental pathology
may lead to repeated excision of facial sinuses because of persistent
infection.
The clinical appearance of sinuses on the face varies according to the
phase of the infection. During an active phase they are open and discharging
small quantities of pus, but during a quiescent phase they heal over.
Occasionally, it is possible to insert a silver probe along the tract as far as
the bone. In an active phase the tissue immediately surrounding the sinus
exhibits signs of inflammation and may be tender, but after pus has been
drained the sinus tends to heal over until another exacerbation of infection
kil
 ORAL SURGERY, PART 1

causes it to burst open again. If the buccal sulcus between the sinus and the
jaw is palpated a firm, fibrous cord representing the sinus track may be felt.
The position of its attachment to the jaw may indicate the site from which
the pus is draining.
It is essential to consider chronic actinomycosis where a sinus persists
in the absence of intra-alveolar disease. Usually but not invariably
actinomyces may be cultured from the pus which should also be examined
by a direct Gram-stained smear. In such cases long-term penicillin or
tetracycline therapy is required given continuously, for example, for 4—6
weeks.
Very occasionally if the abscess drains into the mouth as well as on to the
skin surface a fistula will form from the mouth to the outside of the face
through which saliva escapes. However, persistent inflammation with
salivary fistula should suggest the possibility of an unrecognized malignant
neoplasm.

Sinus Excision
An elliptical incision is made round the external orifice so that on closure
the scar lies in Langer’s lines without puckered ends. Using McIndoe’s
scissors the tract is followed to its source, usually on the bony surface of the
mandible. Some deep soluble catgut or polyglycolate sutures are inserted to
eliminate the dead space and the skin wound is closed with careful eversion
of the edges using interrupted 4/0 proline or other monofilament sutures. If
there is a through and through wound into the buccal sulcus, the oral defect
is closed with black silk sutures at the conclusion of the operation.

SUMMARY OF THE MANAGEMENT OF PATIENTS

WITH SPREADING INFECTIONS
1. An acute abscess with collateral oedema:
a. Extraction of the tooth alone is normally adequate treatment.
b. If root-canal therapy is to be undertaken, open the pulp chamber
to drain the abscess through the root canal and administer
antibiotics.
c. Establish local antibiotic or antiseptic treatment in the root canal as
soon as possible and then seal the opening into the pulp chamber.
2. Cellulitis or tissue space abscess: Administer antibiotics to help
eliminate local infection and prevent its spread elsewhere. Extract the tooth
of origin or establish effective root-canal treatment but only if this is
reasonable. Incise and drain where there is:
a. Fluctuation as in the case of a local abscess;
b. When there is localized pitting oedema with tenderness;
c. When localized dusky redness and a sharp rise in temperature
Suggests a tissue space is involved.
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 PYOGENIC INFECTIONS OF THE SOFT TISSUES

SUGGESTED READING
Birn H. (1972) Spread of dental infections. Dent. Pract. 22, 347-356.
Bosley A. R. J.. Murphy J. F. and Dodge J. A. (1981) Septicemic Haemophilus
Influenzae and facial cellulitis in infants. Br. Med. J. 282, 22.
Frankl Z. (1949) The sub-mandibular space and parapharyngeal spaces: their
topography and importance in oral surgery. Oral Surg. 2, 1131-1139;
1270-1285.
Last R. J. (1984) Anatomy: Regional and Applied, 7th ed. London: Churchill.
McDougall J. D. B. (1955) The attachments of the masseter muscle. Br. Dent. J.
98, 193-199.
Von Ludwig W. (1837) Uber eine hene Art von Halsentzundung. Wirttemb.
KorrespBl. 6, Nr. 4, Schmidts. Jahr 15, 925.

7S
 CHAPTER

INFLAMMATORY DISEASES OF BONE

The bone of the jaw is remarkably resistant to infection. This is illustrated

by the common acute alveolar abscess, where infected exudate induces
resorption of the overlying cortex and penetrates the periosteum to
discharge into the mouth or facial tissues without spreading laterally
through the bone itself. Persistent or spreading infective inflammation of
bone appears to require an element of ischaemia or infarction in addition to
bacterial infection.
Pathological resorption is mediated by inflammatory agents such as the
prostaglandins PGE2 and PGI2, the lymphokine osteoclast activating
factor (OAF) and possibly monocyte cell factors (MCF), all of which
activate directly or indirectly the osteoclast. One of the well recognized
features of bone destruction is the associated local bone regeneration which
is thought to be stimulated by a protein breakdown product of bone matrix
called human skeletal growth factor (HSFG). This coupled effect of bone
formation in association with bone destruction is an essential feature of
most bone pathology and can be seen for instance in the sclerotic areas
around the apices of chronically inflamed, pulpless teeth or the involucrum
of osteomyelitis.

LOCALIZED, OSTELLTIS
Osteitis is a term used to describe a localized small scale infection of bone.
The distinction between an osteitis and a localized, low-grade osteomyelitis
is arbitrary. Periapical and periodontal abscesses are considered under soft
tissue infections (Chapter 6).

ACUTE ALVEOLAR OSTEITIS

Acute alveolar osteitis, ‘dry socket’, alveolitis sicca dolorosa, or fibrinolytic
alveolitis is a well recognized painful complication of dental extractions in
which the blood clot disintegrates exposing an infected necrotic socket wall.
This is characteristically associated with a fetid odour. The average
incidence appears to be 3 per cent of all extractions and may be as high as
22 per cent of 3rd molar extractions under local analgesia, but these figures
will vary with the skill of the surgeon and the prophylactic measures used.
There might be a slightly greater incidence in females than males and the
peak age range is 20-40 years. Few cases are seen in children and the

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 INFLAMMATORY DISEASES OF BONE

elderly. Mandibular teeth appear to be three times more prone than

maxillary teeth.
The aetiological factors responsible for acute alveolar osteitis may be
divided into vascular and infective.
Several possible reasons for the loss of the clot from the socket are
advanced. A popular concept is that the clot is washed out of the socket by
the patient. This idea is not tenable since within a short time of the
extraction the clot adheres quite firmly to the socket wall. Patients are
usually advised not to rinse out the mouth during the first 24 hours after the
extraction, not because of the risk of dislodging the entire clot from the
socket. but because they might start the socket bleeding again. If the clot
were to be forcibly removed from the socket at this time, the result would be
further haemorrhage, not an empty socket.
Infection and fibrinolysis of the clot is another common suggestion. A
variety of organisms can be cultured from dry sockets including fusiform
bacilli, spirochaetes, diplococci and streptococci. Support for the infective
cause of clot destruction comes from the degree to which antibiotic
prophylaxis and careful preoperative toilet of the tooth and oral cavity can
reduce its incidence. For instance 200 mg metronidazole, 8-hourly, for 3
days can produce a significant protection against dry socket, suggesting that
anaerobes may play an important role.
However, infection may not be the only cause of clot lysis because
alveolar osteitis may occur irrespective of the care and skill of the operator
or of the trouble taken to prevent infection of the extraction wound. It has
been suggested that extraction trauma as well as subsequent infection of the
socket activates plasminogen to plasmin which causes lysis of the fibrin
clot. Investigations have demonstrated the presence of both tissue
activators and plasmin in the alveolar bone adjacent to affected sockets, and
stable tissue activators are present in the connective tissue type of marrow
characteristic of the jaws in the age group 20-40. However, an inhibitor of
fibrinolysis, tranexamic acid, failed to prevent the occurrence of alveolar
osteitis. This was considered to be due to inadequate local concentration of
the drug in the alveolar bone.

Predisposing Factors
A number of conditions may predispose to acute alveolar osteitis. The
incidence of alveolar osteitis after extractions for which a local anaesthetic
with a vasoconstrictor has been used appears to be greater than after a
general anaesthetic, although not all investigators have found this to be so,
particularly in relation to the removal of 3rd molars. In theory,
vasoconstrictors may temporarily inhibit the vascular component of the
inflammatory reaction and tend to favour the establishment of a local
infection. Similarly, when excessive vasoconstriction is used the socket
may be open to contamination by saliva for some time before bleeding
occurs.
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 ORAL SURGERY, PART 1
Excess trauma during a forceps extraction is associated with an
increased tendency to dry socket. This may result from the crushing and
devitalization of the socket wall and thrombosis of the underlying vascular
plexus. Such trauma would also increase the release locally of plasminogen
activators. Similarly conditions with sclerotic and relatively avascular bone
are also prone to socket infection. In some otherwise normal jaws a socket
may be related to a localized mass of sclerosed bone. Sclerotic masses may
involve much of the alveolar process in long established Paget’s disease and
the entire jaw may exhibit increased density in osteopetrosis and some other
rare skeletal diseases. In Paget’s disease hypercementosis of the teeth
further increases the difficulty of extractions and the resultant crushing of
the adjacent bone. Incidently, it is only the sclerotic masses in Paget’s
disease which are less vascular than normal. The rest of the abnormal bone
is markedly more vascular. In jaws which have received a therapeutic dose
of irradiation the blood supply is reduced due to obliterative endarteritis.
Furthermore, where there are additional local or systemic factors the
possibility of extension to an osteomyelitis is a possible complication. Pre-
existing infection in the form of acute or chronic periapical and periodontal
disease seems to be of little importance, but the extraction of teeth during an
acute ulcerative gingivitis is an invitation to trouble.
Other factors which might predispose to a dry socket are those which
influence vascular function, such as the oral contraceptive pill and smoking.
A significant higher incidence of dry socket occurs in smokers, especially
those who smoke after the extraction.

Clinical Features
The patient usually presents within 2—4 days of the extraction complaining
of a boring, persistent, dull pain which is well localized to the socket, but
may radiate to the ear or other parts of the face. In some cases the pain is
exceptionally severe. This is attributed to the release of kinins as a result of
the action of plasmin activators on kininogen present in the alveolar
process.
The gingival margin of the socket is usually swollen and dusky red. The
socket itself is either devoid of clot, or contains a brown, friable, sometimes
foamy clot which is easily washed out. Food debris may have accumulated
in the socket which, with the disintegrating clot, produces a foul taste and
smell. If this material is washed away the bone of the socket wall is seen to
be bare and it may be extremely sensitive if touched. If the gingival margin
about the socket has already contracted it can be difficult to examine the
socket and appreciate that it does not contain a normal clot. The regional
lymph nodes may be tender and can be enlarged. There is rarely a
pyrexia.
The critical time for development of a ‘dry socket’ is during the first four
days after an extraction because at about the third day granulation tissue
starts to invade the clot. From this time therefore loss of the clot will no
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 INFLAMMATORY DISEASES OF BONE

longer expose bare bone. Often there is no frank sequestration of bone, but
from time to time exuberant granulations form and small pieces of the
socket wall or parts of the inter-radicular septum separate and are
discharged with small amounts of pus. Occasionally a complete ring, or
even a ‘thimble’ of socket wall is sequestrated. After a period of some 7-14
days granulation tissue lines the socket and gradually fills it up.
Radiographs will show the outline of the socket and should be taken to
confirm the absence of a retained root, foreign body or a loose, fractured
fragment of septal or alveolar bone.

Preventive Measures
1. Preoperatively, scale and clean the teeth and improve oral hygiene as
far as is practical including the use of chlorhexidine gluconate mouthwash,
if possible, starting several days before the extractions.
2. Execute the extraction carefully with minimal manipulation of the
tooth.
3. Where a dry socket may be anticipated, such as following the
extraction of a lower 3rd molar, give a 5 day course of metronidazole
400 mg b.d. postoperatively. Tetracycline 250 mg taken 6-hourly for a
similar period is also effective.
Various cones containing sulphonamides, antifibrinolytic agents such as
tranexamic acid (AMCA) or the propyl ester of parahydroxybenzoic acid
(PEPH) have been tried prophylactically but there is no evidence that they
are better than general measures which leave the socket undisturbed to heal
spontaneously.
Treatment
Because the patient may be suffering severe pain sympathetic and prompt
treatment is required. All disintegrating clot and food debris should be
irrigated away with warm saline and a suitable dressing should be inserted
in the socket. Such a dressing may contain a topical local anaesthetic to
relieve pain and a non-irritant antiseptic to inhibit the growth of bacteria
and fungi. It should also protect the bone from the irritation of food debris
accumulating in the socket. Finally, it should dissolve slowly or extrude as
healing progresses, so that it is neither incorporated in the granulation tissue
nor prevents it filling the socket.
A suitable paste is composed of the water-soluble waxes; polyethylene
glycol, 4000-510g, polyethylene glycol, 1500-510g, incorporating
lignocaine hydrochloride, 20g, domiphen bromide (Bradosol), 0-5g,
distilled water, 20 ml. The material is warmed slightly to soften it so as to
permit it to be inserted painlessly. Ribbon gauze moistened with
Whitehead’s varnish is a useful alternative.
Packs containing eugenol or other essential oils, zinc oxide and cotton
wool relieve pain but the eugenol devitalizes more bone and healing is
delayed. Dry sockets which have persisted for weeks, lined with yellow-
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 ORAL SURGERY, PART 1

brown bone and which show no signs of healing have usually been dressed
liberally with eugenol containing dressing.
The use of inert hydrophilic dextron polymer beads, Dextranomer
(Pharmacia (GB) Ltd), appears both to relieve pain and encourage rapid
healing but the socket has to be dressed daily with the fine beads alone or in
glycerine and then sealed with Orobase gel. The preparation probably
absorbs exudate and toxins, relieving pain and inflammation and does not
interfere with healing.
Irrigation and dressing of the socket should be repeated as often as is
necessary to control pain. In severe cases this may mean daily for several
days. In addition for severe cases an analgesic sufficient to control pain and
night sedation are essential and metronidazole 400 mg b.d. should be
prescribed for 5 days.

OSTEOMYELITIS
This condition is now rare in Western European countries indicating not
only the value of antibiotics and early treatment but the importance of
predisposing factors such as poor nutrition, chronic debilitating illnesses
and gross untreated dental disease. Most cases seen are in alcoholics with
malnutrition, drug addicts, diabetics and patients with impaired immunity
due to the need to take steroids or cytotoxic drugs. Special problems such as
follow the use of therapeutic irradiation and in Paget’s disease will be
discussed separately.
For a true osteomyelitis to occur the infected exudate must spread
throughout the cancellous spaces of the bone producing thrombosis of the
nutrient vessels with ischaemia, infarction and sequestrum formation.
Until old age the main blood supply to the mandible is the central inferior
dental artery with its centrifugal distribution anastomosing with the
peripheral periosteal vessels which enter through Volkmann’s canals. Parts
of the ramus and coronoid process are supplied by additional small nutrient
arteries but are dependent to a substantial extent upon small vessels
entering the cortex from muscle attachments. In elderly subjects the
mandibular arteries may be occluded. When the central vessel is divided, or
thrombosed through the spread of bacteria and their toxins, ischaemia then
infarction will take place. This is a rare problem in the maxilla which has
predominantly cancellous alveolar bone with a thin cortex and a rich
plexiform blood supply.
Experimentally, sequestrum formation in rabbits’ tibias by Staphy-
lococcus aureus has been prevented by treatment with the non-steroidal
anti-inflammatory analgesic indomethacin which inhibits prostanoid
(prostaglandin-like substances) formation. This was probably due to the
inhibition of thomboxanes normally synthesized and released by the
infection, and which are potent platelet aggregation factors and therefore
could be responsible for the thrombosis and infarction.
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 INFLAMMATORY DISEASES OF BONE

Osteomyelitis of Infancy
This condition which occurs sporadically affects infants only a few weeks
old and the maxilla almost exclusively, hence the alternative term,
maxillitis of infancy. The causal organism is the S. aureus which is thought
to be introduced from an infected nipple or incipient breast abscess or
contaminated feeding bottles. Access may be through a break in the
mucosa, perhaps over the eminence caused by the maxillary first deciduous
molar tooth germ. However, the conjunctiva and lacrimal sac or the nose
may be alternative primary infective sites.

Clinical Features
The condition shows considerable variation in severity. There is fever,
anorexia and a swelling or redness below the inner cathus of the eye in the
lacrimal region which leads to marked oedema of the eyelids on the affected
side. Later a frank orbital cellulitis may supervene. A sinus may also open
below the inner canthus of the eye. The alveolar process and palate in the
first deciduous molar region often become swollen and pus discharges
intraorally through one or more sinuses. Eventually, if untreated, sequestra
including tooth buds may be discharged after two or three months.
The oral manifestations help to distinguish the early condition from
dacryocystitis neonatorum, orbital cellulitis, and ophthalmia neonatorum.
Acute cellulitis of the face without bone involvement produces a grossly
swollen dusky red cheek usually in older infants of between 6 months and |
year of age. A similar presentation is also possible with infantile cortical
hyperostosis, but again in older infants.
Treatment is by energetic antibiotic therapy with flucloxacillin and
amoxycillin and surgical drainage. Removal of sequestra should only be
undertaken when they have completely separated, since overenthusiastic
intervention will result in unnecessary loss of teeth and considerable
deformity in later life. Hypoplasia of the deciduous teeth which are not
sequestrated is usual and at least some degree of underdevelopment of the
affected side of the maxilla must be expected. Varying degrees of
disturbance to the adult dentition will occur.
Flucloxacillin 125 mg and amoxycillin 125 mg may be given by naso-
gastric tube 6-hourly. Erythromycin stearate or lactobionate may be given
as an alternative. A swab should be taken to confirm the bacteriological
diagnosis. Adequate fluid intake is important and the child should be barrier
nursed to prevent to spread of the staphylococcal infection to other
patients.

Other Childhood Bone Infection

Infection of the middle ear will penetrate its thin bony floor and enter the
temporomandibular joint space where it is usually confined. Destruction of
the meniscus and fibrocartilage surface of the condyle takes place leading to
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 ORAL SURGERY, PART 1
an irregular proliferative osteitis of the condylar head and ankylosis. The
antibiotic therapy is as already described.
Osteomyelitis of both mandible and maxilla in children can arise
following cancrum oris. This necrotizing infection of the facial tissues
appears to be confined to tropical countries where the predisposing factors
are malnutrition or a virus infection such as measles and malaria.
The principal infective agents are bacteroides especially melanin-
ogenicus associated with Borrelia vincentii and anaerobic Gram-negative
fusiform bacilli, and the treatment therefore is metronidazole. The
additional use of penicillin or erythromycin for the aerobic organisms will
be determined by culture where possible.

ACUTE PYOGENIC OSTEOMYELITIS OF

THE MANDIBLE
Aetiology
The most common cause of pyogenic osteomyelitis of the mandible is
odontogenic infection and the organism is primarily S. aureus. Once
sinuses are formed a mixed infection is usually found. Osteomyelitis can
also occur by direct extension from a source of infection other than the
teeth, such as middle ear disease or a boil on the chin. More rarely the jaw
infection is due to haematogenous spread from a distant focus and this tends
to occur in children.
As stated previously, delay in surgical and antibiotic treatment for a pre-
existing infection together with some underlying predisposing factor are
important in the aetiology.

Clinical Features
Following a periapical abscess with or without surgical intervention the
patient experiences a severe, deep seated pain over the affected part, where
an indurated swelling of moderate size develops. If, as is often the case, the
premolar and molar region is involved, loss of sensation occurs in the lower
lip in the area supplied by the mental branch of the inferior dental nerve.
This is pathognomonic of thrombosis of the inferior dental vasa nervorum
and a rise in pressure from oedema in the inferior dental canal and must be
distinguished from a simple alveolar abscess discharging through the
mental foramen.
A number of teeth may become tender to percussion and loose in the
affected segment of the jaw and eventually pus discharges through sinuses
in the alveolar process, up the periodontal membranes of adjacent teeth,
and also externally onto the face. The lymph nodes draining the area are
enlarged and tender. There is a pyrexia but the adult patient may not feel
particularly ill, which is in marked contrast to the effect of osteomyelitis of
the long bones. Following drainage of pus as a result of sinus formation the
temperature tends to fall and the pain eases. If the condition is not treated a
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 INFLAMMATORY DISEASES OF BONE

protracted chronic state ensues characterized by acute exacerbations at

irregular intervals.

Radiology
Radiographs of the affected area appear virtually normal until osteomyelitis
has been present for about 1-3 weeks. Then the bone takes on a mottled
appearance due to widening of the medullary spaces and enlargement of
Volkmann’s canals. Gradually resorption around the periphery of the
infarcted area of bone separates it off as a sequestrum. The granulation
tissue between the living and dead bone produces irregular lines and zones
of radiolucency. This results in the characteristic moth-eaten radiographic
appearance of established osteomyelitis. Subperiosteal new bone, the
involucrum, can be seen as a fine linear opacity or as a series of laminated
opacities like an onion skin, parallel to the surface of the cortex. This is seen
at the lower border or may be best outlined on the buccal cortex by an
occlusal film. Where the new bone is superimposed upon that of the jaw a
delicate fingerprint or orange peel appearance adds to the loss of
radiographic definition of the original underlying bone structure. The
deposition of subperiosteal new bone is particularly marked in children and
adolescents. Later, substantial fragments of dead bone, especially thick
cortical bone, may be separated from the adjacent bone by well demarcated
radiolucent zones and may even become displaced from their original
position. Sequestra are often prevented from spontaneous discharge
through sinuses in the overlying soft tissues by the enveloping involucrum
and come to lie in granulation tissue and pus filled cavities between the
involucrum and the surviving mandibular bone. At this stage there is a risk
of pathological fracture (Fig. 7.1).

Fig. 7.1. Oblique-lateral radiograph showing extensive osteomyelitis in the

mandible of a child of 10 years.

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 ORAL SURGERY, PART 1
were
In pre-antibiotic days several clinical types of acute osteomyelitis
y related to vascula r factors. Massive ,
seen, the extent of the lesion probabl
frequent ly involve d the whole of one side of the mandibl e,
diffuse infections
opposite
the whole of one side together with the mental region as far as the
mental foramen, and in extreme cases involve ment of the whole of the jaw
(Fig. 7.2). Localized osteomyelitis tended to follow two patterns , vertical

Fig. 7.2. Osteomyelitis affecting the whole of one side of the mandible in an
adult.

and alveolar. In vertical osteomyelitis a short segment of the body of the

mandible was involved in full depth from alveolar crest to the lower border
(Figs. 7.3 and 7.4). In the alveolar form a segment of alveolar bone and the
subapical bone down to the inferior dental canal would separate, containing
the sockets of perhaps three or four teeth (Fig. 7.5). As with other infections
the early administration of antibiotics modifies the natural evolution of the
disease.

Treatment
In the early stages, the clinical and radiological course of an alveolar
abscess and an incipient odontogenic osteomyelitis are the same. The
treatment appropriate to an alveolar abscess is therefore employed. In
many cases this will be sufficient to arrest what, with hindsight, was an early
case of osteomyelitis. This should be extraction of the infected tooth with
incision and drainage. It is rarely necessary to drill holes in the mandible as
with long bones to establish release of the pus as the socket provides a
supplementary exit.
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 INFLAMMATORY DISEASES OF BONE

Fig. 7.3. Osteomyelitis spreading vertically downwards from a lower canine

socket. Subperiosteal new bone (involucrum) encloses a granulation filled
cavity at the lower border containing a sequestrum of cortex.

Fig. 7.4. Vertical osteomyelitis spreading through the mandible from a 3rd
molar socket. Only involucrum (seen in an occlusal film) maintains continuity
of the jaw. There is a sequestrum almost separated.

As it is not practical to wait for the identification of the responsible

organism and the determination of its antibiotic sensitivities, a swab should
be taken when draining the pus but before commencing the antibiotic
therapy.
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 ORAL SURGERY, PART 1

Fig. 7.5. Localized osteomyelitis with a sequestrum of alveolar bone containing

a mandibular canine and premolar.

A broad-spectrum bacteriocidal antibiotic is best combined with one

resistant to staphylococcal penicillinase until the organism and _ its
sensitivities are known. Amoxycillin (SOO mg, 8-hourly) and flucloxacillin
(250 mg, 6-hourly) may be preferred. For patients who are allergic to
penicillin, erythromycin or a cephalosporin alone, or in combination with
sodium fusidate 500 mg, 8-hourly, may be used. Some clinicians advocate
the use of clindamycin 300 mg, 6-hourly, because of its ability to diffuse
widely in bone. It has the advantage of being effective, not only against
staphylococci and streptococci, but also against the anaerobic bacteroides
which can be the cause of a persistent, low grade chronic continuation of
the disease. This drug should be stopped promptly if diarrhoea occurs
because of the risk of pseudomembranous colitis developing (see also
Chapter 8).
There is no simple indication for the best duration of antibiotic
administration, but in early acute cases treatment should be maintained for
a minimum of 2 weeks and may be continued for up to 8 weeks depending
upon the severity of the infection and its response to treatment. With this
type of conservative management even cases which have progressed to the
stage where early radiographic changes are seen will resolve with drainage
as the only treatment.
Once extensive osteomyelitis is apparent radiographically seques-
trectomy will be required and should be undertaken through an intraoral or
submandibular incision depending on the site of the sequestrum.
The bony cavity is saucerized with an acrylic bur so that when the wound
is closed the soft tissues eliminate any dead space. Generous irrigation of
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the bone with sterile saline is important. Primary closure of the soft tissue
wound is carried out with a Yeates drain or suction drainage and antibiotics
are administered for a minimum of two weeks postoperatively or until all
evidence of infection has subsided. Provided that all infected and necrotic
bone is removed healing is uneventful.
Before sequestrectomy consideration should be given to the need to splint
and immobilize the mandible to support it so as to avoid a surgical fracture,
or to avoid displacement of the fragments if a pathological fracture already
exists. Any form of fixation appropriate to the dentition and site of fracture
may be used. General supportive treatment is important. Fluid and food
intake must be maintained. Feeding may be carried out by fine bore
nasogastric tube if the mouth and teeth are tender and jaw movement
restricted and painful. Anaemia, diabetes and malnutrition will need
specific attention.
‘Chronic following on acute cases’ usually have a sequestrum in situ. As
a result, pus is discharged through sinuses which pass through cloacae in the
involucrum onto the surface of the oral mucosa and facial skin. While a free
flow of pus occurs, patients are relatively symptom-free and have little pain,
but at irregular intervals they suffer acute exacerbations of the infection.
Bouts of pain and swelling occur which last for three or four days and then
subside when the abscess discharges, following which the condition
becomes quiescent again. In the absence of surgical intervention to remove
the dead bone, this chronic phase can bé lost indefinitely.
last

CHRONIC OSTEOMYELITIS
Presents with minimal pain and discharge, although the mandible is
invariably enlarged by the deposition of subperiosteal new bone at the site
of inflammation. One characteristic feature is the preservation of mental
and labial sensation.
The patient is usually over forty and may give a history of difficult
extraction perhaps with retained infected roots. Often the patient is
edentulous and the involved segment of mandible is composed of sclerosed
bone. Sometimes there is evidence that this predated the initiating
extraction and the onset of chronic osteomyelitis. Other times the sclerotic
bone forms and spreads with the infection.
There is a combination of resorption and bone deposition both
subperiosteally, thickening the cortex, and in the medulla producing zones
of sclerosis, as a result of a low grade infection centered in a multitude of
small abscess cavities.

Radiology
Radiographs show irregular radiolucencies superimposed on areas of
sclerosis and abnormally thick trabeculation. There is more of an overall
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moth-eaten appearance than in acute osteomyelitis which differs by virtue

of its sequestrum formation.

_ Treatment
Prior to definitive treatment it may be desirable to explore a readily
acessible cavity and enucleate the granulation tissue in it under local
anaesthetic to establish the bacteriology and its sensitivity and also to
provide a biopsy for histopathological examination. This may not only help
by supplementing the bacteriological investigation by revealing, for
example, tuberculosis, but will exclude an infected neoplasm which may
resemble a chronic osteomyelitis.
Surgery is required to remove roots and sequestra and decorticate the
infected medullary area because zones of sclerosed infected medullary
bone rarely become demarcated and sequestrate naturally. Bone removal
should be done generously with a saline cooled acrylic bur until an area of
healthy bleeding bone is established. An intraoral approach is usually the
most appropriate but the wound must be drained to prevent haematoma
formation. Copious irrigation is necessary before closure. If the soft tissues
cannot be closed without leaving a dead space or because of rigid fibrosis,
the wound is packed with 2-inch ribbon gauze moistened with Whitehead’s
varnish.
Completely separated sequestra lie in granulation tissue and are easily
recognized at surgery once any overlying subperiosteal new bone has been
breached. Necrotic but unsequestrated cortex has a dirty white colour
compared with the yellowish hue of living cortical bone. As the removal of
dead cortex approaches normal bone the cutting should cease from time to
time. If the cortex is viable tiny red bleeding spots will appear on the cut
surface after a minute or two. The dense sclerosed medulla is removed until
the inside of the opposite cortex is reached and normal cancellous bone
found at either end. Granulation tissue from cavities in the bone should be
conserved for diagnostic purposes. Some is fixed and sent for histological
section. Other samples are placed unfixed in small sterile containers and
sent to the microbiologist. A chronic non-suppurative osteomyelitis from
which a positive culture is not obtained in this way is probably due to
obligate anaerobes.
Occasionally a chronic intramedullary abscess is encountered. The
medullary bone has an open cancellous structure as there is no living tissue
to deposit new bone. It is grey in colour, does not bleed when cut, contains a
pasty whitish material and is friable. All necrotic tissue must be removed
until fresh bleeding bone is encountered and specimens sent for diagnosis as
above.
On rare occasions when it is apparent that the full thickness of the
segment of jaw is involved and a conservative approach has failed to bring
about a cure, consideration should be given to resection of the involved part.
When the healed wound is infection-free secondary bone grafting can be

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undertaken. During the resection only the soft tissue related to the dead
bone should be elevated, lest adjacent living cortex is devitalized. Antibiotic
therapy will be determined by the culture results but as anaerobes and in
particular bacteroides are important pathogens, metronidazole 400 mg,
12-hourly, should be included in the regime.
Chronic external sinuses may also require gentle irrigation. This can be
done daily with Eusol (calcium hypochlorite 1-25 per cent and boric acid
1:25 per cent) or Milton’s solution (stabilized 1 per cent sodium
hypochlorite solution—Richardson Merrell). Furthermore, where the
bacteriology shows a predominance of exotic antibiotic-resistant micro-
organisms it is advisable to stop all antibiotics except metronidazole and
irrigate and pack daily as described above.
Specific infective forms of chronic osteomyelitis include, tuberculosis,
syphilis, yaws and actinomycosis. These should receive the same surgical
treatment but with the appropriate medication. As would be expected,
tuberculosis may require therapy for up to a year, and actinomycosis for
2-3 months.

POST-IRRADIATION MORBIDITY
AND OSTEORADIONECROSIS
All the tissues of the face and mouth are affected by irradiation, i.e. bone,
teeth, muscles, salivary glands, skin and its appendages. Actual necrosis of
tissues as a result of therapeutic irradiation is a rare event with modern
methods of treatment. True osteoradionecrosis therefore is uncommon.
Bone may be damaged by therapeutic radiation from both external and
implanted sources, such as caesium needles used in the tongue, or more
rarely from absorbed radioactive substances which become trapped within
the mineral component of the bone.
Substantial damage was common with older forms of radiotherapy with
an appreciable incidence of radionecrosis. With high energy sources giving
greater penetration of bone and a more uniform dose between bone and soft
tissues and with the use of multiple portals of therapy, the risk has been
reduced. However, in some centres the increased tolerance has encouraged
the use of higher tumour dosage leaving the bone equally at risk.
The pathological changes appear to be identical irrespective of the nature
of the source of irradiation, resulting in endarteritis obliterans, ischaemia
and a reduction in the viable osteocyte population. The resultant picture is
that of hypovascularity of all elements of the bone, including the marrow
and periosteum as well as the investing soft tissues. In addition there
appears to be a failure of osteoclast activity; whether this is related to the
impaired blood supply or lack of osteoclast stimulation is unknown.
Ionizing radiations destroy malignant neoplasms by damaging the
chromosomes so that cell division is imperfect or impaired. As the
malignant cells are dividing more often than host tissue cells a greater
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proportion succumb and the tumour regresses. Normally, resting

osteocytes are stimulated to activity by bone damage and start to divide
rapidly in order to repair an injury such as a tooth socket. If in the past some
of these osteocytes have suffered radiation injury, cell division may be
imperfect and the osteocytes will die.
These changes make the bone vulnerable to trauma and infection
producing initially a localized osteitis which fails to heal and then tends to
spread as a chronic ischaemic necrosis through bone which is incapable of
endosteal or periosteal repair and prey to infection. Thirty or more percent
of cases appear to arise spontaneously suggesting that repair and
replacement of the damaged bone failed without any traumatic or infective
stimulus.
The irradiation also induces an inflammatory response in the soft tissues
with erythema, desquamation and then pigmentation of the overlying skin
such as is seen with sunburn but with a longer time scale. Similarly there is
an erythema of the oral mucosa with desquamation within the zone of
maximum dose. Here the denuded surface is covered by a yellow fibrinoid
exudate which in a well planned treatment is sharply defined at the margins
and closely related to the tumour. If the salivary glands are within the fields
of irradiation, salivation is suppressed and a scanty, sticky secretion covers
the teeth and gums. The patient adopts a soft, semi-liquid diet rich in
carbohydrate exposing the teeth to a high caries risk. The acute mucosal
and skin changes resolve within a few weeks but salivary flow may be
suppressed for 12-18 months or even permanently.
Following therapeutic irradiation pre-existing periodontal disease is
exacerbated, but there is also a degree of atrophy of the periodontal
membrane even where the gums are healthy and gingival recession occurs
without pocketing which exposes the necks of the teeth. A combination of
xerostomia, a soft, cariogenic diet and a degree of neglect of oral hygiene
measures leads to widespread caries affecting the smooth surfaces of the
crowns of the teeth and the exposed necks as well as fissures and contact
areas. Furthermore, in the absence of saliva recalcification of early (white
spot) enamel lesions cannot occur. This is the so called radiation
caries.
Following treatment the healed oral mucosa tends to be atrophic and
delicate, easily damaged by friction and slow to heal if it is ulcerated.
Dentures must be constructed with great care and should be left out
whenever reasonable. Cotton wool rolls used to control saliva during dental
treatment should be slightly moistened so that they do not adhere to the
mucosa.
The overlying skin shows similar changes: atrophy, loss of sweat glands
and hair follicles and telangiectasia. Where the masticatory muscles have
been heavily irradiated fibrosis may render them inextendable. When the
temporalis, medial pterygoid and masseter are involved marked extra
articular ankylosis is the result. As this is not due to muscle spasm the term

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trismus is not appropriate. Oral hygiene and dental treatment are rendered
additionally more difficult as a result. Where the temporalis is maximally
affected an intraoral coronoidectomy with stretching under a general
anaesthetic can be considered.
A common cause of osteoradionecrosis is the extraction of teeth from the
irradiated area and, as prevention is easier than cure, this should be
anticipated. Once postirradiation caries has become established its control
by restorative measures is usually very difficult.

Prophylaxis
Any teeth in the area due to receive the full therapeutic dose should be
extracted before treatment is started together with any teeth for which the
prognosis is poor. Unless the dentition is generally healthy and well cared
for and the patient likely to be motivated and able to maintain a high
standard of oral hygiene a clearance is, in the long term, the best policy.
Certainly this should be the case where the teeth are generally neglected.
Tact and understanding is necessary in explaining the need for these
measures to a patient who is likely already to be under severe mental
stress.
The extractions should be carried out as soon as possible after
histological confirmation of the diagnosis and a decision on treatment
policy, including the need for irradiation, has been agreed. If a general
anaesthetic is to be given for an examination to enable the full extent of the
neoplasm to be determined, the extractions can be carried out at the same
time, but local anaesthesia, with sedation if appropriate, is quite
satisfactory. Every effort must be made to ensure rapid and trouble-free
healing. There may be a delay in the start of treatment of around 10 days
because of the extractions but this is fully justified and often will occur
anyway while a mask is made and external beam irradiation planned or
while radioactive isotopes for implantation are ordered.
Prominent interdental septa and sharp or splintered socket margins
should be trimmed as remodelling resorption of the alveolar process will not
occur after irradiation. Fractured inter-radicular septa should be removed
and the soft tissues carefully sutured. Unerupted and deeply buried teeth
are probably best left im situ. Difficult, caries-free but partially erupted
lower 3rd molars may create a dilemma if it is thought that their removal
will result in troublesome wounds, protracted healing and, as a result, delay
the start of treatment. There is a further difficulty if the surgery is likely to
disrupt the neoplasm, opening up tissue planes to contamination which may
have to be taken into account with the tumour therapy. Their retention, if
the patient survives for any length of time, is of course also likely to lead to
problems.
As far as possible the mouth should be cleaned up before the extractions,
sloughing malignant ulcers are freely irrigated, and infected and necrotic
tissue sucked away. Penicillin or metronidazole should be given immediately
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before the extractions and afterwards for 5—7 days. During radiotherapy an
0-2 per cent aqueous chlorhexidine mouthwash will help to keep down
secondary infection of any ulcerated mucosa and will reduce plaque
accumulation and caries. Supervised tooth cleaning with the aid of a mirror
and the regular services of an oral hygienist will do much to prevent the
deterioration in cleanliness of the remaining teeth which otherwise
occurs.
Meticulous oral hygiene using a fluoride toothpaste is essential, and the
use of a daily fluoride mouthwash also adds protection. Dietary advice can
both reduce the intake of food and drink with a high dextrose content and
improve nutrition.
Another means of protection is the cementing of vacuum moulded acrylic
or cellulose butyrate acetate splints onto the teeth with a fluoride containing
cement and which remain in place until an adequate salivary flow is
restored which may take up to two years. Unfortunately, cervical caries
may develop unnoticed with this regime.
Sometimes in the months immediately after radiotherapy there will be a
limited break down of the ridge mucosa to expose a patch of bone a few
millimetres across. This should be left to sequestrate and only lifted off
when quite loose, although this may take many months. If a sharp spike is
exposed in this way the point can be nibbled away with bone nibblers.
Should a tooth need extraction from a previously irradiated part of the
jaws this must be done as follows:
1. The mouth should be carefully cleaned and the patient given a
preoperative dose of metronidazole 400 mg.
2. A local anaesthetic not requiring a vasoconstrictor, or one with
felypressin as vasoconstrictor, should be chosen so that there will be free
bleeding from the socket.
3. The gingiva are painted with povidone-iodine.
4. A simple extraction is done with great care, being particular not to
remove the clot from the socket by the use of suction. The extraction of
multirooted teeth may be made easier by dividing them with a tapered
fissure bur, being certain that all debris is removed before the actual
extraction. Resistant teeth can be weakened by cutting into the periodontal
membrane with a No. 2 rose-head bur under a water spray.
5. Mucosal flaps should not be raised as this may kill the underlying
cortex but long prominences and sharp points at the margin of the socket are
removed and the mucoperiosteum sutured.
6. Mucosal flaps should be avoided, while in general limited envelope
mucosal flaps may be raised carefully from the alveolar margin only but
the alveolar bone should be trimmed generously before they are closed
over it.
7. Metronidazole is continued for 10 days or until the wound has
healed.

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N.B. The problem of postextraction osteoradionecrosis can be avoided

by root filling non-vital teeth, even if the crowns are not to be restored.

The Recognition and Treatment of Osteoradionecrosis

Osteoradionecrosis may start as a dry socket, or an area of painful exposed
bone in the base of denture ulceration, or spontaneously. It is seen not
uncommonly in the lingual cortex of the mandible adjacent to the site of a
neoplasm of the lateral border of the tongue or floor of the mouth which has
been treated with a radioactive implantation technique. Radium needles in
particular resulted in this state of affairs because of their proximity and
continuous radiation. The exposed yellow necrotic bone fails to separate,
and either spontaneously or as a result of injudicious surgical interference
further mucosal breakdown exposes more dead bone and small quantities of
pus are discharged. Radiographs reveal the characteristic moth-eaten
appearance of devitalized bone which slowly extends through the mandible.
Only small fragments separate after a period of very many months and
never involve all the dead and infected bone. True sequestration of the non-
vital from vital tissue does not take place. Attempts at local excision simply
extend the area of dead bone. As the osteogenic periosteum is destroyed
by the radiotherapy no involucrum of subperiosteal new bone is formed
(Fig. 7.6), and if pathological fractures occur substantial displacement of
the bone ends follows with little chance of union occuring. Protruding bone
ends may be trimmed and the site packed with ribbon gauze soaked in

Fig. 7.6. Radionecrosis ofthe anterior part of the mandible. Slow sequestration
of the lingual plate. Notice that there is no subperiosteal new bone forming an
involucrum.

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Whitehead’s varnish to give some stability. If there are teeth present in both
jaws intermaxillary fixation will reduce the degree of further displacement
of the fragments.
Histological examination of the bone shows widespread ischaemic
necrosis with no microbial or inflammatory infiltration in the deeper parts.
Active infection is not always present but acute or subacute episodes should
be controlled with antibiotics after culture and sensitivity tests. Co-
trimoxazole (trimethoprim 80 mg and sulphmethoxazole 400 mg) twice a
day is a useful regime, but courses of antibiotics should not be prolonged as
this leads to overgrowth of resistant microbes and without any clinical
benefit. Local irrigation of suppurating cavities and the maintenance of
local hygiene with hot saline or perborate mouthwashes will make the
condition more tolerable for both patient and relatives.
Exposing the patient to a pure oxygen environment at 2:4 atmospheres
pressure for 2 hours a day for 4-8 weeks will increase the concentration of
oxygen in the plasma and tissue fluids (hyperbaric oxygen). This
encourages granulation tissue and leucocytes to migrate into the zone of
necrosis, facilitating the separation of sequestra and enhancing bone
healing. During treatment cyanosis is abolished in tissues which are
normally marginally oxygenated and creates an adverse environment for
anaerobic organisms. Some patients suffer severe pain with osteoradio-
necrosis and this is relieved.
This treatment is not without risk, particularly if the proportion of time
during which the patient is exposed to hyperbaric oxygen is increased or if
higher pressures are employed. Pulmonary congestion can occur and
oxygen toxicity is manifest by convulsions which usually are preceded by
twitching of the lips. There can also be problems in keeping pressure in the
middle ear within acceptable limits. Furthermore, not all patients will
tolerate being enclosed in the treatment tank and emphysematous
pulmonary disease is a contraindication to its use. Enthusiasm for some
other uses of hyperbaric oxygen has waned and in practice there can be
difficulty in finding a unit willing to offer facilities for this treatment.
While patience and a conservative management is appropriate for small
areas of osteoradionecrosis there are several good reasons why this
approach is not suitable for extensive lesions. The patient may be
committed indefinitely to a burden of sepsis, and pain which is in some
cases severe, an objectionable taste and smell, and orocutaneous fistula and
pathological fracture. Therefore there are several alternative surgical
treatments for osteoradionecrosis. These are as follows.

a. Excision of the affected segment of the mandible and accepting the

deformity which results. This may be reasonable where the posterior part
on one side is involved and where the bone of the chin at least as far back as
the canine region can be left. The bone is approached by the most direct
route and sectioned well beyond the infected and necrotic segment. The cut
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in the bone must be made as close as possible to a point where the soft
tissues are still attached. The sharp edges at the bone end are rounded off
and the soft tissues sutured over the bone end. Muscle is best for this
purpose, and a temporalis flap if available will provide vascularity and help
fill the dead space. The rest of the wound is closed carefully in layers with
drainage. The soft tissues may be oedematous and friable and tight suturing
is to be avoided.
b. Trimming away exposed and necrotic bone until the line of attached
soft tissues is reached and bringing in a simple vascular flap to cover and re-
vascularize the area. Again a temporalis muscle flap is ideal and only part of
the muscle may be necessary to fill the defect.
c. Excision of the affected segment and subsequent free bone grafting of
the defect. Considerable care is necessary to provide adequate soft tissue
cover. Again, bringing in a well vascularized muscle flap such as temporalis
or pectoralis major to wrap around the graft and over the bone ends will
improve the chances of success.
d. Excision of the necrotic bone and scarred and poorly vascularized soft
tissue and effecting a repair with a composite flap. This may be a pedicle
flap, for example, a pectoralis major myocutaneous flap incorporating rib or
sternum as the osseous component, or a free flap attached by microvascular
anastomosis, such as the forearm-—radius flap. Surgical healing will also be
enhanced by further hyperbaric oxygen therapy if available.
Sometimes the initial exposure of the irradiated bone results from
ulceration of a recurrent neoplasm. The proliferating and necrosing
malignant tissue may not be recognized immediately amid the granulation
tissue and suppuration surrounding the dead bone. In other cases after a
substantial interval what may be a fresh squamous cell carcinoma arises in
the mucosal margin adjacent to the necrotic and infected bone. Clinicians
should be on the lookout for a combination of osteoradionecrosis and an
active malignancy as this clearly demands urgent surgical treatment.

ASEPTIC NECROSIS OF BONE

It is possible surgically to deprive substantial pieces of bone of their blood
supply so that they are, in effect, attached bone grafts. If the massetter is
stripped from the mandible during an Obwegeser—Dalpont sagittal split
osteotomy much of the buccal cortex after the split is in this condition. Parts
of the facial skeleton must also have at most a tenuous blood supply after the
extensive degloving required for craniofacial surgery. In general this does
not affect the outcome provided that immobilization and soft tissue
coverage is achieved with early reattachment of the soft tissues by avoiding
haematomas. Infection in such cases can be disastrous. Cancellous bone is
less likely to suffer in this way and any ischaemic cancellous bone will be
revascularized.
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Bone necrosis can occur in sickle-cell disease. This is a haemo-

globinopathy principally of negroes where the abnormal haemoglobin HbS
when hypoxic produces elongated erythrocytes which aggregate and
obstruct capillaries and arteries. This may occur spontaneously in the
homozygote sickle disease and rarely in the heterozygote.
Episodes of pain and swelling will suggest local bone infarction and
should be prophylactically treated with antibiotics and analgesics in the
first instance. In sickle-cell disease the continued haemolysis tends to
‘overwhelm’ the reticuloendothelial system and the patient may also be
more susceptible to infections. Surgery is only required if infection
supervenes converting an aseptic necrosis into osteomyelitis. Pus is drained
and sequestra removed in the usual way and if done under a general
anaesthetic an adequate haemoglobin level and full, assured oxygenation
are required.
Herpes zoster may rarely, when it involves the inferior dental nerve, give
rise to infarction of the dental pulps and/or the body of the mandible with
subsequent infection and osteomyelitis. This appears to be usually a
complication of the elderly, of cytotoxic chemotherapy and neoplasia.
Treatment is symptomatic.

CHEMICAL NECROSIS
Bone necrosis due to exposure to phosphorus, mercury or bismuth either
from industrial processes or drug therapy is fortunately rare and largely of
historical interest.
Arsenic trioxide is still occasionally used by dental practitioners to
devitalize inflamed painful pulps. If it accidently extrudes into the
periodontal space it leads to necrosis of the adjacent alveolar process and
sequestration. Similarly, inadvertent injections of phenol, hydrogen
peroxide and the like have been the cause of chemical necrosis of bone and
treatment includes adequate irrigation and debridement of the area and
prophylactic antibiotics. Some root-filling pastes if they are extruded
beyond the apex have a similar effect.
Intraoral haemangiomas involving the buccal and palatal mucosa must
never be treated with sclerosants such as sodium tetradecyl sulphate.
Successful sclerosis of the vascular abnormality will also devitalize
the adjacent alveolar bone and teeth, which will gradually become
sequestrated.

OSTEOMYELITIS DUE TO
NON-PYOGENIC ORGANISMS
Syphilitic Osteomyelitis
Infection by the Treponema pallidum may affect the bones in syphilis in
both the secondary and tertiary stages, and also in cases of congenital
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syphilis, but nowadays, in countries where treatment for syphilis is freely

available, skeletal disease of syphilitic origin is seldom seen.

Pathology
The reactions of bone to the presence of the Treponema pallidum are
essentially similar to those of other tissues, though modified by its special
anatomical and physiological characteristics. At the site of the lesion there
is a chronic, inflammatory granulomatous and necrotizing periarterial
infiltrate accompanied by partial destruction of bone. As the disease
progresses the vascularity of the area becomes diminished and the bone
tends to become sclerosed. Osteosclerosis with new bone formation is more
common than osteoporosis and rarefaction.

Neonatal Syphilis
In neonatal syphilis the involvement of the skeleton takes place approximately
at the end of the fifth month of intrauterine life and the characteristic bone
changes are present at birth. Gummatous destruction of the nasal septum
and hard palate are common and the characteristic saddle-shaped nose is
due to subsidence of the bridge of the nose, a condition which is often
associated with perforations of the palate. However, not all perforated
palates are the result of congenital disease; palatal perforations also occur
in the late stages of acquired syphilis. In the cranium there may be a diffuse
osteitis or multiple periosteal nodes, usually grouped around the anterior
fontanelle. Radiologically, the cranium has a worm-eaten appearance due
to subperiosteal gummas and in the absence of treatment as the patient
becomes older, separation of circular sequestra from the base of ulcerating
gummatous lesions may lead to complete perforation of the bone.

Acquired Syphilis
In acquired syphilis bony changes are seldom seen before the tertiary stage
and the palate, nose, skull and tibia are the bones most commonly affected.
The changes take the form of periosteal and central gummata (Fig. 7.7).
Bone is resorbed at the site of the gumma producing a radiolucency with a
poorly defined margin. The central necrotic mass is rubbery in consistency,
and later becomes cheesy. The overlying tissues may break down to form an
abscess or an ulcer with a characteristic ‘punched out’ margin and
yellowish, sloughing base. At this stage secondary infection with pyogenic
organisms may be responsible for a more extensive bone necrosis and
sequestrum formation.
Syphilitic osteomyelitis of the jaws is not easily distinguished from
pyogenic osteomyelitis on clinical and radiological examination. Unless a
gumma is seen or evidence of tertiary syphilis found elsewhere in the body
and particularly signs of involvement of other bones by syphilis, the
diagnosis may be missed unless serological tests are carried out.
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Fig. 7.7. A gumma ofthe maxilla involving the alveolar process in the premolar
region. Tiny sequestra in the slough.

Pathological fracture often develops but rapid improvement usually occurs

with penicillin or erythromycin therapy.

Yaws
A sclerosing osteomyelitis and periostitis may be seen in patients from the
Caribbean area who give a history of yaws in childhood. This condition
occasionally affects the jaws where, like syphilis, the diagnosis should be
suspected if osteomyelitis is accompanied by much sclerosis and pursues an
unusual course. Unfortunately, the serological tests for syphilis are also
positive in yaws. Treatment is penicillin.

Tuberculosis
Tuberculous osteomyelitis of the jaws is rare.

Pathogenesis
Infection of bone by the Mycobacterium tuberculosis is usually brought
about by metastatic haematogenous spread and is almost always secondary
to a primary focus in the respiratory or alimentary tract. In England prior to
World War II 7% of milk supplies for human consumption contained
tubercle bacilli and much bone tuberculosis at that time was bovine in
origin. However, in countries such as the United Kingdom where
tuberculosis in cattle is now largely eradicated the human bacillus is
responsible for such bone infections as are seen.
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 INFLAMMATORY DISEASES OF BONE

Tuberculous osteitis occurs when blood-borne bacilli lodge in cancellous

bone, especially in the epiphysis of long bones, the phalanges, and the
dorsal and lumbar vertebrae. It usually starts in the metaphysis of a bone
and causes widespread destruction. Large subperiosteal cold abscesses
form and may burrow long distances towards the surface along muscle
planes. It destroys the epiphysial cartilage and so infects the neighbouring
joint, but the temporomandibular joint is virtually never involved.
There are recorded cases in which it has been suggested that the
localization of a tuberculous embolus in bone may be determined by
trauma, but this is very difficult to prove.
Localized osteomyelitis may follow tooth extraction performed on
tuberculous patient. Active tuberculous infection of tooth sockets is seen,
both in patients with pulmonary tuberculosis with a positive sputum and in
patients who have an active infection in cervical lymph nodes. The infected
socket, unlike the normal dry socket, is relatively painless. The attention of
the clinician is drawn to the situation because the socket fails to heal and
continues to discharge small amounts of watery pus. Over a period of weeks
a substantial amount of bone destruction occurs to produce a granulation
tissue filled bone cavity submucosally at the site of the socket. There is no
sequestrum formation and no florid exuberant granulations such as might
accompany a pyogenic infection of the tooth socket. The diagnosis is
usually confirmed by biopsy of the soft tissue forming the socket wall. If the
infection in the mandible is left untreated it may spread into the soft tissues
and form an indolent, chronic, facial sinus.
A superimposed pyogenic infection may cause difficulty in establishing
‘the correct diagnosis. The onset is insidious and pain is not a prominent
feature in the early stages. There may be limitation of opening and if an
extensive area of the mandible is involved a pathological fracture can occur.
Tubercle bacilli may be seen in biopsies or smears from exudate from the
sinuses, but culture is a lengthy process as a means of diagnosis.
Treatment consists of local surgery and antituberculous drug therapy.

Salmonella
Bone infection as a late complication of typhoid or paratyphoid fever and
other forms of salmonella infection is rare. Classically, typhoid osteo-
myelitis affects the vertebrae giving rise to ‘typhoid spine’ but long bones
may also be affected. Occasionally typhoid or paratyphoid bacilli are
involved in infection of the bones of the jaws, and this is more common in
cases of sickle cell disease.

Actinomycosis
Cervicofacial actinomycosis of the soft tissues is not uncommon and the
organism responsible for the condition in human beings is the Actinomyces
israeli, while a similar disease, lumpy jaw in cattle, is attributed to another
organism, A. bovis.
LO,
 ORAL SURGERY, PART 1

‘Actinomyces’ is the generic term given to a group of organisms which

represent the higher bacteria, a number of which are pathogenic for man.
These organisms are Gram-positive filaments which tend to branch and
mat together in an amorphous matrix designated the ‘mycelium’. A
mycelium of this type is found in the pus of actinomycotic lesions, in the
form of a granule, described as the ‘sulphur granule’, and represents a single
colony of the actinomyces organism. The mycelium in the tissues tends to
be surrounded by peripheral Gram-negative clubs, which radiate outward
in the shape of a ring. This appearance explains the expression ‘ray fungus’
which is applied to A. israeli or bovis.
A. israeli is a normal inhabitant of the mouth and can be isolated from
crypts of tonsils, carious teeth, salivary calculi, and the gingival crevice and
it is probable that most cases of actinomycosis are endogenous. Colonies
are reported from time to time in histological preparations of cysts and in
the root canals of teeth without evidence that this was part of a clinical
infection.
Other commensal actinomyces such as A. viscosis may also become
pathogenic. It is also important to establish there is not superimposed
infection by Staph. aureus, or Actinobacillus actinomycetemcomitans.
Actinomycotic osteomyelitis of the jaws is rare but may present as:
1. A periostitis as a result of the involvement of adjacent soft tissue.
2. An actinomycotic osteomyelitis in which the mandible is thickened
and honeycombed by narrow tracts in which the fungus is embedded in
granulation tissue (Fig. 7.8). Eventually sequestration of the bone occurs.
The disease may resemble pyogenic osteomyelitis both clinically and
radiographically or such a proliferative mass of indurated soft tissue and

Fig. 7.8. Actinomycotic osteomyelitis of the mandible.

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 INFLAMMATORY DISEASES OF BONE

subperiosteal new bone forms around the jaw that the whole may be
mistaken for an osteogenic sarcoma or lymphoma.
3. A chronic infection of a fracture and produce a chronic facial
sinus.

Radiology
There are no specific diagnostic features of actinomycosis of the jaws and
the lesion usually appears as irregular areas of bone destruction, as is seen
in suppurative osteomyelitis, or as a massive periostitis. Cases have been
reported which produced a single bone cavity resembling an odontogenic
cyst radiographically.

Diagnosis
The diagnosis of actinomycosis often results from the microscopic
examination of a specimen of pus, but if the condition is suspected the
bacteriologist may culture the organism with the appropriate media.
Sulphur granules are rarely present when the patient has already received
antibiotic therapy.

Treatment
Treatment entails prolonged antibiotic therapy with penicillin, e.g. 500 mg
of phenoxymethy] penicillin, 6-hourly, or 500 mg amoxycillin, 8-hourly, by
mouth for some 6-8 weeks or for several months as necessary. Tetracycline
250 mg, 6-hourly, is a suitable alternative preparation and is active against
the actinobacillus. Surgical intervention will be required to remove any
sequestra which have formed.

CHRONIC HYPERTROPHIC OSTEOMYELITIS

This is a descriptive term from pre-antibiotic days, but a few similar cases
can still be seen. After many years of chronic osteomyelitis the radiographic
appearance comes close to resembling that seen in Paget’s disease of the
mandible. The original cortex is lost, there is much subperiosteal new bone
and even hypercementosis of the involved teeth. With recurrent flares of
infection the case comes to resemble osteomyelitis secondary to Paget’s
disease and only serial radiographs showing the evolution of the disease
permit a differentiation.
Similarly during the healing phase of extensive osteomyelitis in the child
the woven bone of the involucrum, together with new bone deposited to
replace the destroyed part of the jaw, can produce a radiographic
appearance closely resembling fibrous dysplasia, and only the history,
together with the slow return to normal architecture, enables a distinction to
be drawn between the two conditions.
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GARRE’S OSTEOMYELITIS AND

NON-SUPPURATING SCLEROSING OSTEOMYELITIS
Garre (1893) described gross subperiosteal thickening of long bones
resulting from mild irritation or infection. It is difficult to be more precise
about Garre’s osteomyelitis because his description (1893) predates the
clinical use of X-rays in 1896 so there is no descriptive radiology of his
patients. However, the name has been applied by a number of modern
writers to cases of osteomyelitis of the mandible in which there is a marked
periosteal reaction (see also Periostitis below). Since in most of these cases
the patient is a child or adolescent a vigorous deposition of subperiosteal
new bone is to be expected as a response to infection or trauma, or indeed to
any inflammatory condition and so has no special significance.
The mass can mimic a tumour in radiographs and in infective cases may
even have a subperiosteal sun-ray trabeculation rather than the expected
concentric laminated appearance.
Chronic non-suppurating sclerosing osteitis and periostitis ossificans are
also synonyms for this condition. Reference has been made earlier to such
cases and it is likely that they are due to low-grade obligate anaerobic
infections, hence the chronicity, lack of suppuration, poor response to
antibiotics commonly prescribed in the past for osteomyelitis and, of
course, difficulty in culturing the responsible organism.

OSTEOMYELITIS IN PAGET’S DISEASE

Almost always osteomyelitis in Paget’s disease affecting the jaws follows
periapical infection, tooth extraction or other forms of surgery of the
alveolar process such as an alveolectomy. The risk is present once sizeable
‘cotton wool’ masses of sclerotic bone appear in relation to the apices of
teeth. Infection of such a mass as a complication of a periapical abscess or
‘dry socket’ is seen from time to time even if antibiotics are used as part of
the treatment of these conditions. Surgical trimming of the bulky, enlarged
alveolar processes may be undertaken for aesthetic reasons and to make
possible the fitting of reasonable sized full upper and lower dentures. Great
care must be exercised, if this is done, not to leave dense bony nodules at the
cut surface or to permit haematomas to collect beneath the flaps and
become infected.
If osteomyelitis becomes established the safest course is to wait until the
infected bone has completely separated, so that is may be enucleated from a
bed of granulation tissue. There is a risk with premature attempts at
sequestrectomy of infecting adjacent sclerotic masses, starting a fresh cycle
of localized osteomyelitis.
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OSTEOMYELITIS IN OSTEOPETROSIS
(ALBERS-SCHONBERG’S DISEASE)
Several entities are now known to produce the characteristic dense bones of
this condition. There is either an absence of osteoclasts or a failure for these
cells to be produced in a timely fashion to effect remodelling resorption.
There is blurring of the corticomedullary bone border, reduction or
obliteration or marrow spaces and poor remodelling of the external contour
of the bone. Phagocytosis and repair of dead bone are grossly impaired.
Because of the reduction in bone marrow secondary anaemia and extra-
medullary haemopoiesis is often found with enlargement of liver and
spleen.
An intractable osteomyelitis is highly likely to complicate a periapical
abscess and tooth extraction. Once established nothing short of total
resection of the involved bone may control the infection, with all the
consequences which ensue from such a decision. Management of these
patients is similar to that of heavily irradiated patients except that the
control of caries presents fewer problems.

CORTICAL OR SUBPERIOSTEAL OSTEOMYELITIS

Cortical osteomyelitis is the consequence of a sizeable accumulation of pus
being confined beneath the periosteum. It is usually a complication where
the pus accumulates beneath a muscle attachment such as with a
submasseteric or subtemporalis muscle abscess (see pp. 145, Chapter 6). It
may also occur when infection from a boil on the chin involves the outer
cortical plate of the mental region of the mandible.
Blood vessels entering the cortex from the periosteum are thrombosed
and destroyed and infection penetrates the cortex via Volkmann’s canals.
The full thickness of the cortex and the immediately subjacent medullary
bone are involved. It is important to distinguish this entity from
intramedullary osteomyelitis for which it may be mistaken if only rotational
tomographic or oblique lateral radiographs are studied. A PA jaws view for
ramus infections and tangential and occlusal films of the chin will
demonstrate that only one cortex is involved.

PERIOSTITIS
Periostitis refers to a reactive response of the periosteum which is
characterized by the deposition of subperiosteal new bone. Mostly the term
is used for such a response where it forms part of a reaction to infection in
the underlying or overlying tissues. This is often infection within the bone
which may induce osteoblastic activity by the adjacent periosteum by some
unknown stimulus, or by exudate directly spreading to involve the
periosteum and raising it from the cortical surface. Infection in the parosteal
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soft tissues will also invoke a similar response, as in the earlier stages of
submasseteric abscess or where lymph nodes adjacent to the bone are
infected or where the mucoperiosteum is chronically inflamed.
Inflammation of the periosteum as part of the response to trauma to a
bone or to the parosteal tissues will result in a similar reaction, particularly
where the periosteum is raised from the bone by a haematoma. A similar
response seen where the bone has been weakened internally by the presence
of a cyst or neoplasm or raised from the surface of the cortex by neoplastic
tissue is referred to simply as a periosteal reaction and this term may be
used in relation to a traumatic cause also.
Initially a thin shell of new bone is deposited by the periosteum over the
surface of the subperiosteal accumulation of pus or blood. If the cause is a
haematoma or if the pus is drained and replaced by blood a reactive mass of
bone is deposited as the haematoma is organized. The cycle may be
repeated in the case of a chronic infection with subacute episodes, resulting
in a multilayered onion skin lamination, best seen in an occlusal radiograph.
This is in contrast to the radial ‘sun-ray spicule’ appearance produced
characteristically where malignant bone neoplasms raise the periosteum
and where the tumour bone is deposited in relation to blood vessels which
pass from the marrow spaces via Volkmann’s canals.
The proliferative reaction is particularly well seen in children where the
most common cause is periapical infection. Where the infection is of long
standing the swelling may become large enough to be misdiagnosed as an
osseous or fibro-osseous tumour (see Garre’s non-suppurative osteo-
myelitis above). If due to a periapical infection of the lower Ist molar in
children the enlargement is usually mid-body in location whereas
haematogenous metastatic infections tend to involve the angle of the
mandible or incisor region.

Radiology
Only if there is a substantial thickness of new bone will there be a change in
radiopacity in an oblique lateral projection or rotational tomogram and an
appreciable difference in the textured quality of the image. The initial
deposits of subperiosteal new bone will be overpenetrated and not seen but
later the normal bone contours are rounded out and thickened. Subperiosteal
new bone is best seen where the rays pass tangential to the surface of the
bone as in occlusal and PA jaws views, and in taking the film exposure
should be reduced. Initially there is a linear opacity parallel to the cortex
and later a fuzzy mass, usually with a smooth lateral contour or the onion
skin lamination referred to above.

Investigations
Specimens will be required for microbiology and for histopathology as
there is always a possibility of a granulomatous infection, lymphoma or
neoplasm.

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Treatment
Treatment is essentially of the underlying condition. Removal of the
sources of the infection, such as a diseased tooth or root, the drainage of pus
and treatment with antibiotics will bring about resolution of the condition
and resorptive remodelling of the mass.

Denture Periostitis and Pulse Granuloma

This is a chronic periostitis occuring in edentulous mandibles of denture
wearers. It may start as an area of inflamed mucosal thickening often under
the buccal flange of the denture where it rests in a groove between the
residual alveolar bone and the external oblique ridge. A supraperiosteal or
subperiosteal abscess may develop and later a sinus either in the sulcus or
on the face. Sometimes a root fragment is present and its removal with
drainage of the abscess brings about resolution. In many cases there is no
such cause.
A considerable smooth rounded elevation of the periosteal tissues occurs
increasing the irritation from the flange of the denture and a vicious circle is
set up. In time a mass of subperiosteal new bone will be demonstrable by
occlusal radiography.
The condition usually occurs in fit middle-aged patients who have worn
comfortable dentures for many years. The cause is considered to be food
particles implanted into the submucosal tissues, thereby provoking a
foreign body reaction. Leguminous pulse seeds, i.e. fragments of beans,
peas, lentils or peanuts, have been demonstrated in the submucosa
producing a granulomatous reaction. The seeds are recognized as 100u
cellulose bodies containing clusters of starch granules which may be stained
with iodine and PAS.

Treatment
Initially the dentures, which have probably been worn day and night, are left
out completely for at least two weeks. Often this brings about resolution.
Any pus is drained and antibiotics given. If the condition fails to resolve
within reasonable time it should be explored and the granulation tissue
curretted and excised so as to remove the foreign material. A biopsy will be
obtained which may confirm the diagnosis.
Occasionally a similar clinical presentation results where there is a
malignant neoplasm present, characteristically a lymphoma which has
passed through the cortical bone from the medulla but without causing
sufficient bone resorption for its presence to be suspected.
The excess new bone usually remodels, but can be trimmed surgically ifit
fails to do so. New dentures are made and the patient instructed to wash
them and the mouth thoroughly after each meal and not to wear them at
night.
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 ORAL SURGERY, PART “1

INFANTILE CORTICAL HYPEROSTOSIS—CAFFEY’S

DISEASE OF BONE

This rare condition affects infants of less then six months of age, often at
around three months. The child becomes irritable and ceases to take an
interest in food. There is a low fever of about 38°C (100-4°F) and a marked
anaemia occurs. Swelling develops around the eyes and often bilaterally
over the mandible. Other swellings may affect a limb over the long bones,
the clavicle or even the scapula. The nasal bones and bones of the skull are
occasionally involved. The child’s general illness, temperature and the
bony swellings suggest acute osteomyelitis. There is a markedly raised
white cell count with a predominance of polymorphonuclear leucocytes and
a raised ESR. If the rami of the mandible are involved parotitis may be
suspected.
The swellings have a deep, woody, hard and tender component which is
fixed to the underlying bone and produced by the periosteal reaction. The
overlying soft tissues are oedematous but freely mobile and lack the
induration and dusky redness associated with acute osteomyelitis. Nor are
they bruised in appearance as would follow trauma. The regional lymph
nodes are not enlarged as would be expected if the condition was infective in
origin.
Histologically there is acute inflammation with deposition of sub-
periosteal new bone. The bony trabeculae and fibrous tissue extend out
beyond the periosteum into the surrounding soft tissue and muscle. There
may be a thrombocytosis with a danger of hypercoagulability or a
thrombocytopenia.

Radiology
Some two to three weeks after the swellings have become evident suitable
radiographs will demonstrate the subperiosteal new bone and this is
frequently deposited in layers. There may be a substantial degree of
destruction of the original bone.

Treatment
The general condition of the infant slowly improves though there may be
relapses and new bones involved. During some three to six months the
affected bones are remodelled except where the epiphyses are involved.
Mostly spontaneous cure has occurred within nine months of the onset but
occasionally it may take two years.
Several writers have drawn attention to a familial incidence suggesting
inheritance by an autosomal dominant gene. Although bacteria or a virus
have been suggested no organism has been isolated.
In the absence of a known cause rational treatment is difficult. Massive
doses of prednisolone for a desperately ill child have been used and also

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penicillin. Analgesics and general supportive treatment including treatment

of the anaemia are important.

NON-ACCIDENTAL INJURY IN INFANTS

There can be a resemblance between the presentation of these infants and
those with Caffey’s disease. The battered baby may present with
widespread traumatic periostitis often associated with avulsed or loosened
teeth. The infant may also sustain intracapsular condylar fractures with
pain and disturbed occlusion. The long bones suffer fractures, dislocations
and epiphyseal cartilage damage.

Treatment
Admission to hospital for careful assessment is of primary importance. The
lesions usually require minimal active treatment. However, although
usually presented as an accident it is important to realize this problem is the
result of psychopathological parental trauma and the case should be
reported immediately to the general practitioner and through him to a
responsible social worker. Without intervention the child may be killed.

NEOPLASTIC DISEASE
It is often forgotten that metastatic carcinoma, especially from prostate,
neuroblastoma, lymphomas or local primary neoplasms such as Ewing’s
sarcoma may produce swelling of a bone with pain and pyrexia, bone
destruction and periosteal reaction and may simulate an osteomyelitis. In
any patient where the progress of the disease is in any way atypical, or the
response to antibiotics poor, a biopsy should be done with tissue sent for
both histological and microbiological investigation.

SUGGESTED READING
Alling C. C. (1959) Post-extraction osteomyelitic syndrome. Dent. Clin. North
Am. 621-636.
Barba W. P. and Freriks D. J. (1953) Familial occurrence of cortical hyperostosis
in utero. J. Pediatr. 42, 141-146.
Birn H. (1973) Etiology and pathogenesis of fibrinolytic alveolitis (“dry socket’).
Int. J. Oral Surg. 2, 211-267.
Boerema I. (1964) Hyperbaric oxygen. Proc. R. Soc. Med. 57, 817-818.
Bradley J. C. (1972) Age changes in the vascular supply of the mandible. Br. Dent.
J. 132, 142-144.
Brull M. J. and Feingold M. (1974) Autosomal dominant inheritance of Caffe’s
disease. Birth Defects 10, 139-146.
Caffe J. (1957) Infantile cortical hyperstosis: a review of the clinical and
radiographic features. Proc. R. Soc. Med. 50, 347-354.

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Caffe J. and Silverman W. A. (1945) Infantile cortical hyperostosis. Preliminary

report of a new syndrome. Am. J. Roent. 54, 1-6.
Chapotel A. B. (1930) Tuberculose mandibulaire. Rev. Odont. 51, 444-448.
Coffin F. (1973) The control of radiation caries. Br. J. Radiol. 46, 365-368.
Cohen M. M. (1949) Osteomyelitis of the maxilla in the newborn. Oral Surg. 2,
50-52.
Dearden W. F. (1901) The causation of phosphorus necrosis. Br. Med. J. 2,
408-411.
Garre C. (1893) Uber besondere Farmen und Folgezunstande der akuten
Infektionen Ostoemyelitis. Beitr. Klin. Chir. 10, 241-245.
Heslop I. H. (1968) Syphilitic osteomyelitic of the mandible. Br. J. Oral Surg. 6,
59-63.
Heslop I. H. and Rowe N. L. (1956) Metastatic osteomyelitis involving the maxilla
and mandible. Dent. Pract. Dent. Rec. 6, 202-206.
Holman G. H. (1962) Infantile cortical hyperostosis: a review. Q. Rev. Pediatr. 17,
24-31.
Jarrett A. S. (1946) The risks of high pressure oxygen therapy. Proc. R. Soc. Med.
57, 820-823.
Juniper R. P. (1982) Caffe’s disease. Br. J. Oral Surg. 20, 281-287.
Kennon R. and Hallum J. W. (1944) Modern phosphorous caries and necrosis. Br.
Dent. J. 76, 321-330.
Lewars P. H. D. (1971) Chronic periostitis in the mandible underneath artificial
dentures. Br. J. Oral Surg. 8, 264-269.
MacGregor A. J. (1968) Aetiology of dry socket: A clinical investigation. Br. J.
Oral Surg. 6, 49-58.
Mainous E. G., Boyne P. J. and Hart G. B. (1973) Elimination of sequestra and
healing of osteoradionecrosis of the mandible after hyperbaric oxygen therapy.
J. Oral Surg. 31, 336-339.
Major G. S. and Bononi S. (1939) Osteomyelitis of the jaws following acute
mercury poisoning. Am. J. Orthod. 25, 82-84.
Marx R. E. (1983) Osteoradionecrosis. A new concept of its pathophysiology.
J. Maxillofac. Surg. 41, 283-288.
Marx R. E. (1983) A new concept in the treatment ofosteonecrosis. J. Maxillofac.
Surg. 41, 351-357.
Marx E. (1922) Eye symptoms due to osteomyelitis of the superior maxilla in
infants. Br. J. Ophthalmol. 6, 25-26.
McCash C. R. and Rowe N. L. (1953) Acute osteomyelitis of the maxilla in
infancy. J. Bone Jt Surg. 35B, 22-26.
Meng C. M. (1940) Tuberculosis of the mandible. J. Bone Jt Surg. 22, 17-19.
Ritzau M. (1973) The prophylactic use of tranexamic acid (cyclokapron) in
alveolitis sicca dolorosa. Int. J. Oral Surg. 2, 196-198.
Rood J. P. and Murgatroyd D. (1980) Metronidazole in the prevention of dry
sockets. Br. J. Oral Surg. 17, 62-70.
Rowe N. L. and Heslop I. M. (1957) Periostitis and osteomyelitis of the mandible in
childhood. Br. Dent. J. 103, 67-68.
Rud J. (1970) Removal of impacted lower third molars with acute pericoronitis and
necrotising gingivitis. Br. J. Oral Surg. 7, 153-159.
Smith G. (1964) The present position of hyperbaric oxygen therapy. Proc. R. Soc.
Med. 57, 818-820.

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Weiss R. W. and Lewis T. M. (1969) Infantile cortical hyperostosis: a study to
determine if residual deformities exist in mandibles. J. Dent. Child. 36,
441445.
Winiker-Bland E. and Biederman F. (1969) Rontgendiagnostik in der Kiefer-
Gesichts-Chirurgie. Ch. 9, p. 22. Berlin: Volk und Gesundheit.

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 CHAPTER 8

THE CONTROL OF INFECTIONS

Chemotherapeutic agents were originally antimicrobial drugs which were

manufactured entirely by chemical synthesis. Antibiotics were substances
which had been synthesized by living organisms. Once the chemical
structure of these antibiotics was known, and the way in which they
interfered with microbial reproduction or metabolism was understood, the
way was open for the modification of the original molecule either to
enhance its effectiveness or to increase the range of susceptible organisms.
In some cases chemical synthesis has replaced biological methods of
production. The sulphonamides are still referred to as chemotherapeutic
agents but all the others are now generally classed as antibiotics irrespective
of their current method of preparation.
The term chemotherapy is also now used for the drug treatment of
malignant neoplasms. Paradoxically some of the drugs come from
biological sources. In this chapter synthetic anti-infective agents, with the
exception of the sulphonamides, will be grouped with those from a
biological source as antibiotics.
The following groups of anti-infective agents will be discussed:

. Antibiotics
. Sulphonamides
. Antifungal agents
. Antiviral agents
. Vaccines and antisera
. Disinfectants (antiseptics).
NnPWN-

THE PRINCIPLES OF ANTIBIOTIC THERAPY

1. Antibiotic therapy is no substitute for surgery. Pus must be drained,
infected teeth extracted or their pulpal dead space eliminated by root-canal
therapy. Similarly foreign bodies and infected non-vital tissues such as
sloughs or sequestra must be removed. Attempts to treat such conditions by
antibiotic therapy will lead to prolonged or recurrent infective states with a
gradual replacement of common sensitive organisms by uncommon
insensitive ones.
2. The antibiotic used should be appropriate to the anticipated
organisms, e.g. whereas most oral organisms are susceptible to benzyl-

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penicillin, osteomyelitis caused by penicillin resistant Staphylococcus

aureus will require flucloxacillin, sometimes combined with sodium
fusidate. Narrow-spectrum antibiotic therapy avoids superinfection with
resistant organisms which follows the indiscriminate use of a broad-
spectrum drug.
3. Where possible samples of pus, saliva, blood, urine, etc., should be
examined for the infective organisms which are tested against a range of
antibiotics for maximum sensitivity. Where this is impossible it may be
necessary to guess the appropriate drug from previous clinical experience.
Similarly such a blind choice may be employed after taking the specimen
but prior to obtaining the result from the microbiology laboratory.
4. As host defence mechanisms assist the antibiotic in eliminating
microbial pathogens, bactericidal drugs are not always essential, except in
the management of infective endocarditis or with immunosuppressed
patients.
5. Antibiotics should not be used as diagnostic agents in the management
of clinical problems, such as enigmatic pain where there is a temptation to
assume the cause to be an undiagnosed site of infection. This is then treated
with serial courses of antibiotics, each one producing short periods of
placebo relief but ultimately a complex confusing picture. Similarly they
should not be used blindly as antipyretics.
6. Bacterial resistance may result from inadequate antibiotic therapy,
i.e. too small a dose for too short a time, or superinfection with other
organisms, particularly where inadequate surgery has been carried out—for
instance, a failure to remove dead tissue or eliminate a pus-containing dead
space.
7. Apart from the right choice of drug, the appropriate dosage, mode and
frequency of administration are important. With severe infection a loading
dose, i.e. a larger initial dose is useful. Many antibiotics are well absorbed
from the gut even in very ill patients. However, initial administration
intramuscularly or intravenously ensures an adequate blood level. It is
unfair to prescribe frequent intramuscular administration particularly when
the intravenous route can be used with a patient receiving intravenous fluid.
The drug should not be changed until adequate time for evidence of
effectiveness or ineffectiveness has been allowed, i.e. 48-72 hours.
Similarly after successful resolution of the infection, treatment should be
continued for a further 48-72 hours.
8. Two or more antibiotics should not be used simultaneously unless
antagonism has been excluded.
9. Where a patient is hypersensitive to a drug, i.e. develops a rash to
penicillin, an alternative drug must be used. However, it is important to
establish that a description of ‘allergy’ is a true one. Often a patient acquires
the label of being allergic after attributing manifestation of the illness to the
drug. A failure to confirm true allergy may exclude the patient from
valuable therapy.
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ANTIBIOTIC PREPARATIONS
Penicillin
The penicillins are still the least toxic and clinically the most useful group of
antibiotics. Many can be given by mouth as well as intramuscularly or
intravenously and are bactericidal in action. They are principally active
against Gram-positive and Gram-negative cocci, most Gram-positive
bacilli, Actinomyces israeli and Borrelia vincenti. Resistant microbes
include most strains of Staphylococcus aureus, some strains of Neisseria
gonorrhoea, Streptococcus faecalis and occasional strains of ‘Strep.
viridans’.

Benzylpenicillin (penicillin G, crystalline penicillin)

An aqueous solution may be administered intramuscularly or intravenously
for most orofacial infections. The maximum concentration in the serum is
reached within 15 to 30 minutes of injection using an intramuscular dose of
300-600 mg (500 000-1 000 000 units). This may be given 12-hourly.
The frequency of injection can be reduced by using long acting depot
preparations containing procaine penicillin such as Triplopen (Glaxo)—
penicillin G 475 mg. Although benethamine penicillin’s action is considered
to last over a period of 72 hours the blood level is low and therefore this
preparation is best given intramuscularly daily. It is useful as a single
preparation is best given intramuscularly daily. It is useful as a single
injection prophylaxis against endocarditis. Unfortunately, the procaine
component may induce an allergic reaction which would be indistinguish-
able from that to the penicillin itself.
Phenoxymethylpenicillin (penicillin V) is acid resistant and therefore can
be taken by mouth. A satisfactory blood level may be achieved by 500 mg,
6-hourly, taken half an hour before meals.

Amoxycillin
Amoxycillin is a broad-spectrum antibiotic which has superseded ampicillin.
It is acid resistant and therefore can be given by mouth. Its range of activity
includes not only Gram-positive organisms but Gram-negative bacilli and
anaerobes other than bacteroides fragilis. The dose can be 500 mg, 8-
hourly, orally or intramuscularly. It can also be given intravenously. It is
used principally for lower respiratory tract and urinary infections, but it has
also become invaluable as a high dose (3 g) oral endocarditis prophylaxis
when given 60 minutes prior to surgery because of its excellent absorption
and minimal side effects (see p. 222).

Flucloxacillin
Flucloxacillin is acid stable and can be given orally, intramuscularly or
intravenously. The usual dose is 250 mg, 6-hourly. It is not destroyed by

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penicillinase (beta-lactamase) producing Staph. aureus for which it should

be exclusively employed. In severe staphylococcal endocarditis, pneumonia
or osteomyelitis it is given in high dosage, sometimes with fusidic acid or
gentamycin.

Carbenicillin
Carbenicillin is used for serious Gram-negative infections and is active
against Proteus vulgaris and some Pseudomonas aeruginosa, dose 2 gi.m.
or i.v., 4-6-hourly. For severe septicaemia 30 g may be infused intra-
venously over 24 hours with | g probenecid orally 8-hourly in order to
reduce renal excretion and so maintain blood levels. Newer similar
penicillins such as ticarcillin and piperacillin are now available and may be
given with an aminoglycoside such as gentamicin or tobramycin. However,
when resistant strains of P. aeruginosa or Klebsiella appear in the orofacial
region it is often due to a lack of adequate surgery and the indiscriminate use
of broad-spectrum antibiotics, as for instance with infected bone grafts with
discharging sinuses. Here no antibiotics, or simply metronidazole with the
use of frequent hypochlorite packs, is preferable to ‘heavy weight’
antibiotics.

Adverse Reactions
Penicillins are remarkably free from toxic effects and despite their
widespread use, fewer than 5 per cent of patients suffer hypersensitivity
reactions. Such reactions occur most commonly in atopic individuals, i.e.
those who give a history of eczema, asthma, urticaria and other food or drug
allergies. The allergen is the penicillin nucleus and is therefore common to
all members of the group.
Sensitivity usually manifests itself as an erythematous maculopapular
rash or irritant urticaria. Angioedema and anaphylaxis characterized by
bronchospasm, laryngospasm and hypotension are exceedingly un-
common.
Where the use of the drug is highly desirable and a history of allergy
uncertain, a trial dose using an oral preparation may be acceptable.
Occasionally patients with infectious mononucleosis suffer an erythe-
matous rash when administered ampicillin or amoxycillin. This is a specific
drug reaction and does not imply hypersensitivity under other
circumstances.

Clavulanic acid
Available as 125 mg potassium clavulanate in combination with 250 mg
amoxycillin it protects the beta-lactam antibiotic from destruction by some
beta-lactamase producing bacteria such as FE. coli, Klebsiella and other
Gram-negative bacilli.
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Cephalosporins
This large family of antibiotics with low toxicity and wide range of activity
are in some respects related to penicillin and have a beta-lactam nucleus.
They exert a bactericidal effect by interfering with cell wall synthesis and
are usually active against all common Gram-positive cocci including
penicillinase-producing strains of staphylococci. Action against Gram-
negative bacilli is variable and if these organisms are important, sensitivity
testing is required. Cefuroxime is active against both Staph. aureus and
Haemophilus influenzae.
Some cross sensitivity (up to 10 per cent) may occur in patients allergic
to penicillin, although this is only a contraindication to use when a clear
history of penicillin allergy is obtained. Adverse effects include urticarial
rashes and nephrotoxicity.
There is some controversy as to the clinical value of this large family of
drugs. It may be argued that narrow-spectrum specific antibiotics are often
effective in most situations.
Dosage is Cerufoxime 750 mg i.m. or i.v., 8-hourly; orally cephalexin
250-500, 6-hourly, given half an hour before food.
half an hour before food.

Erythromycin
This important macrolide antibiotic has an antibacterial spectrum similar to
penicillin. Its activity may also include Staph. aureus. There is no apparent
cross hypersensitivity in individuals who are allergic to penicillin and it is
therefore a useful alternative drug. Its action is bacteriostatic but at higher
blood levels bactericidal activity is produced. Toxic effects are low
although gastrointestinal irritation consisting of nausea, abdominal pain
with occasional vomiting and diarrhoea may also occur.
Erythromycin estolate causes jaundice.
Erythromycin stearate 500 mg (Erythrocin 500; Abbott) may be given
12-hourly. Erythromycin succinate suspension is useful in children or
adults with intermaxillary fixation 250-500 mg, 6-hourly. Erythromycin
stearate is a useful oral loading dose for the prophylaxis of endocarditis in
adults who are allergic to penicillin.
Erythromycin lactobionate may be administered intravenously 300 mg,
4—8-hourly.

Metronidazole
This is a narrow-spectrum antibiotic active specifically against anaerobes.
With improved culture techniques there has been an increased awareness of
the pathogenic role of anaerobes such as bacteroides either alone or in
conjunction with other organisms in the production of soft tissue infections.
It is active against bacteroides, Clostridium difficile and some protozoa
such as trichomonas and Giardia lamblia. It has proved highly effective in
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 THE CONTROL OF INFECTIONS

the management of most oral surgical infections in addition to acute

ulcerative gingivitis.
Metronidazole is well absorbed when taken by mouth and can be given
either 400 mg, 12-hourly, or 200 mg, 8-hourly. An alternative regime,
particularly when the oral preparation is impossible postoperatively,
especially with intermaxillary fixation, are suppositories 0-5—1-0 g t.d.s.
Metronidazole intravenous infusion 500 mg, 12-hourly, is also very useful.
The drug penetrates abscesses well and crosses the blood-brain barrier.
The side-effects include an unpleasant metallic taste, nausea and gastro-
intestinal upsets but very rarely rashes. Prolonged use, i.e. more than 30 g,
may produce a reversible neuropathy. Some patients experience an
‘antabuse’ effect with alcohol.

Aminoglycosides
These antibiotics are bactericidal and are most effective against Gram-
negative bacilli, but as they are poorly absorbed from the gut are best
administered by injection. Unfortunately, the principal toxic effect is to the
eighth nerve, producing vestibular damage or deafness which may be
preceded by headache, nausea, vomiting, nystagmus and ataxia. Therefore,
blood levels should be monitored, especially if renal excretion is
impaired.

Streptomycin Sulphate
Streptomycin sulphate is given intramuscularly and can be painful. Dosage
is | g a day as a single dose or 0:5 g twice a day. Gentamicin: serum peak
concentrations should be maintained at not greater than 5 mg/l, but trough
levels should preferably not fall below 1-5 mg/l.
This antibiotic is active against Psewdomonas aeruginosa, E. coli,
proteus and resistant staphylococci but is probably best reserved for Gram-
negative septicaemia in combination with penicillin or with metronidazole.
It is not active against anaerobes. Its principal use is as an adjunctive
prophylactic antibiotic in the prevention of high-risk endocarditis. The dose
is 3 mg/kg body weight a day given intramuscularly in 3 equally divided
doses if renal function is normal, or 80-120 mg as a stat dose.

Neomycin
Neomycin is used topically or to decontaminate the gut. It is of value as a
cream for cutaneous Staph. aureus infections but resistant strains are
possible with widespread continued use.

Tetracyclines
Tetracyclines have the broadest antimicrobial spectrum. They interfere
with bacterial protein synthesis but unfortunately are bacteriostatic and
resistance to them frequently develops. They are active against many
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 ORAL SURGERY, PART 1

Gram-positive and Gram-negative pathogenic bacteria strains except for

those of Pseudomonas aeruginosa.
The tetracyclines are probably best used for minor infective conditions in
penicillin allergic oral and antral cases. Being only partially absorbed from
the gut, sufficient concentrations remain in the intestine to alter the flora
which may give rise to local complications such as discomfort, diarrhoea
and suppression of vitamin K synthesis. Additional problems include heart-
burn, nausea and vomiting due to gastric mucosal irritation, skin rashes and
photosensitization.
Absorption is reduced by chelation to calcium in dairy products, and
even more so with antacids and iron preparations. The plasma half-life
varies considerably with the tetracycline and is increased in renal failure
except for doxycycline which is not eliminated by the kidney and therefore
may be used with impaired renal function.
Superinfection may occur with Candida albicans producing a sore
mouth or thrush in addition to a black hairy tongue, diarrhoea and pruritus
ani. Further superinfection with staphylococci, proteus or pseudomonas
causing a fulminating fatal enteritis is also possible if used in heavy
prolonged dosage. Oral, anal and vaginal superinfection may be avoided by
concurrent nystatin or amphotericin tablets and vaginal suppositories.
There is no firm evidence that vitamin B preparations may prevent or arrest
alimentary tract symptoms. Tetracyclines are selectively chelated by the
calcium of growing bones and teeth both in the foetus and children causing
yellow or brownish discoloration of the enamel and in some cases enamel
hypoplasia. Therefore tetracycline therapy should be avoided in children
until twelve years of age.
Dosage is tetracycline capsules or tablets 250 mg, 6-hourly. Demeclo-
cycline is more readily absorbed from the gut and excreted more slowly and
therefore 300 mg may be given 12-hourly. Similarly doxycycline 100 mg
daily may be used.
Parenteral administration is best by intermittent intravenous intusion ot
1 g of tetracycline or oxytetracycline in 0-9 per cent sodium chloride each
24 hours, divided into 2 or 4 doses each infused over 5-10 minutes.
Intramuscular injections are painful.

Chloramphenicol
Chloramphenicol is a broad-spectrum antibiotic with good tissue and CSF
penetration. It is chiefly active against Haemophilus influenzae, pertussis,
salmonellae and other coliforms. Its use is limited by a tendency to cause an
idiosyncratic fatal aplastic anaemia which occurs in about 1 in 50 000
treatments. Bone marrow depression which is dose related is also possible.
In neonates circulatory collapse, the so-called Gray’s syndrome, can occur
due to failure of the liver to conjugate the drug and of the kidney to excrete it
producing toxic high plasma levels. However, it is still useful for certain
conditions such as head injuries particularly where skull fractures involve

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the petrous temporal bone and external auditory meatus where it may be
given with metronidazole.
It is well absorbed from the gut and concentrations in the CSF in the
absence of inflammation are 50 per cent of the plasma levels. However,
where there is meningeal inflammation the concentration approximately
equals those of the plasma. Administration by intravenous infusion is
possible, but absorption is poor by the intramuscular route.
Dosage is chloramphenicol capsules 500 mg orally, 6-hourly. Medication
should not extend beyond 14 days. Intramuscular or intravenously | g may
be given every 6-8 hours.
Chloramphenicol eye ointment introduced into the conjunctival sac is
valuable in preventing infection where there has been local trauma or
surgery and should be applied 6-hourly.

Clindamycin and Lincomycin

Clindamycin is a chlorinated derivative of lincomycin. They both have
similarities in antibacterial spectrum of action to benzylpenicillin but are
also effective against staphylococci and bacteroides.
The drug is well absorbed and widely distributed throughout the body
except the CSF. Unfortunately, it may not only produce diarrhoea but also
a devastating pseudomembranous enterocolitis due to superinfection with
Clostridium difficile. Under these circumstances the drug must be stopped
immediately and the patient treated with oral vancomycin or metronidazole.
The fluid and electrolyte balance must be carefully maintained. Occasion-
ally acolostomy is necessary in the management ofthis condition, therefore
the drug should not be employed without careful consideration.
It may be useful in staphylococcal bone and joint disease where the
infecting strain of Staph. aureus is resistant to other antibiotics and the
patient is allergic to flucloxacillin.
Dosage is 150-300 mg, 6-hourly, orally; 0-6—2-7 g daily in 2-4 divided
doses i.m.; or 15-40 mg/kg daily in 3-4 divided doses by slow i.v.
infusion.

Fucidin
Fucidic acid is a steroid antibiotic used mainly against penicillinase-
producing staphylococci. It is valuable for overwhelming staphylococcal
infections and is best used in combination with erythromycin, flucloxacillin
or rifampicin.
The drug penetrates bone and abscesses well and so has an obvious
application in osteomyelitis. Another use is as a gel or ointment for
staphylococcal infections of the skin, but this should be avoided in hospital
in-patients to present the risk of generating and spreading resistant strains of
Staph. aureus. It is administered by mouth 500 mg, 8-hourly, and is well
absorbed, but can cause gastrointestinal disturbances.
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 ORAL SURGERY RE ARS a

Vancomycin
Vancomycin is a bactericidal drug active against Gram-positive cocci. It is
not absorbed by the gut and has to be administered intravenously, but
because of nephrotoxicity and eighth nerve damage it has limited use. This
should be preceded by an antihistamine such as chlorpheniramine maleate
10 mg intravenously to prevent troublesome histamine release.
The main indications include the prophylaxis or treatment of Strep.
viridans endocarditis where previous antibiotic therapy or allergy
contraindicates other drugs (see p. 223). It may be given by mouth 0:5 g to
1 g, 6-hourly, in the management of pseudomembranous colitis due to
Clostridium difficile which can arise following antibiotic therapy with such
drugs as clindamycin.

SULPHONAMIDES
Sulphonamides inhibit the bacterial synthesis of folic acid from para-amino
benzoic acid, a compound for which they act as a competitive inhibitor. By
combining the sulphonamide, sulphamethoxazole, with trimethoprim, an
agent which inhibits the conversion of folic to folinic acid which is important
for the bacterial synthesis of DNA and RNA, a bactericidal combination
co-trimoxazole is produced from two bacteriostatic agents. Co-trimoxazole
(Bactrim or Septrin) is active against Strep. pyogenes and most staphylo-
cocci and haemophili. It is also useful in managing intermittent acute
episodes in post-irradiation osteomyelitis in osteoradionecrosis, or Actino-
bacillus actinomycetemcomitans in mixed actinomycotic infections with
penicillin.
Prolonged therapy may lead to macrocytic anaemia due to the inhibition
of conversion of folic to folinic acid and rarely the sulphonamide may
produce marrow depression or selective blood dyscrasia. Allergic reactions
are uncommon but include rashes, exfoliative dermatitis, Stevens—Johnson
syndrome, fever, hepatitis, serum sickness-like syndrome, polyarteritis
nodosa and peripheral neuritis.
Tablets consist of trimethoprim 80 mg and sulphamethoxazole 400 mg
(paediatric tablets contain 20 mg and 100 mg respectively). The dose is 2
tablets 12-hourly, these may be dissolved in water and are therefore useful
with patients in intermaxillary fixation. Intravenous and intramuscular
formulations are also available.
Sulphadiazine, because of its ability to penetrate the blood-brain barrier
and achieve high CSF levels, is commonly used in the prophylaxis of post-
traumatic meningeal infection which is discussed on p. 224. A loading dose
of 3 g is followed by | g, 6-hourly, for 7-10 days, depending on the control
of the CSF leakage. The drug may be given intravenously | g, 6-hourly, but
in order to prevent crystalluria and renal damage a fluid intake of at least 2
litres a day must be maintained.
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 THE CONTROL OF INFECTIONS
ANTIFUNGAL DRUGS
Nystatin is used topically for oral candida infections and can be given as an
oral pastille or suspension 6-hourly, but has probably been superseded by
amphotericin B. This is usually given as lozenges 10 mg or a suspension 6-
hourly. These drugs are poorly absorbed from the gut and therefore require
to be given intravenously for systemic mycotic infections. However, this
should be undertaken by a specialist in the management of such
conditions.
Alternative antifungal agents which may be applied topically include
miconazole and clotrimazole. These are both imidazoles which inhibit the
synthesis of ergosteral which is a component of fungal plasma membrane
but which is not required by mammalian cells. They prevent candidal yeasts
developing hyphae and enhance their phagocytosis. However, it is worth
noting that the most common oral fungal infection by Candida albicans is
invariably secondary to some underlying factor such as iron deficiency,
diabetes, dehydration, steroid treatment, cytotoxic drug therapy or
radiotherapy, or an immune deficiency. Where possible these conditions
will also require attention.

ANTIVIRAL DRUGS
Idoxuridine is a competitive inhibitor of thymidine which is necessary for
the synthesis of DNA. It is therefore useful in the control of DNA viruses
such as herpes simplex, herpes zoster and vaccinia.
Idoxuridine 5 per cent dissolved in dimethyl sulphoxide penetrates the
skin but must be applied frequently, i.e. 1-2 hourly. Idoxuridine 0-1 per
cent in purified water is used for oral mucosal and eye lesions.
Topical application is contraindicated in pregnancy in case the absorbed
drug has a teratogenic effect on the foetus.
A valuable antiviral drug which again is effective against herpes simplex
viruses I and II and varicella zoster virus is acyclovir. Acyclovir is
phosphated to the monophosphate by viral coded thymidine kinase and
then converted to the active triphosphate by cellular enzymes. Thus the
active form is only found in infected cells. Acyclovir triphosphate acts as an
inhibitor and substrate for herpes-specified DNA polymerase, so preventing
further viral DNA synthesis. A few herpes viruses do not convert acyclovir
to the monophosphate and are resistant to the drug.
Zovirax cream contains 5 per cent acyclovir in a white aqueous cream
base and is applied to herpes labialis lesions 5 times a day for 5 days.
Preferably it should be applied as soon as prodromal itching and burning
appears and before vesicles form. The earlier in the evolution of the lesion it
is applied the greater the benefit in shortening the episode. The interval
between and frequency of new lesions is also reduced.
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 ORAL SURGERY, PART 1
THE CLINICAL MANAGEMENT OF INFECTION
Soft-tissue infection, alveolar abscess, sialoadenitis, pericoronitis and
postoperative infections—many of these infections not only contain the
commonly recognized streptococci and lactobacilli, but also anaerobes
such as bacteroides, fusobacteria and veillonella. The role of these
anaerobres in oral infections has been well observed in acute ulcerative
gingivitis and in cancrum oris where Bacteroides melaninogenicus may be
an important pathogen. Hence with appropriate surgical management a
choice may be made between the narrow-spectrum anti-anaerobe metron-
idazole and penicillin given by mouth or parenterally if oral administration
is not reliable or possible. The acute phase of severe infections can be
treated with intermittent intravenous antibiotics, given as a bolus 6-hourly
for the first 48-72 hours.
Erythromycin, a cephalosporin or tetracycline may be satisfactory
alternatives. Where possible culture and sensitivity should always be
carried out to confirm the appropriate antibiotic therapy, but, an immediate
Gram-stained direct smear can be of considerable value before culture and
sensitivity results are available.

Osteomyelitis
Acute osteomyelitis is now an uncommon condition in most European
countries and is usually caused by B-lactamase secreting staphylococci
which require the use of flucloxacillin, or erythromycin with or without
fusidic acid or clindamycin. With adequate surgery antibiotic therapy
should not be necessary for more than 2 weeks after drainage or removal of
any sequestrum.
Chronic osteomyelitis requires thorough debridement of necrotic bone
enabling central areas of dead space to be drained. This process of
decortication should be supplemented by metronidazole and any appropri-
ate antibiotic suggested by the microbiology.
Inadequately treated osteomyelitis, especially if the patient is receiving
long-term broad-spectrum antibiotics, will give rise to colonization with
exotic resistant organisms requiring even more exotic antibiotics. It may be
wise to discontinue all antibiotic treatment except for the use of
metronidazole and employ traditional surgical techniques such as antiseptic
packs intraorally, e.g. Whitehead’s varnish (iodoform ether varnish BPC)
or bismuth iodoform and paraffin paste on ribbon gauze. When packs are
used they should be changed as frequently as possible. Extraorally, sinuses
should be irrigated and packed with hypochlorite solution (Eusol or Milton
solution) on ribbon gauze. The external packs should be changed 2-4 times
daily. Surprisingly good results may be achieved with this simple technique,
particularly where sophisticated laboratory facilities are not available. The
same regime applies to infected bone grafts which may be saved by such
methods.

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 THE CONTROL OF INFECTIONS

Osteoradionecrosis is a chronic ischaemic necrosis without the benefit of

viable bone forming or bone removing vascular granulation tissue. Hence
the separation of the dead from living bone is exceedingly slow and in many
cases does not take place. The patient may be untroubled by the presence of
a sequestrum protruding through the mucosa which can be trimmed and left
as a protection for the underlying vital bone. Sinuses can be packed, whilst
providing antibiotic therapy such as metronidazole, penicillin or co-
trimoxazole for acute infective exacerbations. If infection is eliminated
healing may be enhanced with hyperbaric oxygen, although this requires at
least two hours at 2 atmospheres of oxygen 5 times a week for 4 weeks and
is often difficult to arrange.
More radical therapy involves the excision of the necrotic bone leaving a
defect and deformity. However, revascularization of the area using a
temporalis muscle flap appears to be of significant value. This technique
may also enable bone defects to be grafted with cancellous bone which will
require to be secured in place using either lower border wires and prolonged
(8 weeks) intermaxillary fixation or a bone plate and 4 weeks intermaxillary
fixation. However, it is important to achieve good soft tissue coverage with
a perfect intraoral seal using either two layer closure or vertical mattress
sutures. Where soft tissue coverage is not available locally a vascular
anastomosed ‘free’ composite flap such as the forearm radius flap, or an
iliac crest flap based in the internal circumflex iliac artery, can be
invaluable for reconstruction.

Actinomycosis
Cervicofacial infections by Actinomyces israeli are uncommon but should
be suspected when a circumscribed area of cutaneous inflammation
persists. Cases appear to follow surgery or the inappropriate treatment of a
surgical condition such as an infected tooth with short courses of
antibiotics. This chronic condition may occasionally also harbour in
addition Actinobacillus actinomycetemcomitans or be a combination of
Actinomyces viscosis and Staph. aureus.
Any underlying surgical problem must be dealt with, and the patient
treated with continuous phenoxymethyl penicillin 500mg, 6-hourly,
amoxycillin 500mg, 8-hourly, or tetracycline 250mg, 6-hourly, for at
least 30 days. Co-trimoxazole may be required in addition for the
actinobacillus or fusidic acid or flucloxacillin for the Staph. aureus. The
poor penetration of the sulphur granules which may be identified by Gram
staining and the slow rate of division of the organism determine the length
of treatment. Anaerobic culture for 10 days may be required for
identification.
Actinomycotic periostitis or osteomyelitis may require considerably
longer therapy lasting for 3-6 months which can only be gauged by the
clinical response.
pA)
 ORAL SURGERY, PART 1

Sinusitis
The establishment of drainage is essential and may be facilitated where the
problem is merely due to congested mucous membrane by inhalations of
Friars Balsam, Tinct. Benz. Co. or Karvol capsules. Strep. pneumoniae,
Haemophilus influenzae, Staph. aureus, anaerobes and viruses may be the
causative organisms and initially amoxycillin or erythromycin should be
tried. However, the antibiotic therapy of persistent infections should be
reassessed with culture and sensitivity testing and any surgery for
correcting drainage should be carried out.

PROPHYLACTIC ANTIBIOTIC THERAPY

The concern as to whether prophylactic antibiotics should be used for clean
minor oral surgery procedures is based on the fear that resistant strains of
organisms may arise in such patients and by cross infection spread to other
patients and persist in hospital units. In general this problem only arises
when broad-spectrum drugs are used for long periods of time on in-patients.
It is particularly likely to arise when other important considerations such as
early wound drainage and debridement, careful appropriate surgery and
aseptic technique both within the theatre and ward have been ignored. In
any surgical situation the possibility of the spread of difficult resistant
strains of bacteria from patient to patient must be considered against the
possibility of avoidable morbidity.

Guidelines
One important rule is the use where possible of narrow-spectrum antibiotics
for the shortest period of time. Metronidazole has been shown to be highly
effective in preventing dry socket, and reduces wound breakdown and
postoperative morbidity in 3rd molar extractions when given for 3-5 days
postoperatively. Similarly the same narrow-spectrum antibiotic has
reduced wound breakdown and fistula formation following major
resections.
The loss of a bone graft is a surgical disaster, therefore a combination of
metronidazole and flucloxacillin or a cephalosporin such as cefuroxime
against cutaneous staphylococci and Gram-negative bacilli, immediately
preoperative and postoperatively for at least 72 hours, has been of great
value. Another regime would be metronidazole and erythromycin.
However, such a regime is no alternative to general surgical cleanliness.
Hands should be washed before patients are examined and particularly
when moving from patient to patient in a ward. The patient should have a
Savlon bath and hair wash early in the morning of the operation day. Teeth
should be scaled and polished about a week before the operation and tooth
brushing supervised in the ward to see that it is effective. Chlorhexidine

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mouth washes and Hibitane pastilles to suck before the premedication will
reduce the bacterial count in the mouth which can be swabbed out with
Physomed when the patient is on the theatre table. Here also the skin is
washed again with Savlon solution, dried and meticulously prepared with
povidone-iodine solution. Efficient towelling and theatre technique with
careful wound closure and suction drainage to prevent haematoma
formation are all important. The application of antibiotic powder to bone
grafts merely kills off the osteoblasts and reduces the graft viability as does
its preservation for more than | hour in normal saline (see Bone grafting
below). A 1g suppository preoperatively or an infusion of 0-5g metron-
idazole i.v. prior to taking the graft should give the bone adequate protection
against anaerobic contamination when being manipulated into the mouth
wound. Similar precautions apply to skin grafts.
Feeding by fine bore or 12 FG nasogastric tube for 5-7 days
postoperatively appears to make an important contribution to intraoral
wound healing in major oral surgery. Careful aseptic management of wound
dressings and tracheostomy patients on the ward is crucial. Where a
tracheostomy stoma is slow to close and continues to discharge, twice daily
cleansing with 0-1 per cent aqueous hibitane or hypochlorite solution with a
hypochlorite soaked gauze pack is preferable to systemic antibiotics which
will rapidly encourage superinfection. Surface infection of moist unhealed
wounds, especially those which are granulating and not yet fully covered by
epithelium, is inevitable but can be controlled by simple local measures.
The infection subsides as the wound heals. Patients with intractable
infections with resistant organisms or immunosuppressed patients must be
isolated and barrier nursed.
Bacterial endocarditis prophylaxis in patient with defective heart valve
disease is an area where empirical attitudes create conflicting recom-
mendations. It is well recognized that many vulnerable patients with
defective valves do not suffer endocarditis either following dental
extractions or from the evident bacteraemia during mastication, which
occurs in the presence of periodontal disease. It is equally baffling when an
endocarditis due to oral Streptococcus viridans arises in edentulous
patients. Despite these enigmas which indicate a currently unrecognized
aetiological factor or factors, every care should be taken to identify and
protect such patients from a condition which, once established, is difficult to
treat successfully. The maintenance of good oral hygiene and the
application of 0-5 per cent chlorhexidine or povidone-iodine solution to the
gingival margins before dental treatment will reduce the severity of any
bacteraemia.
Bactericidal antibiotics should be given in adequate dosage immediately
prior to surgery, and continued for the period during which the bacteraemia
is anticipated, plus sufficient additional time to destroy those organisms
which have been arrested at vulnerable sites.
The patients at risk are those with:
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1. Congenital heart disease, apart from uncomplicated atrial septal

defects.
2. Rheumatic valvular disease, including that associated with
Sydenham’s chorea.
3. Prosthetic heart valves and those who have had other forms of cardiac
surgery, including those who have pacemaker electrode wires in situ.
4. Previous episodes of infective endocarditis.
5. Mitral valve prolapse.
Frequently unrecognized risks are bicuspid aortic valves in the young
and degenerative aortic valvular disease in the old. Functional systolic
murmurs which are common in children and adolescents do not usually
signify heart disease. However, in the absence of a specialist cardiologist’s
opinion, prophylaxis must be considered to be both useful and harmless.
The main causative group of organisms from oral sources is viridans
streptococci. Surgical procedures which create the risk include extractions,
scaling, gingivectomy and root-canal therapy. Where a non-vital tooth is
considered to be essential for preservation in a low risk patient, root-canal
therapy and orthograde root fillings possibly combined with minimal
apicectomy and if necessary a retrograde root filling can be carried out.
Theoretically the risk to the patient is reduced if this is done in one session,
but with high dose amoxycillin cover this is not essential (see below).

PROPHYLACTIC REGIMES
Prophylactic regimes as recommended by a Working Party of the British
Society for Antimicrobial Chemotherapy (1982) are as follows.

1. Oral Regimes
a. Amoxycillin 3g 1 hour preoperatively on an empty stomach,
preferably under supervision. For children under 10, half the adult dose,
and one quarter of the adult dose for children under 5.
b. Where the patient is allergic to penicillin or has received penicillin
therapy within the previous month, erythromycin stearate 1-5g 1 hour
before the procedure and then 500 mg six hours later. As before half doses
for children under 10 and quarter-doses for those under 5.

2. Parenteral Regimes
Alternative prophylactic parenteral regimes which may be more useful in
hospital practice prior to a general anaesthetic are as follows:
a. Amoxycillin 1g in 2-5ml of 1 per cent lingnocaine hydrochloride
(instead of sterile water) given intramuscularly before induction of the
anaesthetic followed by 500mg orally six hours later to maintain an
adequate blood level. Children under 10 should have half the adult
dose.

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 THE? CONTROL! OF -INFECTIONS

b. All high-risk adult patients, i.e. those with a previous history of

bacterial endocarditis or prosthetic heart valve replacement and who are to
be given a general anaesthetic, should be given intramuscular amoxycillin
prior to surgery as recommended above together with gentamicin 120mg
given by i.m. or i.v. injection followed by 500mg amoxycillin by mouth six
hours later. In children under 10 who are considered to be high-risk
patients, half the adult dose of amoxycillin and 2mg/kg body weight of the
gentamicin.
c. All adults who are allergic to penicillin or who have had penicillin in
the previous month and require a general anaesthetic should have
vancomycin | g by slow intravenous infusion over 20-30 minutes followed
by gentamicin 1 20mg intravenously before the induction of the anaesthetic.
This should be preceded by chlorpheniramine maleate 10mg intravenously
as vancomycin may cause an unpleasant histamine release producing a
pruritic rash. Children under 10 should be given vancomycin 20 mg/kg and
gentamicin 2 mg/kg, also intravenously.
It is important never to give prolonged antibiotic therapy prior to surgery
otherwise opportunist resistant organisms will colonize the mouth.
However, repeated short courses of say amoxycillin separated by a month
do not appear to cause this problem and should be used for a series of
endodontic or periodontal treatments.
In all cases it is important that povidone-iodine be interfaced into the
gingival crevice of the teeth under treatment as this reduces the size of the
bacteraemia resulting from trauma to the gingival margin.

Prosthetic Heart Valve Patients

Although prosthetic heart valve patients may not be exposed to a higher risk
of endocarditis than those with congenital defects or rheumatic heart
disease, they do have a greater mortality from this disease and of course
may also be on anticoagulant drugs. Particular care should be taken with
regard to their dental assessment. With a poor dentition where extractions
are anticipated for periodontal disease a dental clearance with the provision
of dentures preoperatively is probably the wisest policy.

Coronary Artery or Vein By-pass Patients

Patients who have had coronary artery or vein by-pass operations and those
with implanted pacemakers do not appear to represent a special risk for
endocarditis.

Arterial Graft Patients

Arterial grafts, particularly those involving the aorta, do not appear to pose
a great risk of infection from dental sources. However, an appropriate
preoperative dental assessment is wise and within six months of the
procedure prophylactic antibiotic cover should be prescribed.
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Cardiac Transplant Patients

Cardiac transplants, although rare procedures, involve the suppression of
immunity and the long-term administration of drugs which predispose to
infection such as corticosteroids and azathioprine. Thus dental disease
should be carefully eliminated prior to such surgery and extractions should
be carried out taking into consideration the anti-rejection regime together
with the use of anticoagulants.

Joint Replacement Patients

While the risk of infection of a prosthetic joint is probably low the resultant
loss of the artificial joint is catastrophic and a prophylactic regime similar to
that for bacterial endocarditis is appropriate where active oral infections are
being treated.
Post-traumatic Meningitis
The risk of meningitis following fractures involving the base of skull is
difficult to evaluate and much controversy exists in this area as to whether
prophylaxis is necessary. It would seem logical to assume that prophylaxis
is desirable especially where a cerebrospinal fluid leak has been
established. Although it has been traditional to use sulphadiazine because
of its ready penetration of the blood-brain barrier this drug is bacteriostatic
and it is likely that some of the organisms against which the patient needs
protection are resistant to this drug, especially those from the external ear.
Furthermore, following trauma and hence inflammation of meninges,
amoxycillin or erythromycin probably penetrate into the CSF adequately
and provide appropriate bactericidal action.
A more appropriate regime for severe skull fractures, and in particular
those compounded into the external ear which may be colonized by
staphylococci and Gram-negative bacilli, is a combination of chlor-
amphenicol 0-5 g, 6-hourly, and metronidazole 400 mg, 12-hourly, which
should be used especially during the surgical procedure. However, the risks
associated with the use of chloramphenicol must be weighed against the
danger that the patient faces from the injury and from meningitis, and is
small with short-term usage.
Intermaxillary Fixation
Intermaxillary fixation presents problems of drug administration which can
be overcome easily as follows:
1. Although most antibiotics may be given intramuscularly it is kinder to
the patient to administer them as an intravenous bolus at the required time
intervals. This is facilitated both during and immediately after operative
procedures when the patient is receiving intravenous fluids. Of course care
should be taken to check that the addition of the particular drug to the
infusion solution is appropriate. Drugs such as metronidazole may be given
as a 20-minute piggyback infusion.
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2. Most antibiotics are available in a syrup form and can be delivered

through a nasogastric tube or orally. Metronidazole can also be admini-
stered as a rectal suppository 1g, 8-12-hourly, or children 0-5g,
8—12-hourly.

Viral Hepatitis
The two most common causes of viral hepatitis are the hepatitis A (HAV)
and hepatitis B (HBV) viruses. Although they cause similar illnesses their
epidemiology differs.
HAV contains RNA and is shed in the faeces in large quantities and
infection follows ingestion of contaminated food. It has an incubation
period of 30-35 days. In the week prior to icterus, the virus is probably also
shed in the urine and saliva. Subclinical infections are rare, the mortality
rate is low and specific antibodies (anti-HAV) confer life-long
immunity.
HBV is a hepa-DNA (DNA containing) virus usually contracted by
parenteral inoculation, although infection via mucous membranes such as
the conjunctiva may occur. The incubation period is about three months
and arthralgia and urticaria may precede the jaundice. The acute illness
may be short, perhaps two or three days, and ‘flu’ like but accompanied by
anorexia. This is followed by a prolonged period during which there is a
variable degree of malaise with episodes of toxaemia. Frank skin jaundice
does not always occur, with the only indication of its presence being dark,
frothy urine and a yellow tinge to the sclera. The liver is enlarged and tender
and there is a gastrointestinal disturbance. The nature of the infection may
be overlooked in some cases and of course subclinical cases occur.
The most important route of transmission is contamination of cuts or
scratches on the surgeon’s hands by infected blood. However, infection can
also be carried in other body fluids, including saliva where the virus may be
present in minute quantities, especially if the saliva is mixed with
blood.

Sources of Infections
1. Patients with acute hepatitis type B. These patients may be infectious
for a few weeks before hepatitis is clinically detected. The infection will
usually be eliminated soon after the end of the illness, probably within 2-3
months. Dental treatment may be deferred until the patient is shown to be
free of infection by testing for the disappearance of HBsAg and the
appearance of anti-HBs antibody. HBsAg is a fragment of the viral coat
which was formerly called ‘Australia antigen’.
2. Carriers. A small number of patients become carriers of hepatitis B
virus after acute infection. Carriers often do not give a history of hepatitis
with or without jaundice and are apparently healthy, although some may
have abnormal liver function as shown by biochemical tests. A past history
of jaundice (which possibly was obstructive) is not by itself an indication for
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HBsAg testing. The presence of the ‘e’ antigen, HBeAg, a fragment of the
viral core, indicates high infectivity.

Incidence of Carriers
In the British population, the carrier rate is approximately | : 1000, but
there are recognizable groups who have considerably higher carrier rates,
and in some countries outside Europe and North America the general
carrier rate is very much higher than in Europe and may be as high as 10 per
cent.
Special categories in which the carrier rate may be especially high
are:
= . Patients from countries other than Western Europe, North America and
Australasia, especially from the Far East.
2. Drug addicts.
3. Mentally handicapped children living in institutions.
4. Promiscuous male homosexuals.
5. Patients who have had multiple blood transfusions (particularly if these
have been given abroad), or who have received multiple injections of
pooled blood products (e.g. haemophiliacs).
6. Patients who are heavily tattooed, particularly in circumstances in which
the equipment may have been inadequately sterilized between clients.
7. Patients with chronic liver disease.

Recognition of HBsAg Positive Patients

The presence of HBsAg in the blood is always associated with a risk of
transmission of hepatitis B infection. The test for this antigen is easily
available. Approximately a quarter of HBsAg positive patients are also
positive for HBeAg.
The patients with only surface antigen (HBsAg) are much less likely to
transmit their infection than those with both HBsAg and HBeAg. However,
while it is recognized that presence of HBeAg indicates high infectivity, it is
not thought that this should alter the treatment offered to carriers in general.
While patients in the special categories should always be treated with care
to prevent cross-infection, the only way to determine the presence of
infection is to test for HBsAg. This test can easily be obtained for patients
who might be carriers, but it will not be required if the history is of a HAV
infection.

Operative Procedures
1. Precautions to control cross-infection and infection of staff with
hepatitis virus, applicable to all patients. Infection carried by infected
instruments and materials should be controlled by routine autoclaving of all
instruments between each patient. Note that chlorhexidine and many other
commonly used disinfectants are not effective against viruses.

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For protection the operator must avoid the contamination of his skin with
blood. Blood should be regarded as a dangerous material. It is preferable
now that gloves should be worn as a routine even when examining mouths.
They must be worn regularly during exodontia and for the surgical
treatment of patients and are essential on all occasions when handling
patients from high-risk groups—see (2) below.
2. Precautions applicable to detected carriers of hepatitis B antigen
(HBsAg). Detected carriers are probably less dangerous than the much
larger number of undetected carriers. There is no justification for refusing
treatment of HBsAg or HBeAg positive patients, but special care can and
must be taken to avoid infection of staff and other patients.
The following suggestions are made:
a. Infected patients should be treated in a single chair surgery.
b. Turbine handpieces should not be used for surgical operations as
infected aerosols may be formed. Conventional handpieces should be run
more slowly, and ‘splashy’ procedures avoided.
c. The operators should wear gowns, gloves, surgical masks and
spectacles as eye protection.
d. After the operation, all used instruments should be put in a marked
sterilization box for separate cleaning and then autoclaving. Small aliquots
of any consumable materials should be dispensed beforehand and the
surplus discarded. Blood contaminated swabs should be disposed of in
specially coloured bags and doubly bagged. All linen should be bagged for
sterilization and laundering.
e. Where disinfectants are used to clean surfaces and floors, a 10 per
cent dilution of household bleach (e.g. Domestos) is recommended (see
Sterilization and disinfection below).
3. The protection of patients at special risk. It is important that patients
on immunosuppresive drugs, particularly patients having renal dialysis and
who are not carriers, should not be infected during any surgical procedures,
and treatment of these patients may be best supervised by the dialysis
treatment centre staff who are known to be free of infection themselves.
Some renal dialysis patients may have become carriers in which case
they should be treated as detected carriers.

Accidents
Any accident involving the penetration of the skin and contamination of the
wound with blood from any patient known to be infected with HB virus
should be reported at once to a microbiology laboratory. The suspected
patient must have a blood examination to determine the possible presence
of HBsAg.
In cases of accidental infection of staff from patients shown to be HBsAg
positive, hepatitis B immune globulin must be administered as soon as
possible, certainly within 2-3 days.
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Immunity of Staff
It is known that about 10 per cent of dental surgeons have developed
immunity to hepatitis B through previous contact with the virus. Further, a
satisfactory hepatitis B vaccine has recently become available (H-B-Vax;
Merck Sharp and Dohme) and is given as a series of three intramuscular
doses. Dental surgeons, hygienists and surgery assistants are advised to
seek active immunization.

Sterilization or Disposal of Instruments etc.

1. All non-disposable instruments should be cleansed of all traces of
saliva, blood or serum and rinsed and sterilized in an autoclave, e.g. at
134°C for 3 minutes, or by hot air, e.g. at 160°C for 1 hour.
2. After use, all used disposable instruments should be placed in an
impervious container (for sharp instruments this should be of metal or thick
cardboard) and incinerated or, if appropriate, autoclaved.

Disinfection
1. Allinstruments that cannot be sterilized by heat should be disinfected
by immersion in a suitable disinfectant solution (see below) for at least 1
hour. This is less satisfactory than sterilization by heat.
2. All working surfaces should be disinfected after use by wiping with
disinfectants containing 1 per cent of available chlorine, or, if made of
metal, with aldehyde disinfectants.
3. Bulky equipment cannot be sterilized by heat and hypochlorite
solutions will corrode metal equipment, so the latter must be disinfected
with an aldehyde disinfectant.

Disinfectant Solutions
1. Hypochlorite solution containing | per cent of available chlorine. The
solutions available through retail outlets contain 10 per cent of available
chlorine (e.g. Chloros, Domestos) and are diluted one part of solution in
nine parts of water for use.
2. Aldehyde solutions:
a. Glutaraldehyde 2 per cent. Cidex is a 2 per cent solution to which an
activating powder is added before use to make a buffered alkaline solution
which is stable for 14 days.
b. Formaldehyde 4 per cent. A 10 per cent dilution of formaldehyde
solution BP (Formalin) should be diluted appropriately.

AIDS
AIDS, the acquired immune deficiency syndrome, was first recognized as a
new, serious medical problem in the USA at the end of 1980 and cases have
been reported in the UK and other countries from 1981 onwards. It is
possible that the disease originates in central Africa where it affects
heterosexual individuals of both sexes, spreading to the USA, perhaps via
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Haiti. A substantial percentage of the early UK patients had travelled in the

USA and Caribbean. Some patients acquired the infection from blood
products prepared in the USA and others direct from sub-Saharal Africa.
The number of reported cases is increasing rapidly.
In 1983 a lymphadenopathy associated virus (LAV) was isolated at the
Pasteur Institute, and in 1984 the human T-cell lymphotrophic virus III
(HTLV-II) was isolated at the National Cancer Institute in the USA. In
the same year an AIDS-associated virus ARV was identified at the San
Francisco School of Medicine. These have proved to be variants of a single
heterogenous RNA virus which shows differences in the outer envelope and
is now designated the human immunodeficiency virus (HIV).
Homosexual and bisexual men form the largest group of patients, with
intravenous drug addicts next in frequency. Recipients of multiple blood
transfusions or infusions of blood products comprise a small, but significant
group at risk, together with the female partners of bisexual men and babies
born to women with AIDS.
In most cases the initial infection is symptomless but a glandular fever-
like illness may occur. It is possible that some acquire immunity and
recover completely. Others become asymptomatic carriers. The degree of
risk for these that they will eventually develop clinical AIDS is still
uncertain but substantial (more than 30 per cent). A varying period of
between 5 and 8 years elapses after infection and before the onset of clinical
disease in those destined to develop AIDS. Some develop the persistent
generalized lymphadenopathy (PGL) syndrome. The latter suffer from a
minor degree of malaise and weight loss and have symmetrical enlargement
of groups of lymph nodes and hepatosplenomegaly. PGL patients may not
progress to AIDS.
The onset of clinical AIDS is a serious matter. The patients become
lethargic, lose weight and have night sweats. They often present with
opportunistic infections or with Kaposi sarcoma. Some develop
lymphomas. These infections occur because the numbers of T-lymphocytes
are reduced and in particular the OKT4 helper T-cells are depleted.
Of the opportunist infections Pneumocystis carinii pneumonia (PCP) is
the most important. Patients with PCP develop a non-productive cough,
shortness of breath and fever, then become markedly hypoxic and die
unless treatment is given. Confirmation of the diagnosis is not simple, but
requires bronchial lavage and transbronchial biopsy. The multiflagellate
protozoa is seen in stained specimens. Treatment is by high dose i.v. co-
trimoxazole for 3 weeks or pentamidine intramuscularly. The protozoa
may persist in the lungs after clinical recovery with relapse in the ensuing
months. Cytomegalovirus, mycobacterial and cryptococcal infections also
occur, either as chest or CNS infections.
AIDS patients may present to the dentist with oral Kaposi sarcoma,
widespread oral and pharyngeal candidiasis or severe ulcerating herpes
simplex infections. Kaposi sarcoma can be seen unrelated to AIDS in
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middle-aged and elderly Eastern Europeans and Africans. Kaposi sarcoma

occurring in young men almost always means AIDS. The tumours are a
reddish or purplish colour and either raised or flat. They are often multiple,
affecting the skin, gastrointestinal tract and oral mucosa. ‘Epulides’ or
‘fibro-epithelial polyps’ of unusual appearance should be treated with
respect. Leucoplakia of the oral mucosa affecting young individuals is also
suspicious, particularly hairy leucoplakia affecting the side of the
tongue.
If the diagnosis of AIDS is suspected the patient should be referred
urgently to a consultant physician, but it is wise if the patient is not told of
the suspected diagnosis until it is proved.
Affected individuals develop antibodies to the virus, though the virus
may be recoverable from blood or secretions for months before the
antibodies appear. Various tests for antibodies, notably an enzyme-linked
immunosorbent assay (ELISA) are available. From what has been said
above the significance of finding detectable antibodies in relation to the
person eventually developing clinical AIDS is not clear.
The HIV uniquely prevents a successful deployment of the body’s
defences by its effect upon the patient’s immune system. The variable
composition of the outer envelope suggests that development of a useful
vaccine will be difficult. Despite treatment of opportunist infections and
tumours the prognosis for the patient with developed AIDS is poor with few
surviving more than two or three years.
The virus can be recovered from the blood, plasma, saliva and seminal
fluid of affected individuals and the mode of infection is probably similar to
that of hepatitis B, but with a lower risk of infectivity. The most common
modes of transmission are via semen and mucosal abrasions during
homosexual activities or via the shared hypodermic syringes and needles of
drug addicts. Blade razors and toothbrushes which might be contaminated
with blood also constitute a risk to other users.
Normal social contact, airborne droplets, domestically clean cutlery and
crockery and toilet facilities do not seem to carry a risk of transmission.
There does not appear to be much risk of transmission by saliva and a lower
risk than hepatitis B following accidental needle punctures.

Prevention
Known or suspected cases should be treated with all the precautions used in
the treatment of hepatitis B carriers (see above). The present prevalence of
the disease in the population is low but the number of cases is increasing.
Unsuspected cases present a potential hazard to dentists so that the time
has come to advise the wearing of well-fitting rubber gloves as a routine
particularly during any procedure which may shed blood, as a protection
against a variety of infections not solely hepatitis B and AIDS. Such gloves
need not be sterile, but should be washed in the same way as the uncovered
hands would be for the intended procedure. Greater care should be
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hands would be for the intended procedure. Greater care should be

exercised as a habit to avoid accidental puncture of the skin with sharp
teeth, needles, ends of wire, etc. As a profession we have become too
unconcerned about touching undiagnosed oral lesions with ungloved hands
since the virtual disappearance of ulcers in the mouth due to syphilis.
Dental surgeons often have practical hobbies which result in minor
cuts, scratches and abrasions of the hands and arms. Again, practitioners
should be more careful, so reducing the incidence of damage to the hands,
wherever possible. If the hands are scratched or cut, waterproof dressings
should be applied before the gloves are put on for dentistry until they are
healed.
While the development of an effective treatment or a vaccine must
present great difficulties, some measures can help to reduce the spread of
this disease. Extra precautions to prevent transmission via transfused blood
and blood products are already being taken. A change of attitudes and a
reduction in promiscuous sexual activity and in particular, homosexual
sexual activity is an obvious preventive measure. So also would be a
substantial reduction in intravenous drug abuse.
Tetanus
This is an uncommon infection in Britain and occurs when a deep or heavily
soiled wound is infected by the anaerobe Clostridium tetani. The organism
and its spores are ubiquitous in soil and the faeces of horses and cows, etc.
Its insidious onset, ususally 3-21 days after wound infection, produces
widespread muscle spasms including trismus, dysphagia and opisthotonos
and is difficult to diagnose and treat. Death from exhaustion and respiratory
failure may occur in the region of 60 per cent of cases outside specialist
centres, hence prevention is of the utmost importance.
Preventive measures in appropriate trauma patients are as follows.
1. Careful toilet and debridement of all wounds especially deep or
penetrating ones, removing dead tissue and foreign bodies.
2. Patients who (a) have not previously had tetanus toxoid immuniz-
ation and who therefore are not immune, or (b) those for whom the last dose
was given more than 10 years previously, or (c) those who are unaware if
they have been, should be given immediate passive immunization with
human hyperimmune tetanus immunoglobulin.
3. Active immunity should be ensured by giving tetanus toxoid.
Therefore (a) the immune patient will be given a booster dose of 0-5 ml
tetanus toxoid unless he or she was immunized during the previous year. (b)
Non-immune patients should be given 0-5 ml absorbed tetanus toxoid deep
subcutaneously into one arm at the same time as 250 units of human tetanus
immunoglobulin (HTIG) is administered intramuscularly into the other
arm. The tetanus vaccine dose should be repeated after 6-12 weeks then
after a further 4-12 months.
4. Antibiotics should be considered an ancillary measure but are also
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required. Amoxycillin 500mg and flucloxacillin 250mg will control the

Clostridium tetani and any associated penicillinase-producing organisms.
Erythromycin or clindamycin may be necessary in allergic cases.

DISINFECTANTS
This group of antimicrobial agents is usually used for the decontamination
of inanimate objects, such as working surfaces or instruments. Less irritant
preparations, the so called antiseptics, are available for the skin.
Unfortunately in most cases increased efficiency is related to increased
toxicity. If they are to be of value, certain important limitations must be
recognized:
a. The object to be disinfected must be thoroughly cleaned of debris,
blood or pus, etc., which will inactivate many agents.
b. Many antiseptics only retain their efficacy when stored in concen-
trated form and in some cases at particular temperatures, and dilute
solutions for use must be freshly prepared. Dilute solutions not only lose
their antimicrobial potency but become contaminated and actually grow
bacteria and yeasts. Absorbent stoppers for bottles such as corks must not
be used as these will become colonized by organisms which are resistant to
the particular agent and a source of contamination for dilute solutions.
Sealed sachets help to overcome this problem.
c. The appropriate concentration and period of exposure to the agent is
required for adequate disinfection.

Alcohols
Isopropyl and 70 per cent ethyl alcohol are effective against most Gram-
negative bacteria on clean surfaces in 30 seconds. They are not active
against spores and fungi but are useful for skin preparation prior to
venepuncture and for working surfaces.

Aldehydes
Glutaraldehyde and formaldehyde are active against most Gram-negative
bacteria, spores, viruses (including hepatitis B) and fungi, but require up to
three hours exposure. Both are irritant and toxic, glutaraldehyde less so but
needs to be alkaline; 2 per cent glutaraldehyde solution is useful for
fibreoptic and other non-autoclavable instruments but must be rinsed off
completely with sterile water before they are used.

Diguanides
Chlorhexidine is active against Staph. aureus and some Gram-negative
bacteria but not spores, fungi or viruses. It can be made up in alcohol or with
cetrimide. As it is readily inactivated by soap, pus, plastics, etc., its value
for disinfecting equipment is limited.
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Its principle use is for cleaning skin and mucous membranes, e.g. 0:5 per
cent chlorhexidine in 70 per cent alcohol or chlorhexidine with cetrimide
(Savlon or Savlodil, ICI) or a 4 per cent solution with detergent (Hibiscrub)
as a preoperative scrub. Alternatively chlorhexidine—alcohol-glycerine
solution (Hibisol) can be used for rapid hand antisepsis.
As a 0-2 per cent aqueous gluconate solution or | per cent gel it can be
used for the suppression of oral plaque and postoperative infection.

Halogens
1. Hypochlorites are active against bacteria, spores, fungi and viruses,
including hepatitis B virus. Unfortunately they are readily inactivated by
blood, pus and dilution. Eusol, calcium hypochlorite and boric acid or
sodium hypochlorite with sodium chloride (Milton) diluted prior to use are
valuable as a cleansing agent for wounds and sinuses. Hypochlorite packs
must be changed frequently, 2—4 times a day. Strong solutions are used for
cleaning blood contaminated surfaces.
2. Iodophors and iodine are active against bacteria and spores and some
viruses and fungi, but can be inactivated by blood and pus. Iodine may
cause a skin reaction. Both are useful as a | per cent alcohol solution for
skin disinfection. The aqueous detergent iodophor solution (povidone-
iodine) is used as a surgical scrub.

Phenolics
Hexachloraphane is the most useful of this group, especially as a skin
cleansing agents against Staph. Aureas, but has limited activity against
Gram-negative bacilli. Used as a 3 per cent solution or a surgical scrub
(Phisomed).

Quaternary Ammonium Compounds

Compounds such as cetrimide are anionic detergents active against
staphylococci. They are easily inactivated, especially by water and soap,
etc., and can become contaminated by pseudomonas. Probably best used as
a mixture with chlorhexidine (Savlon).

SUGGESTED READING
Cawson R. A. (1983) Antibiotic prophylaxis of infective endocarditis. Br. Dent. J.
154, 183-184.
DHSS (1986) Acquired Immune Deficiency Syndrome AIDS, Booklet 3.
Guidance for Surgeons, Anaesthetists, Dentists and their Teams in Dealing
with Patients Infected with HTLVII. DHSS, CMO(86)7 April, 1986.
Dinsdale R. C. W. (1985) Viral Hepatitis, AIDS and Dental Treatment. London,
British Dental Journal.
Innes A. J., Windle-Taylor P. C. and Harrison D. F. N. (1980) The role of
metronidazole in the prevention of fistulae following total laryngectomy. Clin.
Oncol. 6, 71-77.

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Kaziro G. (1984) Metronidazole (Flagyl) and Arnica Montana in the prevention of

post surgical complications, a comparative placebo controlled clinical oral trial.
Br. J. Oral Surg. 22, 42-49.
Lindemann R. A., Henson J. L. (1982) The dental management of patients with
vascular grafts placed in the treatment of arterial occlusive disease. J. Am. Dent.
Assoc. 104, 625-628.
Little J. W. (1980) Dental management of patients with surgically corrected cardiac
and vascular disease. Oral Surg. Oral Med. Oral Path. 50, 314-320.
MacFarlane T. W. and Follett E. A. C. (1983) hepatitis B vaccine. Br. Dent. J.
154, 39-41.
MacFarlane T. W., Ferguson M. M. and Mulgrew C. J. (1984) Post-extraction
bacteraemia. Role of antiseptics and antibiotics Br. Dent. J. 156, 179-181.
McGowan D. A. (1982) Endodontics and infective endocarditis in hospital
dentistry. Int. Endodont. J. 15, 127-131.
Millard H. D. and Tupper C. J. (1960) Sub-acute bacterial endocarditis: a clinical
study. J. Oral Surg. 18, 224-229.
Okell C. C. and Elliott S. D. (1935) Bacteraemia and oral sepsis: with special
reference to the aetiology of sub-acute endocarditis. Lancet. 2, 862-872.
Rood J. P. and Murgatroid J. (1980) Metronidazole in the prevention of dry
sockets. Br. J. Oral Surg. 17, 62-70.
Shanson D. C. (1982) Microbiology in Clinical Practice. Bristol, Wright.
Thornton J. B. and Alves J. C. M. (1981) Bacterial endocarditis. Oral Surg. 52,
379-383.
Watkinson, A. C. (1982) Primary herpes simplex in a dentist. Br. Dent. J. 153,
190-191.
Working Party of the British Society for Antimicrobial Chemotherapy (1982) The
antibiotic prophylaxis of infective endocarditis. A report. Lancet 2,
1323-1326.

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 CHAPTER 9

SINUSITIS, OROANTRAL FISTULA AND REMOVAL OF

A TOOTH OR ROOT FROM THE MAXILLARY SINUS

SINUSITIS
Sinusitis may be primarily an allergic condition or due to an infection.
Upper respiratory tract allergy can occur seasonally as hay fever or non-
seasonally as allergic rhinitis. In the latter case the allergies tend to be house
dust mite, or animals. The mucous membranes of the upper respiratory
passages are swollen and pale and an excess of clear mucus is produced. If
drainage of secretions from the maxillary sinus is obstructed discomfort will
be experienced and the swollen mucosa with or without a fluid level will be
seen in an occipitomental radiograph. Stagnant secretions are likely to
become infected and bacterial sinusitis will supervene which, depending
upon the circumstances, will be either acute or chronic.
With an acute upper respiratory tract virus infection a similar sequence is
seen. During the acute infection the nasal mucosa will be found to be
swollen and red. With the onset of secondary infection purulent secretions
will be seen, particularly by posterior rhinoscopy. Acute bacterial
maxillary sinusitis occurring under these circumstances is usually bilateral,
but may persist on one side if drainage from that side is impeded due to a
deviated nasal septum.
A unilateral maxillary sinusitis with an obviously odorous pus is
suggestive of an odontogenic infection and this has been discussed
elsewhere. Another and more sinister cause of a unilateral chronic
suppurative sinusitis is a maxillary carcinoma. If the neoplasm fungates
into the nose it may obstruct the orifices of all the sinuses on the side to
produce the radiographic appearance of a unilateral pan sinusitis.

Radiographic Features
Because the radiopacities of oedematous mucosa, mucus and pus are
similar no distinction can be made on the density of the radiographic image.
Swollen mucosa can be visualized in an occipitomental radiograph while
outlined by an air filled cavity. A thin or thick mucosa thickening may be
distinguished, or if the layer is no longer uniform, but heaped up, a polypoid
thickening. A single rounded mucosal image which can be seen in tilted
views to ‘flop’ from side to side is a mucosal cyst. These need to be
distinguished from odontogenic cysts which have an unvarying shape and a

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denser margin as they are covered by a thin layer of periosteal bone on the
antral aspect.
Mucus or pus which is still draining via the ostium will show a fluid level
provided the occipitomental radiograph is taken with the head vertically.
The appearance is sufficiently characteristic that rarely is it appropriate to
take a second radiograph with a lateral tilt to confirm the presence of fluid.
Once the sinus is filled with swollen mucosa and either mucus or pus a
completely opaque image will be seen. It must be remembered, however,
that oedema of the overlying cheek will also produce a unilateral difference
in opacity which must not be mistaken for opacity due to replacement of the
air in the antrum by soft tissue and fluid.
Also a carcinoma will initially produce a detectable thickening of the
mucosa. Then, as the tumour enlarges, complete opacity will be produced,
either because the neoplasm fills the antrum, or because it occludes the
ostium impeding the drainage of secretions. In time of course a carcinoma
will destroy part of the bony wall making the diagnosis all too obvious.
The detailed diagnosis and management of these conditions is usually the
province of the general medical practitioner or ENT surgeon, but their
diagnosis and differential diagnosis is of concern to dentists should their
patients be afflicted.

OROANTRAL FISTULA
The accidental production of an oroantral communication is probably a
relatively common occurrence during the extraction of maxillary posterior
teeth. Extractions of Ist and 2nd molars are most likely to be complicated
by the production of a breach of the floor of the sinus. Such incidences also
occur during the removal of 3rd molars, 2nd premolars, occasionally Ist
premolars and even canines, depending upon the size of the maxillary sinus
and the length of its floor within the alveolar process. The close relationship
between the sockets of these teeth and the antrum is more frequent when the
teeth are impacted or unerupted. There is a male predominance of 2 : 1 with
a peak age distribution in the third and fourth decades perhaps because the
sinuses tend to be larger and the alveolus denser in men. These figures are,
of course, related to the frequency and the age at which tooth extraction is
required as well as to variations in anatomy.
With increased size, the maxillary sinuses extend downwards into the
alveolar process between the palatal and buccal roots of the teeth and into
the interdental bone. When the bony floor of the sinus is viewed from above
the roots of the teeth raise oval swellings on the buccal and palatal aspect
respectively, the apices of the roots and supporting periodontal membranes
being separated from the sinus by a thin layer of bone. Anteroposterior
extension of the sinus carries the cavity into the tuberosity and palatally to
the canine and even the upper incisors. It is likely that minor cracks and
defects in the floor of the maxillary sinus are created during the rocking
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movement of tooth extraction fairly frequently, but that spontaneous

healing occurs and neither patient nor operator is aware of the fact. Indeed
in some cases it may be that the bone is naturally deficient at some point. In
other instances the roots may be hypercementosed and bulbous or the two
buccal roots of a molar may come together at the apices embracing the
inter-radicular bone so that segments of socket wall are torn off during the
extraction. A rough extraction technique will increase the size of such
fragments and the chance that the maxillary sinus will be opened.
The bone between the tooth and the antrum may be destroyed by disease.
A periapical granuloma or cyst is frequently the cause of such bone
destruction but advanced local periodontal disease can destroy the whole of
the socket bone. When the tooth is extracted the granulation tissue tends to
adhere to the tooth roots. If it also adheres to the sinus mucosa a hole may
be torn in the lining creating an opening right into the antral cavity.
Sometimes when a tooth is extracted an opening is produced into an
unsuspected dental cyst, creating a diagnostic dilemma. The reason for the
fistula may be apparent if there is an obvious discharge of cyst fluid rather
than air or mucopus such as might escape if an opening is made into an
inflamed sinus. Neoplastic destruction of alveolar bone can have a similar
result and may present following spontaneous tooth loss. Where there has
been a reason to take preoperative radiographs some of these problems will
be anticipated. If a difficult extraction is anticipated a mucoperiosteal flap
should be raised and an attempt made to minimize damage to the antral
floor either by surgical bone removal or separation of the roots of the tooth.
A two-sided flap can be used making a single relieving incision which starts
at the mesial papilla of the tooth to be extracted, so that the flap can be
converted if necessary by a second distal relieving incision into one suitable
for advancement to cover a fistula. Such an approach is also appropriate if a
fistula has healed spontaneously but a root remains to be removed from the
socket.
The first clue to the occurrence of a fistula is likely to be the recognition of
the antral floor being attached to the roots of the extracted tooth. The
appearance of the thin, smooth, curved plate of bone is quite characteristic.
Preservation of the integrity of the delicate lining mucosa, if it has not been
breached already, is important as it prevents contamination of the sinus
cavity and reduces the chance of subsequent sinusitis.
Where it is believed that complete perforation already exists it is
reasonable to instruct the patient to occlude the nostrils and blow gently so
as to produce an air stream passing from sinus to mouth, perhaps with
bubbling of blood in the socket. Blood trickling from the nostril on that side
also confirms the presence of acomplete opening and an antrum filled with
blood. The temptation to explore the socket with suckers and probes to
establish the size of the opening should be resisted as this merely disturbs
the newly established clot, risks breaching a possibly intact lining and may
carry infection into the wound.
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If a fistula is created during the surgical removal of a root a characteristic

hollow sound will be produced by the sucker due to an echo from the sinus.
If the defect is large it is possible to observe whether the lining is inflamed,
swollen and polyphoid or thin, delicate and normal in appearance. Any
mucus or pus should be aspirated but irrigation is probably harmful if
drainage is impaired.
The safest surgical action at this stage where the floor of the antrum has
been breached is to place a horizontal mattress suture across the mouth of
the socket and to tie it firmly. Normally contraction of the gum margin
greatly reduces the size of the socket opening during the first 24 hours. With
a mattress suture present the mouth of the socket will virtually close in this
time, supporting the clot within. Where there is a large defect, and the
buccal mucosa is untorn and where the operator is reasonably experienced,
a buccal advancement repair can be undertaken as a primary
procedure.

Radiographic Features
Periapical, oblique occlusal or rotational tomographic radiographs
will demonstrate the defect in the bony floor of the antrum, but are
not essential unless a fractured root fragment is still present.
An occipitomental radiograph will record the state of the sinus at this
stage but the floor of the antrum cannot be visualized. Immediately
following the creation of the opening little will be seen except some local
swelling of the lining unless there has been a haemorrhage into the antrum
or the sinus has been irrigated when there will be either opacity or a fluid
level. Generalized mucosal thickening or opacity, particularly if bilateral,
signifies pre-existing sinusitis. The rarer possibility of a pre-existing cyst or
malignant neoplasm must always be borne in mind as a cause predisposing
to the creation of a fistula.

Persistence of Fistulae
Now a further set of factors needs to be considered which prevents the
successful healing of the socket and results in the production of a persistent
fistula. Healing of the fistula depends upon the establishment of a clot
within the defect and the maintenance of its integrity and freedom from
infection until it has been invaded and replaced by granulation tissue.
If the defect is small and at the bottom of a deep socket it is likely that the
blood clot will be well supported and that the part immediately over the
defect will be successfully and completely invaded by granulation tissue.
This is best seen in 3rd molar fistulae which invariably close
spontaneously.
If there has been a substantial loss of height of the socket as a result of
advanced periodontal disease, and particularly in the case of a 1st molar
socket, then the bony defect is likely to be wide in proportion to the shallow
depth of the socket. A thin layer of clot will be supported only at the

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periphery and lysis of the centre is likely long before the granulation tissue
has penetrated that far. Without a scaffold of fibrin the granulations are
unlikely to reach across and occlude the opening. Also if there is a pre-
existing infection in the antrum, mucopus will drain through the opening
from the start and impede the formation of an occluding clot.
Even if a clot is formed, if infection is present above or develops in an
antral haematoma, the vital clot in the opening will be destroyed. Similarly
if the clot in the socket is destroyed by the formation of a dry socket the odds
are against the granulation tissue sealing the opening. The insertion of
foreign materials such as packs, pastes, haemostatic sponges or antibiotic
cones all destroy the integrity of the clot and jeopardize spontaneous
closure. The granulation tissue needs also to be attached to all aspects of the
bony wall of the socket. If it is unable to attach to one aspect because of a
retained root of a multirooted tooth or the exposed surface of the root of an
adjacent tooth, there is likely to be a continuing communication between
mouth and antrum.
Some operators like to construct a simple plate to cover the defect and to
protect and support the clot and developing granulation tissue. Such plates
are obviously useful in preventing food debris entering the antrum through a
large unhealed fistula where they will constitute a source of infection, but it
is doubtful if they are useful when used to cover a fresh socket. As already
advocated, with the help of a mattress suture the gingival margin soon
contracts, greatly reducing the exposed surface of the supported clot.
In the larger defect, where this is unlikely to happen, given reasonable
surgical skill on the part of the operator it is better to cover the defect by
advancement of a buccal mucosal flap. From time to time it is advocated
that small sheets of inert and self-adhesive material should be used to
protect the organizing blood clot, but the value of these is also doubted.

The Chronic Fistula

If the creation of an oroantral communication is unrecognized, untreated or
spontaneous closure does not occur, then a chronic fistula becomes
established. Contamination of the antrum with infected oral fluids and food
debris leads inevitably to chronic sinusitis. When the residual defect is very
small—and some are only pin-hole in size—the consequences may be slight
and symptoms only arise following an acute upper respiratory tract
infection. The mucopurulent phase is more marked on the side with the
fistula, a purulent maxillary sinusitis develops and persists when all other
signs of the illness have subsided.
Conversely with very large defects, though reflux of food, drink and
saliva is an obvious nuisance to the patient, it may allow such free drainage
of secretions from the sinus that any infection is readily drained and
symptoms are slight. Occlusion of the opening during the day time with a
dental plate reduces contamination of the sinus and prevents the
embarrassment of soup and drinks escaping from the ostium and down the
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nose. However, in the case of a full denture, retention may be adversely

affected by the opening.
Fistulae of intermediate size tend to be both a nuisance and a source of
recurrent symptoms. The patient suffers intermittent episodes of pain and
local tenderness along with a chronic, foul-tasting discharge. Drainage may
be obstructed by an oedematous lining or by polyps which can prolapse
through the fistula into the mouth. Prolapsed polyps can be quite large,
become fibrosed and even covered by stratified squamous epithelium on
their surface. At this stage they can be mistaken for an epulis until, as the
lump is excised, the opening into the antrum becomes apparent. If the
correct diagnosis is suspected the pedicle of the tumour can be explored
with a blunt periodontal probe. It will slip up between the pedicle and the
ridge mucosa into the antrum, and can be passed right round the pedicle,
indicating that the mass has come down through the opening.
Where a fistulous opening is partially blocked by swollen mucosa, a
polyp or purulent granulation tissue, excision of this tissue promotes
drainage of the antrum and makes it possible regularly to irrigate the sinus
cavity with warm water or saline. This, along with a single course of
penicillin, if there is a lot of pus, aids resolution of the sinusitis, prior to
surgical closure. To avoid food entering the now widely open fistula, which
would be counter-productive, an acrylic plate or simple vacuumed plate can
be made to cover it. Care is required whenever impressions are taken with
an oroantral fistula to prevent the impression material entering the sinus. If
the material sets hard it may lock the impression in place and if it is readily
torn, a fragment may be left in the antrum. A sizeable patch of tullegras
placed over the fistula will prevent alginate impression material entering the
opening while providing an impression sufficiently accurate for the purpose.
It should be remembered that a carcinoma of the antrum can present
through a tooth socket and may even have been the cause of pain or tooth
mobility which led to the extraction. As always, any excised soft tissue
should be examined histologically. Good periapical, occlusal and occipito-
mental radiographs should reveal irregular bone destruction and opacity
due to a soft tissue mass if a malignant neoplasm presents in this way.
Irrigation of the maxillary sinus is best carried out with a 20 ml syringe
and a soft plastic catheter, which should pass readily through the opening
without occluding it, in case the swollen mucosa prevents the escape of the
irrigation solution through the ostium. The patient should hang the head
forward so that the solution can run out of the nose and out of the mouth and
not back into the pharynx.
Once the infection is controlled, a few fistulae may close spontaneously,
particularly in the 3rd molar region. In general, however, the object of the
treatment is to bring the patient to operation with the maxillary sinus in as
healthy a condition as can be achieved. Where progress cannot be observed
directly as through a large fistula, serial occipitomental radiographs will
monitor an improvement.
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Surgical Closure ofan Oroantral Fistula

The patient should be warned that even the most promising of operations
may fail and a fistula be re-established. Re-operation after past failures at
the hands of other operators should be approached with due humility! As far
as possible a flap should be raised which will cover not only the fistula but a
ledge of bone which will support the suture line. The flap should have a good
blood supply and should be handled gently and not grasped and crushed
with dissecting forceps. It should lie in its new position without tension.
There should be good haemostasis because a haematoma creates tension,
delays healing and provides a nidus for infection. Failures occur where
these precepts are neglected, but also because for anatomical reasons it is
not always possible to carry out a fault-free operation.
Three types of repair are used as described below.

The Buccal Advancement Flap

The most useful is by a buccal advancement flap. This is a Y—V
advancement in that a Y shaped wound is created which is sewn up as a
V after advancement of the tissues between the arms of the Y. Advancement
is possible after careful division of the inelastic periosteum on the deep
surface of the flap, but depends upon the elasticity of the mucosa and
submucosa so that the repair is not entirely tension free, which is one reason
why it may break down.
Other problems are where teeth are still present on either side of the
fistula and there is not room to create a ledge of surrounding bone. If the
roots of the teeth are exposed in the fistula, the flap will not attach to the root
surface and will fail. Teeth not supported by alveolar bone must therefore
be extracted before closure is attempted. Sometimes there is recurrent
bleeding from the incision in the periosteum which leads to a haematoma in
the sulcus. Also the distal end of the flap is often quite narrow and its blood
supply is easily impaired by the retaining sutures.
This flap may be used to close an established fistula, a newly created
opening at the time of the extraction or to close a fistula in combination with
exploration of the maxillary sinus to remove a displaced root. The
procedure for closing an established fistula will be described first (Fig. 9.1),
then the modifications appropriate in the other circumstances. In the
majority of cases the procedure is not stressful and may be performed under
local anaesthesia, but access may be improved if an endotracheal general
anaesthetic can be used. The injection of a vasoconstrictor facilitates the
surgery even if a general anaesthetic is used.
There is less chance of a reactionary haemorrhage if felypressin is the
vasoconstrictor rather than adrenaline, and although the reduction in ooze
is not so great it is adequate for the procedure. Between 2 and 3 ml of local
anaesthetic solution containing felypressin is given buccally so as to
anaesthetize the tissues for at least two teeth anterior to the fistula and two
posterior. Between 0-5 and | ml of solution is injected palatally. The patient
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Fig. 9.1. Closure of oroantral fistula by buccal advancement (Y-—V) flap.

Diagrams of a fistula: lateral view of the alveolar process, below a plan view,
right the fistula in section. a, The margins of the fistula are excised and the
buccal flap outlined. An incision is made close to the mid line of the palate, and
short relieving incisions at either end of the operative area on the palatal side. b,
The palatal mucosa is undermined beneath the periosteum. The buccal flap is
raised, held taut and the periosteum incised above the level of the sulcus. The
palatal mucosa is raised at the edge of the defect. c, Plan view only. The buccal
flap is advanced and sewn in eversion against the palatal mucosal edge.

is positioned so that the operator has a clear view of the operative field
without stooping. Effective suction and a good assistant are essential.
In the case of a chronic fistula a rim of mucosa should be excised from the
edge of the opening with a No. 11 scalpel blade exposing a rim of bone to act
as a supporting shelf for the flap. At this stage, the palatal margin of the
opening should be undermined for 2-3 mm to ease later suturing. Two short
relieving incisions opposite the buccal ones will permit eversion of the
palatal wound margin.
Two divergent buccal incisions are then made up towards the buccal
sulcus. The ends of the incisions are turned in a curve outwards parallel with
the top of the sulcus. Where the gap between adjacent teeth is narrow the
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gingival papillae at each end are included in the flap. Where there is at least
the width of a molar socket the mesial and distal interdental tissues are left
undisturbed. The size and shape of the flap is designed with coverage of the
fistula after advancement in mind.
The buccal flap is reflected, subperiosteally, undermining the tissues well
up above the sulcus. The end of this flap is grasped, either gently with
toothed dissecting forceps or better still with skin hooks and everted and
pulled so as to tense the inelastic fibrous periosteum which lines its
undersurface. This tense lining layer is then /ightly incised from distal to
mesial, curving the cut upwards, well above the level of the sulcus at the
centre of the flap.
Following this, the flap, which now consists at its base of extensible
mucosa and submucosa only, can be easily advanced over the defect. Any
difficulty in extending the flap fully is usually due to tethering at one or other
edge of the periosteal layer and can be cured by completing the cut. Care
should be taken to examine the periosteal surface of the flap before the
incision so that the cut is placed to avoid any obvious vessels. Furthermore
the periosteal incision should only just divide that layer. Any small bleeding
point should be grasped precisely with mosquito artery forceps and
crushed. The corners of the distal end of the flap are now trimmed a little
with a sharp blade to fit the defect.
The flap is then sutured into position. Two plain sutures are placed
bisecting the mesial and distal angles of the flap and holding these two
points in position against the palatal gingiva. Next a horizontal mattress
suture is inserted between them to evert the wound margin and ensure a
broad area of apposition of the tissues. It must be tied without undue tension
or the ischaemic margin will necrose and fail to heal. Further sutures can be
placed to close the buccal limbs of the incision.
Sutures must be placed carefully and should embrace only sufficient
tissue to hold the flap securely in place, so minimizing damage to the
delicate flap; 4/0 (1-5 metric) synthetic absorbable sutures should be used.
If non-absorbable sutures such as silk or proline are used they should not be
removed in less than two weeks as it takes this time for a firm, strong
attachment to develop.
Where the gingival papillae are included in the flap it should be wide
enough to evert a little against the abutting teeth. In cases without
neighbouring teeth, the procedure is similar except where the margin of the
fistula is excised, mucosa can be removed mesially and distally to create a
distinct shelf of bone on which the flap can rest. A broad end to the flap can
be created of thick masticatory mucosa and all wound margins raised
enough to facilitate suturing. Bone buccal to the fistula may be trimmed if
the neighbouring ridge areas have resorbed so as to improve the lie of the
flap.
During the initial healing period, the patients must be advised to avoid
movements which stretch the cheek or activities such as nose-blowing or
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forceful mouth-rinsing which produce a pressure difference between the two

sides of the wound.
Inhalations in steam and a suitable antibiotic are prescribed. The use of a
steam inhalation such as menthol and benzoin 6-hourly directly moistens
the airway and stimulates serous gland activity preventing crusting of blood
and mucus, and patients also find its use comforting. Amoxycillin 500 mg
8-hourly, is a suitable antibiotic with doxycycline 200 mg first day and
100 mg daily as an alternative.
Some operators extend the anterior limb of the incision and explore the
sinus itself through a Caldwell—Luc opening in the canine fossa, removing
polypoid lining and establishing an intranasal antrostomy through which a
drain such as a Yeats tubing or a Jacques catheter is inserted to prevent the
accumulation of an antral haematoma which prejudices the success of the
fistula closure procedure.
A simple method for establishing an intranasal antrostomy is to pass
heavy curved artery forceps into the nose along the floor and laterally into
the antrum. A length of tinch ribbon gauze can then be inserted (from
within the antrum) between the open tips of the forceps, grasped and then
partially pulled back out through the nose. A slicing action grasping both
ends of the gauze will create a smooth margined defect in the medial antral
wall. A tubular drain is then drawn in a similar manner from antrum out of
nose and sutured to the alar margin with one retaining stitch. The drain is
removed in twenty-four hours.
Where this procedure is to be used to close a fistula at the time of its
creation some variation is appropriate. The operator must not forget to
explain the proposed procedure to the patient and the reason for doing it.
Additional local anaesthetic injections will be necessary to increase the
anaesthetized area and to ensure adequate painless operating time. Where a
flap has been reflected to retrieve a root a two-sided flap has been
advocated. This is more easily retracted without trauma to the tissues than a
three-sided flap. A narrower flap is needed to repair the fistula than would
be proper if only the root were to be removed which makes retraction even
more difficult.
Where the operation needs to be combined with an antrostomy through
the canine fossa to remove a root from the antrum, the part of the mesial
buccal incision which curves forwards up into the sulcus is extended to the
lateral incisor region.

The Palatal Transposition Flap

A finger-like strip of palate containing the greater palatine vessels is raised
and the end rotated laterally and transposed over or under the intervening
mucosa onto the ridge and the fistula. Because the flap has an axial artery its
blood supply is ensured irrespective of its length. Success or failure hinges
upon correctly estimating the length of flap required and not making it too
short. Also the palatal tissues are thick and stiff and resist being twisted to
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Fig. 9.2. Closure of an oroantral fistula with an arterialized palatal flap. The
diagram illustrates the importance of an adequate length of flap.

lie in the new position. On the other hand they are tough and hold sutures
well (Fig. 9.2).
Such a flap is used where there have been previous unsuccessful attempts
to close the fistula using a buccal flap and the buccal mucosa in scarred and
unsuitable for further surgery. Sometimes too the opening of the fistula may
be towards the palatal aspect of the ridge. In these circumstances a palatal
flap is more convenient.
The fistulous tract is excised as before and a shelf of bone established
around it if possible. Any granulations or polyps at the mouth of the fistula
are removed. A flap is outlined on the palate following the course of the
palatine artery and shaped to include the vascular bundle on the deep
surface. The flap curves towards the incisive papilla and so has a convex
buccal margin and a coneave palatal one. It must be turned laterally to
cover the fistula and the length of the shorter palatal edge governs its ability
to do this. Failure to recognize this will mean that the flap will be too short.
It may be possible to incise around the margin of the fistula and then raise
the soft tissue edge of the tract in continuity with the antral mucosa. If this is
so it can be inverted into the antrum with a purse-string-like suture, but if the
tissue is scarred this manoeuvre may not be easy. A single stitch is passed
through the buccal side of the wound, then through the tip of the palatal flap,
under the divided vascular bundle back through the tip and again through
the buccal mucosa. This forms a mattress suture which also occludes the cut
artery.
The flap is drawn into position but the suture is not yet tied. As the flap
rotates buccally it will override a triangle of palatal mucosa which must be
excised. When this has been done the mattress suture is tied and others

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placed to hold the flap in position. Coe Pack dressing or ribbon gauze and
Whitehead’s varnish is placed over the bare bone of the donor area and
retained firmly with tie over sutures. It is difficult to use an acrylic plate for
this purpose because of the way the palatal flap folds at the hinge as it is
rotated into place. The rotation of this thick peninsula flap may be difficult
for posteriorly placed fistulae and so its conversion into an island flap is
worth considering.
After the flap has been raised, the greater palatine vessels on the
undersurface of the base are identified and gently dissected free from the
overlying musoca with McIndoe scissors. The scissors are then passed
between vessels and submucosa and kept there for protection whilst the
mucosa is transected with a sharp No. 15 blade. The flap is now pedicled on
the blood vessels which can be carefully dissected back to the foramen
allowing easy rotation of the flap to be sutured into place. A pattern made
from the suture wrapping foil can be very useful in outlining the exact shape
and size of the flap to be raised (Henderson, 1974).

Rotation Flaps
A palatal rotation flap is only possible in the edentulous subject. A
substantial part of the palatal and ridge mucosa anterior to the fistula and up
to the midline of the palate is raised and rotated backwards to cover the
opening. The fistula is excised to create a triangular defect with a ledge of

Fig. 9.3. Diagrams illustrating a palatal rotation flap and a buccal rotation flap.
In each case the fistula is excised, the defect triangulated and a large flap of
tissue with adequate blood supply is moved sideways to cover the opening.

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bone distally. An incision is carried forwards from the base of the triangle
on the crest of ridge. At first the incision swings a little buccally, then
follows the crest of the ridge to the lateral incisor region, radially across the
palate to the midline and then back down the midline of the palate to beyond
the fistula. The whole of the outlined palatal mucosa is raised and
undermined posteriorly until the flap can be displaced backwards to cover
the opening. It is sutured into place around the margins.
For a large buccal opening where there is no tissue for an advancement
flap a buccal rotation flap is used. The fistula margin is excised and the
surrounding mucosa raised from the bone. Sometimes it is possible to turn
in flaps from the margin to form an inner layer. A vertical buccal incision is
made well forwards of the fistula and curved forwards at the top of the .
sulcus in the usual way. A large rectangular flap must be outlined which is
considerably wider than the fistula. By undermining well up onto the
maxilla and dividing the periosteum it will be possible to rotate the flap
backwards to cover the opening (Fig. 9.3).

DISPLACEMENT OF A TOOTH OR ROOT

INTO THE MAXILLARY SINUS
While creation of an oroantral fistula is often inevitable, the displacement
of a tooth or root into the sinus occurs only as a result of the operator’s
actions and is usually avoidable. In the much rarer case of a whole tooth
being displaced, unerupted 3rd molars, 2nd premolars or canines are most
at risk. When general anaesthetics for tooth extraction were less
sophisticated than today, cases were occasionally recorded of erupted teeth
being forced into the sinus by excessive pressure from a gag used to open the
unconscious patient’s mouth. Otherwise, displacement of whole erupted
teeth is unlikely except in severe maxillofacial injury.
Displacement into the antrum of unerupted teeth occurs during their
elective removal when force is substituted for skill and where patience has
been lost. The prudent surgeon is always aware of the possibility of this
problem arising and will plan his operation accordingly. Good quality
radiographs should show the position of the tooth relative to the antrum.
Generous reflection of soft tissues and removal of overlying bone ensure
good access, and force should be applied only in directions calculated to
dislodge the tooth towards the mouth, and of course away from the
sinus.
When displacement has occurred, the position of the tooth should be
demonstrated by radiography in more than one plane, for example, using a
rotational tomogram, or a lateral sinus view together with a postero-anterior
jaw or occipitomental view and an occlusal view. It is usually necessary to
open the sinus anteriorly by the classical Caldwell—Luc approach through
the canine fossa which overlies the biscupid apices in order to recover a
sizeable object such as a whole tooth. This provides much better vision and
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access than an approach via the defect through which it originally

entered.
The canine fossa is reached through a horizontal incision through mucosa
and periosteum in the upper buccal sulcus commencing at the zygomatic
buttress opposite the 1st molar-and running forwards to the central incisor.
The tissues are reflected off the surface of the bone until the infraorbital
foramen and infraorbital nerve are identified. A window of about 1-5 cm
diameter is made with a chisel, gouge or bur in the anterolateral surface of
the maxilla and care must be taken not to approach too close to the apices of
the bicuspid teeth or the infraorbital nerve. The aim is to avoid premature
penetration of the antral lining which lies beneath the thin bone
(Fig. 9.4).
Once the lining is exposed, it is opened with pointed scissors or scalpel,
and the cavity entered. Good lighting is essential and, if available, a
fibreoptic probe is most useful. When the tooth is found, it may be lifted out
with the sucker or grasped with a toothed Fickling’s forceps or other
suitable forceps and withdrawn. Irrigation with saline, inspection of the
recesses of the sinus with a tiny laryngeal mirror, or insertion of a gloved
finger may help to locate a tooth lodged in an awkward position. Grossly
polypoid antral lining should be excised, but stripping of the entire lining
should not be attempted. Once haemorrhage has ceased and after a final
irrigation, the incision is closed with black silk sutures. A five-day course of
inhalations and an antibiotic should be given as previously described on
p. 244.
Displacement of a fragment of root is much more common and more
difficult to avoid, but, again, poor surgical technique is often a contributory
factor. It is the palatal roots of upper Ist and 2nd molars which are
dislodged most frequently into the maxillary sinus, followed by the buccal
roots of the same teeth, the roots of the 2nd premolar, the 3rd molar, the Ist
premolar and occasionally the canine. When the root of an upper molar is
retained following an extraction, examination of the socket may reveal the
creation of a fistula in which case any unwise manoeuvre will soon displace
the complete root into the sinus. Even in the absence of such a discovery, a
close relationship of the roots of upper 2nd premolar and the Ist and 2nd
molars to the sinus floor should be assumed.
If a root fragment is to be removed, the application of force with forceps
or an elevator in an apical direction must be avoided. In general a
mucoperiosteal flap should be raised and sufficient bone removed to give
good access to the root and to allow its elevation in an outwards and
downwards direction.

Fig. 9.4. Removal of a tooth or root from the maxillary sinus. a, Incision in the
buccal sinus. b, Chiselling through the outer bony wall of the maxillary sinus. c,
Lifting off the outer plate of bone. d, Incision through the lining of the maxillary
sinus. e, Separating the edges of the incision to expose the sinus. f Tooth
removed from the sinus with forceps. g, Closure of the wound.

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SINUSITIS, OAF AND ROOT IN ANTRUM
 ORAL SURGERY, PART 1

If, despite these precautions, a root is displaced into the sinus then every
sensible effort should be made to remove it without delay. If the root has just
‘popped’ through into the antrum in response to a small force it is reasonable
to assume it is close to the socket and to explore the adjacent part of the
sinus on that assumption. It is probably wise to take a radiograph at this
stage. A periapical radiograph of the socket and an oblique occlusal view
are the most useful in these circumstances. While the films are being
developed the problem and the proposed course of action are explained to
the patient and additional local anaesthetic solution is injected to take
account of the wider operative field, to allow for a more prolonged
procedure, and to enhance vasoconstriction.
If a flap has already been raised the original incision may need to
be extended forwards in the sulcus and backwards at the gingival margin
so as to permit reflection of the soft tissues well above the level of the apical
part of the socket. The bone over the apical half of the socket and of the
antral wall just above it is removed freely using a large rose-head bur with
light pressure. The defect is then explored with the sucker tip, gently
elevating the antral lining from the floor of the sinus, immediately over the
socket. The root may be picked up at this stage by the sucker, or at least
located, especially if the antral lining is still intact. Ifit is not found and there
is an obvious tear in the lining this is widened and the sucker tip advanced
into the sinus cavity. During both manoeuvres the sucker should be directed
mostly towards the location of the root as seen in the radiograph. In the
absence of success, the patient should be instructed to pinch the nostrils and
to blow, thus creating an airstream from the sinus into the mouth, which
may carry the root with it. If this also fails the antrum is irrigated with
normal saline while continuing to move the sucker tip around the cavity.
Mostly one or other of these measures will retrieve the missing root,
but if they are unsuccessful attempts to locate it should not be unduly
prolonged so as to exceed the patient’s tolerance. It is wiser to suture back
the flap, to take a further periapical and oblique occlusal film as a
record of the current position of the root, and to arrange for a further
exploration through a Caldwell—Luc approach under a general anaesthetic.
Sometimes the problem is that the maxillary sinus is chronically infected
and the root is trapped in folds between polyps. Once a root has been
pushed in and the sinus has been opened, swelling of the mucosa can occur
quite rapidly.
Immediately before the further exploration another set of periapical and
oblique occlusal films should be taken, together with lateral sinuses,
occipitomental and postero-anterior jaw views which will all help to locate
the root tip. Rotational tomographic films will not demonstrate the root if,
as may be the case, it lies outside the trough of sharpness. While the
removal of the root at this stage hardly counts as a surgical emergency,
nevertheless the attempts should not be unduly delayed. Problems with
infection tend to arise if several days pass before the root is removed.

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Spontaneous expulsion of a root from the maxillary sinus is described

from time to time; presumably it is carried out of the ostium by the cilia on a
stream of mucus. Usually the root is sneezed out of the nose or coughed out
of the pharynx but there would appear to be a chance of inhalation, though
the risk must be small.
From time to time roots are discovered in the antrum without a history
of their displacement. Investigation of recurrent sinus infections may
lead to such a discovery. Sometimes there is a complete absence of
symptoms, perhaps because the root is between the lining and the bony
wall. If the sinus appears healthy radiographically the question is bound to
be raised whether it needs to be removed. On balance it is probably wise to
do so in a fit patient because of the risk of future infection or spontaneous
expulsion.
In longstanding cases every effort should be made to reduce any active
infection before the operation. As before the root should be localized
radiographically just before the patient is premedicated. The choice of
approach and design of the flap will depend upon whether the root is still
close to the original socket or remote from it and probably within the antral
cavity, and whether there is a patent oroantral fistula which also needs
repair. If the root is close to the original socket or to a fistula it is probably
best to approach it directly by the local removal of bone. If it is away from
the original socket a Caldwell—Luc approach is used.
In such cases it is of course necessary to be reasonably certain that the
object seen in the radiograph is a root and that it is in the antrum. Apart from
the general shape the detection of a root canal or a root filling is the clearest
indication of the nature of the image. Small bony excrescences and ridges
arising from the sinus floor or wall can closely mimic a root, but will not
have a root canal. Taking a further radiograph from a slightly different
position may alter the appearance of the image enough to make it clear that
is is not a root.
Antroliths which are formed from calcified inspissated mucus may be
mistaken for roots. As they tend to increase in size by accretion of fresh
material on their surface and also give rise to infections, to mistake one
for a root and to remove it will benefit the patient rather than other-
wise. A root which remains in its socket will have a lamina dura and
periodontal membrane space image about it in radiographs and will be
correctly orientated in relation to the alveolar process. One which is
displaced into the antrum is likely to lie at an unusual angle and will not
be surrounded by a lamina dura. Where there is doubt exploration should be
avoided rather than that the operator should chase a possibly non-existent
fragment.
In the past, much was made of the distinction between a root lodged
between the sinus lining and the bony wall and one free in the cavity with
advice that the patient should shake the head between radiographs and any
change in position noted. As a root inside the cavity may be trapped in folds
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in the swollen lining or simply stuck to the wall by mucus, a failure of the
root to move in this way does not mean that it is not in the cavity. Roots high
in the antrum are usually lifted up by swollen mucosa and are in the cavity,
as are ones which are a distance from the socket of origin. Those still close
to the socket may be under the lining but equally can lie just inside.

FRACTURED TUBEROSITY

A fracture of the maxillary tuberosity usually occurs during a forceps

extraction of a resistant upper 2nd or 3rd molar, but may also happen during
distal elevation of an impacted 3rd molar. Almost always there are marked
alveolar and tuberosity extensions of the maxillary sinus so that the
supporting bone is quite thin.
The cause of the difficulty with the extraction may be no more than
bulbous roots or recurved roots which embrace the inter-radicular bone. An
unerupted 3rd molar which is tightly impacted against the 2nd may be
sufficient to require the operator to exert more than average force during the
attempted extraction of the latter. In extreme cases there is false
germination between the 2nd and 3rd molars, the latter being disto-
angularly inclined, so that the roots of the two teeth are united by
cementum. Resorption of the distal aspect of the 2nd molar in response to
the presence of a high mesio-angularly impacted 3rd molar can also result in
the two teeth becoming interlocked. Hypercementosed molar roots in a
thickened Paget’s alveolar process also predisposes to a large tuberosity
fragment being separated.
extraction of the molar is not easy, unusual fragility of the bone is probably
the major predisposing factor, especially when there is no obvious
abnormality of the tooth being extracted. In many ordinary patients quite
substantial force has to be applied to dislodge an upper molar tooth, but
without a fracture occurring. Indeed, in the majority of cases in which there
is a mechanical problem, either the crown fractures from the roots, or the
surgeon fails to move the tooth with the use of forceps and elevators. Where
the bone is eggshell thin the canals for the posterior superior dental vessels
and nerves constitute a line of weakness through which the buccal part of
the fracture can take place.
The exodontist is immediately aware that the tooth and tuberosity bone
are moving together between the supporting finger and thumb. Furthermore,
although the tooth moves freely in a buccopalatal direction it is not
delivered from the socket by buccal movement. It is important that no
attempt should be made to twist or manipulate free the tooth and the
fractured fragment as this will tear the mucous membrane. Severe tears can
lead to sloughing of the tissues and a large oroantral communication. The
greater palatine vessels may even be torn with substantial blood loss.

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The simplest course of action is to dissect out the entire tuberosity. An

incision is made backwards from the distal surface of the last molar, over
the tuberosity. The molar is grasped with extraction forceps and the
fragment steadied while the buccal mucoperiosteum is elevated off the
bone. The tooth is tilted a little buccally and the palatal mucosa also is
raised from the fractured fragment. If a retractor is placed under the buccal
flap and the tuberosity tilted palatally it is usually possible to separate the
antral lining, so freeing the entire fragment. If the antrum has been opened it
should be sucked out and emptied of blood, and a damp swab packed into
the wound for 5 minutes to effect haemostasis.
It is usually a simple matter to suture the buccal and palatal flaps together
to achieve a sound closure of the wound. While the soft tissues tend to
shrink, subperiosteal new bone is deposited which will provide
a satisfactory, if smaller, tuberosity from the point of view of the
prosthetist.
Consideration can be given to the alternative policy of splinting the
fractured fragment until it has united and then removing the tooth or teeth in
it surgically at a later date. If the reason for extracting the tooth is an acute
abscess this is unlikely to be wise, but if there is no acute infection and the
patient has not been in pain this approach may be worth considering. It is
particularly applicable if the piece of bone which has fractured off is large so
that its loss will affect denture construction.
However, in making the decision to splint the fragment thought must be
given to the surgical problem which will be posed by the eventual removal of
the tooth or teeth. Sufficient bone will have to be removed at the time of the
extraction, not only to overcome the mechanical difficulty which
contributed to the fracture, but enough to make the extraction so easy that
the bone is not once more fractured. If this means the cutting away of a great
deal of the alveolar process the benefit to be expected from splinting the
fragment may not be achieved.

SUGGESTED READING
Henderson D. (1974) The palatal island flap in the closure of oral-antral fistulae.
Br. J. Oral Surg. 12, 141-146.

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 CHAPTER 10

SURGICAL ENDODONTICS

INFLAMMATION AND NECROSIS

Inflammation and septic necrosis of the dental pulp arises most commonly
as a result of a carious lesion penetrating the dentine as far as the pulp
chamber. Organisms may also reach the pulp through the deficient enamel
and dentine in the depths of a cingulum invagination or dens en dente, a
fracture of the crown which exposes the pulp, or an inadvertent traumatic
exposure during cavity preparation. Just occasionally a deep, infected
periodontal pocket will cause thrombosis of the apical vessels and infection
of the pulp.
Inflammation of the pulp and sterile necrosis may follow thermal
irritation from inadequately cooled rotary cutting instruments, chemical
irritation from certain restorative materials, or a blow to the tooth which
tears the periapical vessels or fractures the root. A pulpitis may follow
chronic trauma resulting from mastication on an inadequately contoured
filling. If necrosis follows chronic inflammation of the pulp there may be few
symptoms and little to suggest the onset of periapical inflammation. A
necrotic pulp which initially was sterile may become infected as a result of
organisms reaching it. In the absence of an open communication with the
mouth the most likely route is from the gingival crevice and via the veins and
lymphatics in the periodontal membrane.

Radiographic Considerations
Initially radiographic changes are minimal. An acute pulpal infection
spreading to involve the periapical tissues will cause oedema of the
periodontal membrane, elevating the tooth in the socket and widening of the
periodontal membrane space in the radiograph. The difference is subtle and
hardly adequate evidence on its own for a firm diagnosis.
The first indication of bone destruction is loss of the periapical lamina
dura. For this to be appreciated a sharp image of the apex and periapical
bone must be achieved. If the apex is pointed, and therefore the apical end
of the socket is a segment of a sphere of small radius, insufficient lamina
dura will be tangential to the X-ray beam to produce a linear image and the
lamina dura will not be seen in the radiograph even though the tooth is
normal. Conversely, if the root is broad and flattened it is possible for part of
the lamina dura at the apex to be destroyed and a linear image still to appear

254
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in a radiograph. Thus early radiographic changes must be interpreted only
in conjunction with other evidence as to the nature of the disease.
The tracery of cancellous bone trabeculae seen in clinical radiographs
represent those which lie tangential to the X-ray beam. Destruction of
cancellous bone results in the disappearance of some of these thin linear
images but no detectable change in the overall radiopacity of the part. The
loss of the trabeculae immediately outside the lamina dura can only be
detected as a local change in trabecular density if a previous film is
available for direct comparison. Also, experiment suggests that loss of the
apical lamina dura is more readily appreciated when these adjacent bony
trabeculae have been destroyed. A complete absence of trabecular
markings will only occur when all the trabeculae have been destroyed, up to
and including those which are attached to the insides of the adjacent
cortices.
As the two cortical plates are responsible for most of the radiopacity of
the alveolar process, a detectable loss of radiopacity signifies that one or
both cortical plates is resorbed. This may be a saucer-shaped depression on
the inside of the cortex which will produce an ill defined circular image with
a gradually increasing radiolucency towards the centre or a dark, sharply
defined image when the cortex is perforated.
If longitudinal sections are prepared through the teeth and alveolar
process radially to the dental arch, it will be seen that the lamina dura is
fused with the buccal and lingual cortical plates for a substantial distance
below the alveolar crest. With the exception of the lower molars up to two-
thirds or three-quarters of the labial aspect of the socket is fused with the
cortex. This brings the majority of the apices close to the labial or buccal
cortex with the result that cortical bone destruction and a periapical
radiolucency occurs relatively early in the evolution of an inflammatory
periapical lesion.
When a tooth is radiographed during the early days in the development of
an acute periapical abscess and is found to have a substantial degree of
periapical bone destruction this suggests that the acute episode has followed
a previous symptomless chronic one. Paradoxically, chronic low-grade
infection will cause increased bone formation on the surfaces of the
adjacent cancellous trabeculae at the expense of the marrow spaces to
produce a surrounding zone of bone sclerosis. Therefore the degree of
periapical radiolucency depends upon the thickness of cortical bone which
has been destroyed and whether this radiolucency has a well defined or ill-
defined margin depends, not upon the activity or chronicity of the
inflammatory process, but whether the cortical plate has been perforated or
merely thinned out over the granuloma. Nor is there any reliable
radiographic criteria, other than size, to differentiate between a periapical
cyst and a granuloma. Beyond an arbitrary diameter of, say, 1 cm it is likely
that the lesion is a cyst rather than a granuloma and the larger the lesion, the
more likely.
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 ORAL SURGERY, PART 1
Treatment
The lack of vitality of a tooth should always be confirmed by electrical and
thermal pulp tests before root-canal therapy is commenced because of the
following.
1. Itis not always easy to interpret the widening of the apical periodontal
membrane space or loss of the periapical lamina dura. A number of
anatomical arrangements will produce radiographic burn-out of the edge of
the apex and apparent widening of the periodontal membrane. A natural
foramen superimposed over the apex of a tooth may also simulate
periapical radiolucency.
2. A number of other pathological processes other than infection may
destroy periapical bone.
The first choice of treatment for a non-vital tooth is orthograde
endodontic therapy to (a) remove necrotic pulp remnants, (5) drain any
exudate and eliminate active infection, (c) ream out the inside of the canal to
an adequate size for instrumentation, to achieve a circular cross-section and
to produce a suitable taper towards the apex, and then (d) obliterate the
dead space within the tooth with a suitable root filling.
Successful root treatment and root filling is followed by a resolution of
the inflammatory reaction in the periapical granuloma and its replacement
by bone or a fibrous scar. In the majority of cases the normal bony anatomy
of the apical part of the socket is restored. In some cases a uniform space in
the bone remains over the apex filled with mature fibrous tissue with little or
no inflammatory cell infiltration. This type of healing is more likely to be
seen where there has been some form of periapical surgery. It is normally
considered that once a periapical cyst has formed treatment by endodontics
alone will not be sufficient and that additional surgical treatment of the cyst
will be required. However, there is considerable radiographic evidence that
even quite large cysts have healed following no more than efficient
orthograde endodontic treatment.
The commonest cause of failure of endodontic treatment is a root filling
which does not seal the apical third of the root canal. Such a case presents as
a persistent discharging sinus in the sulcus, or a recurrent subacute abscess
with pain and swelling. The proper treatment for such a tooth is removal of
the faulty root filling and further orthograde endodontic treatment. There
are fewer chances of technical error with orthograde treatment especially
due to accessory canals than with the placement of a retrograde root filling.
The patient is also saved the additional stress and discomfort associated
with a minor surgical procedure.
However, there are circumstances where an orthograde root filling is not
possible and the management will have to be surgical. These are as
follows:
a. Where it is not possible to prepare mechanically and fill the apical
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 SURGICAL ENDODONTICS
third of a root canal because it is sharply angled, irregular or almost
obliterated by secondary dentine.
b. Where the canal is obstructed by a fractured root canal instrument
which cannot be retrieved or an imperfect root canal filling which cannot be
removed.
c. Where the tooth has been crowned or supports a bridge retainer and
where it is inappropriate either to drill through the restoration into the pulp
chamber or remove it.
d. Where there is a continuous and copious drainage from a periapical
cyst which would prevent effective sealing of the apical root canal. (In
general it is preferable to root fill the tooth of origin by the orthograde route
before removing a periapical cyst, though it may be wise to fill the root not
more than 24 hours before the operation as sometimes an acute infection is
precipitated following the root filling.)
Other indications for surgery include:
a. The presence of surgically accessible root perforations.
b. A fractured apex which can be removed to leave a sufficient length of
undamaged root to support the tooth crown.
c. The removal of irritant root-canal filling material which has extended
into the periapical tissues (see later).
d. Where for overriding social reasons a one stage procedure for
treatment is required and orthograde root filling without periapical counter-
drainage would be likely to fail.
e. Where for no obvious reason an apical granuloma fails to heal or
where a small cyst fails to regress after orthograde root canal therapy.
It used to be taught that organisms in the apical delta of root canals or in
the cell spaces ofthe apical cellular cementum were a cause ofsuch failures
but this is no longer believed to be the case. Drainage of a periapical abscess
and the control of active infection by antibiotics should precede
apicectomy. Drainage may be obtained through the root canal, or by an
incision in the buccal sulcus, or both. Aspiration of periapical pus through
the buccal mucosa with a syringe and wide bore needle after infiltration of
the site with a local anaesthetic is an alternative to incision. While such
measures may render the tooth symptomless they will not be sufficient to
prevent recrudescence of the infection or, in some cases, cyst formation
unless a proper apical seal is subsequently achieved.

APICECTOMY AND RETROGRADE APICAL SEAL

A common error in the performance of apical surgery is a failure to produce
anaesthesia of a sufficient volume of tissue. As a consequence sensitive
spots are encountered in the periapical bone or while enucleating a cyst and
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 ORAL SURGERY, PART 1

the insertion of sutures is painful. Buccolabially in the maxilla the alveolar

process should be anaesthetized for the width of two teeth either side of the
tooth or teeth to be operated upon. This will ensure the painless insertion of
sutures. Also solution should be injected well above the sulcus to
anaesthetize the superior dental neural arcade before it reaches the
periapical lesion. Where a central incisor is to be operated upon either local
anaesthetic solution should be introduced up the incisive canal or
lignocaine urethral gel should be applied to either side of the nasal septum
on ribbon gauze so as to anaesthetize the long sphenopalatine nerves. Both
ends of a single strip of ribbon gauze should be used to prevent its
displacement backwards into the inferior meatus.
A substantial degree of vasoconstriction is also desirable to ensure as far
as possible a near bloodless field, particularly while the apical end of the
root canal is identified and while the amalgam seal is placed. Contamin-
ation of the amalgam with blood is obviously detrimental to its properties.
Therefore, although mandibular and lingual nerve blocks will readily
provide a wide field of anaesthesia in the mandible, the infiltration of further
solution buccally and lingually to the operation site is desirable. It will be
seen that a total of 4 ml of local anaesthetic solution will be required for
most cases. Even where a general anaesthetic is used the injection of an
adequate amount of solution locally to produce vasoconstriction is
necessary. Where it is feasible, the immediate preoperative placement of a
root-canal filling will improve the prognosis perhaps by obliterating
unidentifiable lateral canals which might lead to the failure of a solitary
apical amalgam filling.
The operation may be performed through a broad based, three-sided,
rhomboidal flap which includes the interdental papillae at either side of the
tooth or teeth involved. This flap provides better access to and visualization
of the operative field over and above the apex than the semilunar incision,
and the ooze from the laterally placed margins is less likely to interfere with
the operative procedure. The alternative semilunar incision carried out over
the midpoint of the tooth root has the value of not disturbing the gingival
margin related to a crowned tooth, but unless there is gingival pocketing,
postoperative exposure of the edge of the crown can be overcome by the
careful resuturing of a rhomboidal flap using vertical mattress sutures
through the interdental papillae.
The mucoperiosteum is reflected well above the apex of the tooth, the
position of which is estimated from any root convexity on the alveolar bone
and by reference to the crown of the tooth and the relative root length in a
radiograph. There may be a perforation in the cortical plate over the
periapical bone defect, or exploration with the sharp pointed end of a
Mitchell’s trimmer may locate the cavity by penetrating the thin layer of
bone over it. If the procedure is to be completed without excessive
shortening of the root and with the accurate placement of a filling in the root
canal, the undamaged apex must be uncovered first. An inverted semilunar
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 SURGICAL ENDODONTICS
cut is made with a No. 3 rose-head or narrow taper fissure bur over the
estimated site of the apex and the labial cortex prised off. The cavity is
gradually enlarged until the apex is exposed. There can be unexpected
difficulty in the location of the apex of an upper lateral incisor which may lie
at some depth, close to the palatal cortex. Once the apex has been
uncovered a minimum amount of root tissue is shaved off at an angle of 45°
to provide access to the apical canal. The canal can be identified by a probe.
The top of the root must be seen clearly because it is possible to create an
artefactual canal in the periodontal membrane between the root end and the
bone.
A size one-half rose-head bur is carefully inserted into the apical opening
to enlarge the end of the canal and to create an undercut cavity. It is possible
to do this with a straight handpiece when operating on prominent, labially
placed canines and central incisor roots by tilting the patient’s head
appropriately. However, a special right-angled handpiece with a miniature
head makes both access and vision easier. A X 4 halo magnifier facilitates
this stage of the operation. The apical areas should be curetted and irrigated
free of debris and granulation tissue. The latter, which is essentially a non-
infected reparative tissue, need not be meticulously removed. Indeed, the
benefit is largely from the removal of a vascular tissue which may ooze
during the next procedure.
The bony cavity is packed with ribbon gauze and the pack left in place for
5 minutes. The gauze may be moistened with a drop of 1 in 10000
adrenaline solution to aid local haemostasis. If there is still some ooze from
the bone a small amount of Abseal (Ethicon Ltd) can be smeared on to the
walls of the cavity with back of a spoon excavator. The apical canal is
inspected to see that it is clean and dry and then filled with amalgam.
Suitable miniature amalgam carriers can be made from spinal needles or
1 mm orthodontic tube and wire. The amalgam is condensed either with a
ball ended plastic or the back of a spoon excavator. Any excess is scraped
away and irrigated and sucked out of the cavity taking special care not to
impregnate it into the cancellous bone. The seal is inspected by reflecting
light onto the root end with a small mirror or polished retractor, then the
wound closed with 3/0 black silk or resorbable sutures.
Accessible perforations may be treated in the same manner. A
discharging sinus overlying the midpoint of the root of a tooth the subject of
root-canal therapy is evidence of such a perforation and a reamer track
directed towards the surface of the root may be demonstrable by obliquely
taken periapical radiographs. However, both a chronic palatal periodontal
abscess and an abscess related to a root with a longitudinal fracture may
point on the labial aspect in this way. In both cases an elongated
periradicular radiolucency will be seen in the radiograph. Where the cause
is a deep palatal pocket, with care the reduced height of the palatal alveolar
bone margin may be traced out in a good quality periapical radiograph and
the presence of a deep pocket confirmed clinically, though not always is it
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 ORAL SURGERY, PART 1

easy to introduce a periodontal probe into it. A longitudinally fractured root

is not amenable to treatment.
Where apical surgery is required to enucleate a cyst and where the canal
has been root filled preoperatively it is not essential to perform an
apicectomy. However, access to the cavity behind the root and detachment
of the lining from this aspect of the periodontal membrane may prove
difficult and an apicectomy may be carried out to improve access. The seal
created by the root filling should be inspected as both gutta percha and
silver points can be disturbed by the apicectomy and, if this is likely, a
retrograde amalgam filling should be inserted.
Marked postoperative swelling lasting 4-5 days is not infrequently seen
after an apicectomy and patients should be warned about this. One factor
may be the vasoconstriction needed to ensure adequate visibility and a dry
field for the placement of the amalgam seal. Reactionary hyperaemia and
an ooze into the tissues may occur some time after closure of the wound.
Swelling from this cause may be reduced by a pressure dressing over the lip
where an anterior tooth has been treated. The preoperative administration
of 10 mg of intramuscular or intravenous dexamethasone will reduce
postoperative oedema where this is likely to cause concern. A course of
antibiotics and appropriate analgesics should be prescribed and the first
dose of the latter should be given before the patient leaves the surgery so
that the drug is active before the local analgesia wears off.
Sometimes infection persists or recurs. A faulty apical seal or an
unobliterated accessory canal in the unfilled canal below the amalgam
filling may be the cause. It is possible that local resorption of the cut dentine
can undermine the relatively shallow apical root filling and may follow from
the lack of cementum repair over the root end. Re-treatment, perhaps in
conjunction with simultaneous orthograde root filling, should be considered
if the tooth is to be preserved.
Apicectomy with a retrograde seal may be carried out with care on most
single-rooted teeth though it is doubtful if it is often justified on lower
incisors. Access is not easy, the root ends are of such small diameter and a
reduction in root length soon affects the long-term prognosis for the tooth.
The position of the mental nerve and the curved course of the mandibular
nerve as it approaches the mental foramen must be considered in the case of
lower premolars. :
The 2nd and 3rd lower molars are next to impossible to treat in this way.
The overlying cortex is thick and the root apices some distance into the
cancellous bone and access is poor. However, the lower 1st molar may be
tackled by experienced operators.
As the upper Ist premolar usually has two apices a low resection of the
buccal one may be necessary in order to reach and seal the palatal one. A
transantral approach through a low alveolar extension of the antrum can be
carried out but as it is rarely possible to keep the antral lining intact, great
care must be taken not to lose bone debris, a root apex or amalgam
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fragments into the sinus cavity where they can cause chronic infection.
With upper Ist molars the buccal roots are readily treated surgically, but
the palatal one is usually impossible and is best root filled orthograde or
excised and sealed at the level of the trifurcation, if necessary from the
palatal side.
Other inaccessible molar roots may also be amputated and sealed close
to the pulp chamber or the tooth hemisected to leave a single well supported
root.
It is important, particularly where surgically difficult procedures are
envisaged, to consider carefully the benefits and possible complications of
what is proposed and to discuss these matters and the likely results in the
long term with the patient. The patient must understand what will be
involved and the chances of success or failure. Where the practitioner does
not have the personal experience to undertake what is required there should
be no hesitation in referring the patient to someone with the requisite special
skill.

ENDODONTIC ENDOSSEOUS IMPLANTS

Endosseous implants may be used to stabilize teeth where attached root
length has been lost either due to some pathological process or to excessive
surgical enthusiasm. The technique has also been recommended to stabilize
unsupported teeth following periodontitis. However, the prognosis in sucha
situation is poor unless there has been complete control of the periodontal
bone loss and of active periodontal infection. The implant may be
fabricated from Wiptam*: nickel chrome wire 1-3 mm or 1:5 mm in
diameter. It must be of sufficient length to extend to the original position of
the tooth apex and must also penetrate at least 5 mm into sound bone. At
the coronal end sufficient wire will be required both for manipulation and
also for the construction of a core to carry a crown. This may be done
outside the mouth in the laboratory. Ready made endodontic implants
together with appropriate bone drills are also available commercially.+
First the canal must be carefully and completely reamed to the implant
diameter. The apical area is then exposed surgically, irrigated and dried
with ribbon gauze and the canal also dried. The cement is then applied to the
canal walls. This may be either EPA (epoxyorthobenzoic acid) or cold cure
acrylic. The coronal half of the implant is also covered with cement and
then the implant inserted into the canal and through the apex where it is
carefully wiped with a sterile pledget of cotton wool prior to removing the
ribbon gauze pack. The post may then be tapped firmly into the overlying
bone and any excess cement carefully curetted and washed out of the bone
wound. The closure is as described for an apicectomy.

* Wiptam clasp wire, Fried. Krupp, Essen, West Germany

+ Dental Orotronic (UK) Ltd, 59 Queen Anne Street, London, WIM OHQ

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Care must be taken in planning this procedure to ensure that the direction
of the root is such that there will be apical bone to receive the implant.
Occasionally with a Class 2, division II retroclined upper incisor where
there is a concave alveolus the apex may be so superficial that an implant
extends into the buccal soft tissues.

REMOVAL OF PERIAPICAL ENDODONTIC PASTE

Over-enthusiastic use of endodontic pastes may cause extrusion into the
periapical bone. Usually this may be removed by a simple apicectomy.
However, the introduction of a paraform containing paste into the inferior
dental canal will give rise to impaired labial sensation which may persist.
Transalveolar attempts to remove the paste from the molar region with or
without extraction of the associated tooth often fail due to poor access and
may damage the neurovascular bundle. Subsequent bone healing can even
irreversibly obliterate the nerve canal.
The most rational means of removing such paste is by sagittally splitting
off the outer cortex between two vertical cuts. The canal can often be
exposed even without separation at the lower border, so that only an
intraosseous wire is required for postoperative bony union. With a
complete split intermaxillary fixation for 2-3 weeks is desirable.

SUGGESTED READING
Harty F. J. (1981) Endodontics in Clinical Practice. Bristol: Wright.
Monsour F. N. T. and Adkins K. F. (1985) Aberrations in pulpal histology and
dentinogenesis in transplanted erupting teeth. J. Maxillofac. Surg. 43, 8-11.
Nehammer C. F. (1985) Endodontics in practice: surgical endodontics. Br. Dent. J.
158, 400-409.

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 CHAPTER 11

CYSTS OF THE JAWS

A cyst is an abnormal cavity lined by epithelium, fibrous tissue or

occasionally by neoplastic tissue. Its contents may be fluid or semi-solid.
Some cysts are believed to contain gas, but the only instances in which this
is known for certain to be so are the gas filled cysts of the wall of the intestine
and colon (pneumatosis cystoides intestinales).
While cyst contents may become infected so that pus is formed, cysts do
not contain pus _ initially. Encapsulated chronic abscesses are not
considered to be cysts although the pus may be described as ‘encysted’.
Most forms of cysts in the jaws, floor of the mouth and neck are lined on
the inner surface by a layer of epithelium. The connective tissue comprising
the outer aspect of this sac forms a capsule and the whole forms a
dissectable lining. Some types of cyst have no epithelial component to the
sac, which in these cases is formed solely by a connective tissue membrane.
This is often quite thin and may be intimately joined to the adjacent
surrounding tissues so that it is not readily dissectable as in the ranula or the
solitary bone cyst.
Cystic lesions of the jaws may be divided into three groups: odontogenic,
fissural cysts and bone cysts. The odontogenic cysts arise from the
epithelium concerned in tooth formation and comprise three main types:
follicular (dentigerous), periodontal and keratocysts. There are also other
cysts which are named on the basis of their clinical presentation, but which
may not form a single entity and therefore are difficult to classify.
A simple classification of cysts of the jaws is as follows (Fig. 11.1):

Cysts of the Jaws

A. Of odontogenic epithelium:
1. Derived from the dental lamina:
a. Keratocysts:
i. Solitary or primordial cysts
ii. Pseudo-follicular or extra-follicular dentigerous cysts
b. Calcifying odontogenic cysts.
2. Derived from reduced enamel epithelium:
a. Eruption cyst
b. Follicular or dentigerous cysts:
i. Pericoronal
ii. Lateral
ili. Residual.
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3. Derived from epithelial debris of Malassez:
a. Inflammatory periodontal (radicular):
i. Apical
ii. Lateral
ili. Residual.
B. Of non-odontogenic epithelium (Fissural):
1. Nasopalatine
2. Nasolabial.
C. Bone cysts:
1. Solitary bone cyst
2. Aneurysmal bone cyst.
There are two phases to the growth of an epithelium lined cyst: initiation,
which results in the first small cavity, and subsequent enlargement. The
initiation is different for each group of cysts, but with variations the
enlargement process is probably similar for all epithelium lined cysts.
Nothing is known for certain about the origin of bone cysts and little about
their mode of enlargement.

CYSTS~OF ERUPTION AND FOLLICULAR

OR DENTIGEROUS CYSTS
These form from the reduced enamel epithelium present on the surface of
the tooth crown after it has become completely calcified. Normally this
epithelium proliferates towards the surface of the alveolus where it meets
and fuses with the downward proliferating basal cells of the alveolar
epithelium. Lysis within this mass of cells forms an epithelium lined defect
through which the tooth erupts (McHugh, 1961). Failure of the overlying
alveolar epithelium to break down will give rise to an eruption cyst.
Cysts of eruption present as bluish, fluctuant swellings in the mucosa
immediately over an erupting tooth. With few exceptions this is a primary
molar but sometimes an incisor. Almost always the cyst ruptures
spontaneously and the tooth erupts. Very occasionally the cyst remains
intact and the child and parents suffer a succession of sleepless nights. If,
under these circumstances, the cyst is incised a clear or yellowish fluid
escapes from a cavity between the mucosa and the enamel of the tooth
crown. If asegment of cyst wall is removed the cavity surface will be found
to be incompletely lined by a thin, stratified, unkeratinized squamous
epithelium. The histological appearance suggests that the follicular tissues
have separated from the surface of the enamel, with patches of the reduced
enamel epithelium adherent to their inner aspect.
Where eruption is impeded or delayed these cells may continue to
proliferate around the crown of the tooth and then the mature inner layers
undergo liquefaction degeneration leaving a pericoronal cyst. Occasionally
the cyst is related to the lateral aspect of the crown or exceptionally may

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Fig. 11.1. Diagrams of cysts of the jaws.

a, Fissural cysts: Top left. Diagram of the face of a human embryo at 6 weeks.
Top right. Diagram of sections through the developing nasal pit showing how
the nasal fin is breached by maxillary and premaxillary mesoderm. a, Site at
which nasolabial cyst develops. b, Site at which globulomaxillary cyst develops.
c, Nasal pit. d, Lateral nasal process. e, Naso-optic or nasomaxillary groove. f,
Nasal fin. g, Olfactory placode. h, Bucconasal membrane. Bottom left.
Diagram of the developing palate. Bottom right. Sites of fissural or non-
odontogenic developmental cysts. J, Primary palate or medial palatal process. k,
Lateral palatine processes. m, Site of nasopalatine (incisive canal) cyst. n,
Incisive canal cyst. 0, Globulomaxillary cyst. p, Nasolabial cyst.
b, Periodontal cysts: A, Lateral. B, Apical. C, Residual. D, Residual (deciduous
tooth).
c, Primordial cysts: Top. Replacing tooth. Bottom. Distal to 3rd molar.
d, Bone cysts: A, Stafne’s idiopathic cavity. B, Solitary bone cyst.
e, Dentigerous and developmental periodontal cysts: Dentigerous cysts—A,
circumferential; B, pericoronal; C and D, Lateral. Periodontal cysts—E,
Lateral; F, Distal.

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surround the neck or root of the tooth as it continues to erupt through it in
which case it is described as being circumferential.
Where a lateral dentigerous cyst forms distal to a vertical or disto-
angularly impacted 3rd molar a subsequent attack of acute pericoronitis
may result in the rupture and regression of the cyst. Usually the cyst pulls
away with the tooth if it is extracted but it has been known for the cyst sac to
remain behind and to continue to enlarge as a residual cyst.
Dentigerous cysts (follicular cysts) form around the crown of an
unerupted tooth. They involve teeth of the adult dentition or occasionally
supernumerary teeth. The proliferation, liquefaction and separation process
involving the reduced enamel epithelium which initiates cyst formation
occurs at a time other than when eruption is briefly delayed. In some
instances a cyst is discovered when only a short length of root has formed
and long before the normal time of eruption. Where there is a deciduous
predecessor even the process of root resorption may be far from complete.
Other dentigerous cysts develop on teeth which are impacted or unerupted
and where eruption is delayed. In some cases they develop in middle age
when they can achieve a large size. The cyst sac is lined by a stratified
squamous epithelium of variable thickness. Sometimes there are epithelial
discontinuities and sometimes patches of mucus secreting goblet cells. The
capsular connective tissue contains little or no inflammatory infiltrate.
The recognition of a dentigerous cyst radiographically in the early stages
of development is not easy. As a tooth moves towards the alveolar crest
when the time for eruption approaches the follicular space widens and the
gubernacular opening enlarges. The bone is resorbed away from the crown
producing a series of outlines like the opening of the petals of a flower. If the
tooth is radiographed at the beginning of the eruptive stage the widened
follicle may be mistaken for a cyst, particularly if the appearance of
widening is enhanced by magnification due to projection over a distance on
to the film.
Dentigerous cysts which develop around the crowns of Ist or 2nd molars
may produce a bluish fluctuant swelling involving the overlying alveolar
mucosa. However, unlike cysts of eruption, spontaneous rupture is
uncommon and there is a substantial concavity in the underlying bone.
Elsewhere the first indication of the presence of a dentigerous cyst is likely
to be the failure of eruption of the involved tooth at the appropriate time. A
radiograph will then reveal a rounded bone cavity surrounding the crown of
the tooth. The tooth will be displaced by the expanding cyst away from the
alveolar process, at first with its long axis radial to the cyst cavity but later
as the root impinges on the inside of the cortex it is deflected to lie nearly
tangential to the cyst.

Inflammatory Periodontal Cysts (Radicular Cysts)

The periodontal cyst arises from the cell rests of Malassez and usually
forms at the apex of a tooth with a necrotic pulp where it appears to act asa

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lympho-epithelial barrier to the spread of pulpal infection into the

surrounding tissues. If associated with an accessory pulp canal the cyst will
develop in a lateral relationship to the root where it will be morphologically
and radiologically indistinguishable from the lateral periodontal cyst
associated with a vital tooth, which is presumed to be the result of cell rest
proliferation brought about by bacterial provocation from the gingival
crevice. Although periodontal cysts may regress spontaneously following
root-canal therapy or extraction of the associated tooth, occasionally one
may persist and is called a residual periodontal cyst.
Periodontal cyst epithelium is stratified squamous with rete pegs but
varies in thickness and in some areas may be keratinized or even absent.
The surrounding connected tissue capsule has a varying degree of
inflammatory cell infiltrate often with dense foci of lymphocytes and
monocytes. The infiltrate is usually more intense in the smaller and
presumably younger cysts, than in the larger ones.

Keratocysts
Keratocysts arise from remnants of the dental lamina. Those which develop
posterior to the 3rd molar, between standing teeth or, as occasionally
happens, where a tooth of the permanent series is missing, are sometimes
called primordial cysts. It has been suggested in the past, but without
evidence, that primordial cysts arise by degeneration of the stellate
reticulum in a tooth germ. This theory requires that there was a
supernumerary tooth germ from which the cyst developed in cases where
the adult dentition is complete, but many keratocysts arise in parts of the
jaw where supernumeraries are uncommon. On the other hand, keratinizing
cell rests of the dental lamina are particularly abundant in the submucosa of
the retromolar regions, a part of the jaws where primordial cysts are
frequently found, so that this more elaborate suggestion as to their origin is
unnecessary.
Daughter cysts are sometimes seen developing from groups of epithelial
cells in the capsule of a cyst wall removed at operation. The epithelial cells
become orientated with the cuboidal basal cells on the outer, connective
tissue aspect of the sphere, and the mature squamous ones towards the
centre where they keratinize and are shed. Initially a keratin pearl is seen,
but later, where the shed cells have degenerated, a cyst cavity forms.
Keratocysts may also develop from dental lamina rests immediately
above a tooth in the gubernaculum between the follicle and the overlying
mucosa (the epithelial ‘glands’ of Serres). Such cysts envelop the crown,
displacing it and preventing its eruption. Clinically and radiographically
of
these cysts resemble dentigerous cysts, but if they are opened the crown
the tooth is not seen protrudin g into the cavity. Histologi cally the cyst wall
envelops the crown of the tooth which is separated from it by the tooth
follicle, hence they are sometimes described as pseudo-follicular cysts or
extra-follicular dentigerous cysts. The stimulus which initiates proliferation
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of the cell rests and hence the development of keratocysts is unknown. It

may be genetic as seen in the basal cell naevus syndrome (see below).
The epithelium lining keratocysts is 6-8 cells thick and with a basal layer
of cuboidal or low columnar cells with nuclei which may exhibit reversal of
polarity. There is an abrupt transition between the stratum spinosum anda
surface layer of para-keratinized cells. There are no rete pegs. The enucleated
and fixed lining shrinks slightly with a tendency to separation of the
epithelium from the underlying connective tissue. The contraction throws
the keratin layer into small folds. The capsule is quite thin and normally free
of inflammatory cells, but often contains strands of odontogenic epithelium
resembling the dental lamina, cell nests, with central keratinization and
daughter cysts. Sometimes the epithelial strands are connected to the basal
layer of the lining epithelium as though developing from it.

The Basal Cell Naevus Syndrome

(Gorling and Goltz syndrome)
This could equally be called the multiple jaw cyst syndrome because it is
usually through the appearance of jaw cysts that sufferers present. The
condition follows a dominant mode of inheritance with high penetrance and
variable expressivity but sporadic cases also occur.
The jaw cysts are keratocysts of both the solitary and the extra-follicular
dentigerous (pseudo-follicular) varieties. These start to develop about the
time of the eruption of the adult dentition. The skull is often brachicephalic
with frontal and parietal bossing and ocular hypertelorism. Ocular
abnormalities are apparent in childhood and a mild prognathism due to the
short cranial base may be the cause of an orthodontic consultation.
During adolescence tiny whitish epidermal cysts or ‘milia’ appear in the
skin around the eyes and tiny circular patches of epithelium may be shed
from the thick skin of palms and soles to produce pitting. Epidermal cysts
may develop under the skin in various parts of the body. Later, pinkish or
white, circular skin plaques develop on the face, cheek and trunk which are
basal cell naevi, some of which can progress to frank basal cell carcinomata.
Ovarian cysts and rarely medulloblastoma formation can complicate the
presentation.
A variety of skeletal abnormalities may be seen in radiographs including
calcifications of the falx cerebri seen in postero-anterior skull radiographs,
calcific bridging over the sella turcica on lateral skull radiography, fusion of
cervical vertebrae or occult spina bifida in the cervical or thoracic regions
and bifid ribs. Many other less common anomalies are described.

The Calcifying Odontogenic Cyst

(Calcifying and Keratinizing Odontogenic Cyst)
This rare lesion can occur in a unilocular and a multilocular form. The latter
variant may develop a thick capsule into which strands of epithelium
resembling the dental lamina proliferate, forming daughter cysts.
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In both unilocular and multilocular forms dental tissues may be induced
giving rise to multiple small odontomes. The variable presentation may
account for its inclusion in the classifications of odontogenic tumours.
The most common site is the anterior part of the mandible with a peak
incidence in the second decade.

Clinical and Histological Features

Mostly a single cavity lesion is discovered originating between standing
teeth and displacing or resorbing their roots. Some appear to develop
superficially with a substantial part producing a fluctuant subperiosteal
swelling. Examples are sometimes found in the retromolar region entirely in
the soft tissue and presumably developing from local dental lamina
remnants. Tiny. highly radiopaque bodies may be spotted in the radiograph
lying in a layer parallel to the inner surface of the bone cavity.
Histologically the odontogenic type lining epithelium is 6-8 cells thick
and has a columnar or cuboidal basal layer of cells with their nuclei
polarized away from the basement membrane. There can be a superficial
resemblance to a keratocyst in a small biopsy. In patches the epithelium
proliferates, the cells becoming swollen and then eosinophilic, due to a form
of keratinization, but with persistence of pyknotic nuclei. These are called
ghost cells. Later these cells fuse and tend to calcify. If pyknotic nuclei are
included in the calcified mass it may resemble cellular cementum at first
sight. It is the calcification in these epithelial cell masses which forms the
opacities seen in radiographs.
Where the eosinophilic change involves the whole thickness of the
epithelium it may be shed or incite granulation tissue to appear in the
adjacent connective tissue capsule with giant cells phagacytosing some of
the cells. Occasionally inductive changes are seen both under the ghost cell
masses and the taller basal cells with the formation, first of an atubular
dentinoid, and then tubular dentine. Unlike keratocysts, simple enucleation
is never followed by recurrence.

NON-ODONTOGENIC FISSURAL CYSTS

These include the naso-palatine or incisive canal cysts and the nasolabial or
nasoalveolar cysts. Globulo-maxillary, median mandibular, median
alveolar and median palatine cysts are also described but their authenticity
or even the actual existence of some of these entities is in doubt.

The Nasopalatine or Incisive Canal Cyst

Fusion between the primary palate and the two palatine processes of the
maxilla is completed at the centre of a triradiate junction. Later the bony
incisive canals are formed by the developing maxillary bones for the
passage downwards of the terminal parts of the long sphenopalatine nerves
and the passage upwards of the greater palatine vessels which will
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anastomose with the sphenopalatine vessels on the nasal septum. In the

foetus, cords of epithelial cells which sometimes canalize, and which
are referred to as the nasopalatine ducts, are found in relation to the incisive
canals. Nasopalatine cysts are believed to develop from these structures.
Incisive canal cysts are nasopalatine cysts which produce a cavity in the
bone. The majority develop within the incisive fossa and are covered only
by palatal mucoperiosteum on the palatal aspect. They enlarge upwards
and backwards towards the nose and palate but also forwards between the
roots of the central incisors where a swelling in the labial sulcus may be
produced.
A deep incisive fossa may be difficult to distinguish radiographically
from a small cyst. As these cysts enlarge only slowly and do not cause
problems until they reach around 1-5 cm diameter a policy of observation is
the correct approach in doubtful cases. Indeed, in the absence of symptoms,
only if the cyst is sizeable—and only rarely do they enlarge much beyond
2cm diameter—is surgery necessary. Indications for treatment are
encroachment on the central incisors, and attacks of infection, especially
when a communication develops with the mouth and when a fluctuant
palatal swelling appears, especially in the edentulous patient.
Particular care must be taken not to mistake an incisive canal cyst for an
apical periodontal one arising from a central incisor because often the
image of these cysts coincides with the apex of the incisors in periapical
films. Examples involving just the incisive canals singly or bilaterally can
be found.
Histological examination of these cysts reveals a lining which may be of
stratified squamous epithelium or, less frequently, ciliated and pseudo-
stratified columnar cells with mucous glands which secrete into the
cyst.

Incisive Papilla Cysts

These develop entirely in the soft tissues of the incisive fossa and cause
recurrent swellings just posterior to the incisive papilla. They produce no
radiographic changes but frequently discharge a salty tasting fluid into the
mouth. A tiny opening may be found lateral to the incisive papilla or
longitudinal ruga.

Nasolabial Cysts
Nasolabial cysts are rare and arise above the buccal sulcus under the ala of
the nose. They grow slowly, lifting up the nasolabial fold and bulging into
both the inferior meatus of the nose and the labial sulcus. They lie outside
the bone, but cause pressure resorption of the margin of the anterior bony
aperture of the nose and the labial aspect of the base of the alveolar
process.
A standard occlusal radiograph demonstrates the resorption of the
inferior margin of the anterior bony aperture. Normally the two inferior
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nasal margins together with the buttress of the anterior nasal spine produce
a ‘bracket’ shaped line in this view. A nasolabial cyst converts one half of
this line into a concave rather than a convex shape.
The epithelium of the lining is usually pseudo-stratified columnar or
cuboidal, or ciliated and with the goblet cells. Sometimes it is stratified
squamous. The fluid is either straw-coloured or whitish with a mucoid
consistency.
Several explanations have been advanced for their origin. Some believe
that they are mucous cysts arising from epithelium lining the floor of the
nose or a mucous gland in the labial sulcus. However, around 10% of cases
are bilateral which supports the alternative explanation that they are
developmental in origin, possibly fissural cysts. If so, sequestered
epithelium from the depths of the groove between the maxillary and lateral
nasal process would seem to be the most likely origin.

Other Types of Fissural Cyst

These have been described, notably the globulomaxillary cyst. At one time
examples purporting to be globulomaxillary cysts were reported regularly,
but when looked at critically most were apical periodontal cysts arising
from pulpless lateral incisors. Since the canine erupts normally they must
develop after this has happened.
The characteristic appearance of a globulomaxillary cyst is that it has a
pear shape, occupies the interdental bone between the maxillary lateral
incisor and canine roots, and pushes them apart. Radiographs of apical
periodontal cysts on lateral incisors can be found which show how, in some
cases, they enlarge progressively into the interdental bone rather than
expand symmetrically about the tooth apex.
Cysts of the characteristic pear shaped appearance can be found where
both the lateral incisor and canine have vital pulps but they are rare. It has
been suggested that these may be residual apical periodontal cysts from
teeth of the primary dentition, possibly a displaced lateral follicular cyst from
the canine, or keratocysts (primordial cysts). Keratocysts are uncommon in
the upper incision region and of course are readily recognized histologically.
If indeed globulomaxillary cysts exist as arare developmental entity then
they develop from sequestered epithelium from the nasal fin which is
formed by fusion of the surface epithelia of the maxillary and medial nasal
processes as they bulge forwards in contact with one another below the
nasal pit. This epithelial sheet subsequently disappears and maxillary
ectomesenchyme migrates medially.
The two palatine processes of the maxilla join first by fusion of the
epithelium covering their edges and this subsequently fenestrates and
breaks down to form keratin pearls and microcysts at the line of fusion.
Epstein’s pearls seen in many neonates in a diamond shape at the junction
of the hard and soft palate are thought to derive from these epithelial
remnants. However, no case of an inclusion cyst (median palatine cyst)
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 ORAL SURGERY, PART 1

developing in the midline of the palate posterior to the nasopalatine region

has been reported in an unequivocal fashion and the existence of such cysts
is doubted.
Some writers mention median alveolar cysts of the maxilla but the
primary palate develops as a median structure which rules out such a
possibility, and again no case which could not have been a nasopalatine cyst
is described.
The mandibular mesenchyme from each side migrates medially and fuses
beneath the epithelium to form the mandibular arch so that median
mandibular fissural cysts should not exist. A number of authors have
collected cases in which a cyst is present in the midline of the mandible
between the divergent roots of vital central incisors. Such cysts could be
residual apical periodontal cysts from the primary dentition, keratocysts
which are common in the lower incisor region, or lateral periodontal
cysts.
Median dermoid cysts of the floor of the mouth are scen from time to
time, in the midline just behind the mandible, and of course the anterior two-
thirds of the tongue develops from paired processes which develop on the
back of the mandibular arch.

BONE CYSTS
The solitary or unicameral bone cyst is usually symptomless and detected
as an incidental finding during a radiographic examination. If the cyst
becomes large enough it may cause expansion of either the buccal or lingual
cortex or both so that the patient complains of a swelling. They occur
mostly in the premolar and molar region of the mandible above the inferior
dental canal, but may be found also in the lower incisor region and the
ramus. As they enlarge they push up into the interdental bone between the
teeth to produce a characteristically scalloped outline to the upper
margin.
Downward extension carries the cyst to the lower border, sometimes
displacing the inferior dental bundle, but at other times progressing around
it, so that the nerve and vessels are within the cavity. The cortex is usually
thinned but expansion occurs late on and may first involve the lingual
aspect below the mylohyoid ridge where it may be overlooked. The
associated teeth are normally vital and the lamina dura persists around
them for some time. The roots of related teeth may be displaced by the
enlarging cyst and unerupted teeth, usually molars, are prevented from
eruption. The inner aspect of the cavity is covered by a delicate vascular
connective tissue, folds of which may contain neurovascular bundles to the
apices of the teeth and enclose the inferior dental bundle. Clumps of
granulation tissue containing masses of foamy macrophages may be
encountered. The bony walls lack the smoothness of other jaw cysts and of
course there is no dissectable lining composed of epithelium and a fibrous
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capsule. These lesions share features in common with the unicameral bone
cysts of long bones and are found most often in the first, second and third
decade but may be encountered in older individuals.
If the larger examples are aspirated with care a deep yellow coloured
fluid may be obtained. This contains plasma proteins and will clot if left to
stand. From smaller ones a heavily bloodstained fluid or fresh blood may be
drawn off. If the bloodstained fluid is spun down, a yellow supernatant
plasma will be recovered with, as in the case ofthe clear yellow fluid, a high
content of bilirubin. It is quite easy to induce haemorrhage from the cyst
wall so the aspiration of fresh blood is easily understood. The bilirubin is
evidence of past haemorrhage and also a lack of drainage of the contents
into the lymphatics. Some cysts are reported as ‘empty’ and it has been
suggested that they contain gas such as nitrogen, oxygen and carbon
dioxide.
Occasionally cysts diagnosed on radiographic grounds heal spon-
taneously. Others do so after aspiration which induces haemorrhage.
Removing part of the bony wall and lightly curetting the lining membrane
where no damage to neurovascular bundles will be caused usually provokes
most bone cysts to heal. The wound is primarily closed after haemostasis.
Recurrence tends to occur in the case of those operated upon before
adolescence.
Histological examination of the wall of these cysts casts little light upon
their origin. Outside a vascular connective tissue membrane, lamellar bone
or sub-periosteal new bone is seen with either osteoclastic resorption or
even bone deposition taking place on the inner aspect, but neither very
actively.
Occasionally the cavity is associated with an area of fibrous dysplasia.
Their origin is uncertain. A local abnormality of endosteal bone
remodelling has been suggested with, from time to time, haemorrhage
occurring into the cavity from the small vessels in the wall. There is no good
evidence that they arise as a result of trauma.
The Aneurysmal Bone Cyst
This should not be confused with the solitary bone cyst. Indeed, the cavity
in the bone is filled with a vascular sponge of soft tissue so it is not
completely cystic. The name refers rather to the radiographic appearance of
a blown out bone cavity outlined by subperiosteal new bone.
The lesion usually presents during adolescence as a large expansile
lesion in the mandible or, more rarely, the maxilla. The radiographic
n
features are an oval or spherical bone cavity showing substantial expansio
and covered by sub-periosteal new bone but with internal ridges and
incomplete septa giving a septate appearance. Occasional patches of fine
bony trabeculation are seen in some examples.
Histologically the lesion is composed of sinusoidal vascular channels and
cystic areas of varying size with connective tissue septa between. Woven
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 ORAL SURGERY, PART 1

bone may be deposited in these and aggregations of giant cells may be

found. The histology of the solid component varies from that of a giant cell
granuloma with spindle cells and multinucleate giant cells to tissue
resembling an ossifying or cementifying fibroma, i.e. small trabeculae of
osteoid, woven bone, or cementoid.
A persistent ooze impedes the operation of enucleation but once the soft
tissue contents have been removed haemorrhage from the bony wall may be
controlled by the application of Abseal (Ethicon Ltd), a putty-like mixture
of fibrin and collagen. If necessary the cavity can be packed with ribbon
gauze soaked in Whitehead’s varnish. Recurrence occurs after incomplete
removal and so large lesions may have to be resected as a benign tumour
and reconstructed with an iliac crest bone graft.

OTHER CYSTIC ENTITIES

Gingival Cysts
Several types of small cyst may be found in the gingival mucosa. Bohn’s
nodules are tiny white keratin pearls seen on the crest of the ridge of
neonates and probably represent superficial remnants of the dental lamina.
In some negro children they may enlarge to 2-3 mm in diameter and take on
a pale violet colour. After a few weeks they are shed spontaneously. Micro
cysts and keratin pearls are sometimes found on histological examination of
gingivectomy specimens and small cysts identified outside the alveolar
bone in the buccal and labial mucosa. Some are small mucous cysts.

Developmental Lateral Periodontal Cysts

These are found lateral to the roots of the vital teeth. These cysts probably
include more than one entity.
Cysts develop against the distal root surface of the lower 3rd molars
which are clearly unrelated to the crown and are not lateral dentigerous in
origin. They immediately destroy the lamina dura and adjacent bone
whereas when a lateral dentigerous cyst enlarges downwards the lamina
dura persists for some while. They probably arise from epithelial rests of
Malassez proliferating as a result of bacterial provocation from organisms
under the gum flap. Another entity develops in the bifurcation between the
3rd molar roots, either buccally or lingually but more often on the buccal
side.
Hodson (1957) described a specimen which developed in continuity with
a cord of epithelium arising from the reduced enamel epithelium. Crain
(1976) demonstrated this relationship in a series of specimens and
established an association with an enamel projection on the buccal aspect of
the root bifurcation. He showed that the periodontal membrane was
exterior to the cyst capsule, between it and the epithelial debris of Malassez
which was inactive. He calls these cysts paradental cysts and believes
chronic pericoronal infection initiates their growth.
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Some of these cysts develop lingually in which case they soon perforate
the lingual plate of the mandible below the mylohyoid ridge. Infection of
such a cyst has been seen to produce a fulminating submandibular
infection.
Another form of periodontal cyst involves the inter-radicular bone in the
canine and premolar region. These may be residual cysts from carious
primary molars as retained deciduous molar roots are found in the same
location. They need to be distinguished from keratocysts which can develop
at this site. Cysts found lateral to the canine and premolar roots which
perforate the buccal wall of the socket may be gingival cysts which have
enlarged inwards rather than cysts of periodontal origin.

CYST ENLARGEMENT
Once the initiation of cysts has been considered, their continued
enlargement has to be explained. Any explanation for cyst enlargement has
to account for:
a. An increase in the volume of the contents;
b. An increase in the surface area of the sac, and if this is lined by
epithelium, this also has to increase in area; and
c. Displacement of the surrounding soft tissues or resorption of the
surrounding bone where the cyst develops within bone.
If enlargement is prevented or delayed on one aspect by the consistency
of the surrounding tissues, it will progress at other sites where the tissues are
more easily displaced, stretched, resorbed or disrupted. Where there is an
epithelial component, thickness of the epithelium depends upon the rate of
multiplication of the basal cells, their speed of maturation and rate at which
they are shed. The rate of mitotic division of the basal cells in a keratocyst is
greater than in an apical periodontal cyst.
If proliferation of the epithelium leads to an increase in surface area
which is closely related to the increase in volume, the inner surface of the
sac remains smooth. If the increase in surface area exceeds the increase in
volume of the contents, inwardly directed folds result to produce a papillary
appearance on histological section.
is evident that
In the case of some cysts like dermoid cysts, it
ous glands
desquamated epithelial cells, hair and secretions from sebace
lining is mucus secreting
add to the volume of the contents. Where the
the increas e in volume . In the case of
an accumulation of mucus explains
tandin g of cyst enlarg ement is incompl ete, but
cysts of the jaws our unders
stages are recogni zable for the periapi cal inflam matory
the following
cysts.
tes the cell rests of
Low-grade infection of a non-vital dental pulp stimula
period ontal membr ane to proliferate to form
Mallasez in the periapical
ery of the periapi cal granul oma. They eventually form
arcades at the periph
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 ORAL SURGERY, PART 1

a confluent layer sealing off the apical foramen (Valdehaug, 1971) and
the contained granulation tissue and round-cell infiltrate liquefies. Cyst
epithelium does not appear capable of inducing an endogenous vascular
connective tissue stroma in the same way as a Solid epithelial tumour by
releasing the so-called tumour angiogenesis factor, and so the cells are seen
to proliferate in layers from the surface of the adjacent vascular connective
tissue. This connective tissue becomes organized as the cyst capsule. In the
periodontal cyst the epithelial-capsular interface usually forms rete pegs.
The number of epithelial layers is presumably determined by the period of
viability of each cell as it is separated from the basement membrane by the
dividing basal layer and by the rate at which maturation and desquamation
occurs. As these cells divide the cyst is able to enlarge within the rigid bony
environment by the release of bone resorbing factors from the capsule
which stimulate osteoclast function. These consist of prostanoids PGE,
(Harris, 1978), PGI, (Harvey et al., 1984) and leukotrienes (Makejka et
al., 1985). Inflammatory cells which are commonly seen in the capsule also
release cofactors. Lymphocytes release the lymphokine, osteoclast
activating factor (OAF), and monocytes, interleukin I, which stimulates the
fibroblasts to release the prostaglandins (Harvey et al., 1984). This cyst
enlargement is principally determined by the continued stimulation of
epithelial proliferation which in turn activates the all-important capsule.
The osmotic theory of enlargement reviewed by Main (1970) and Harris
and Toller (1975) is both popular and readily understood, but unfortunately
the concept that epithelial cell breakdown products produce a hyper-
osmolar cyst fluid which draws in fluid from the surrounding tissues is
difficult to sustain as the principal mechanism of growth. The presence of
large intracystic molecules such as globulins, fibrinogen and fibrin
degradation products makes it impossible to consider the complex cyst wall
as being a semi-permeable membrane. In fact the contents of periodontal
cyst fluid suggests that transudation, exudation and haemorrhage all take
place through the mural vessels. Furthermore, the apparent intracystic
hydrostatic pressure measured by inserting a fine bore needle attached to a
manometer (Toller, 1948) is more likely to result from a change in volume
due to cyst wall contractility or swelling of the lining than from an outwardly
acting force capable of inducing bone resorption.
Any process that leads to the involution of the cyst epithelium such
as extraction of the necrotic tooth or endontic therapy, or its conversion
to oral mucosa as with marsupialization, will cause the connective tissue
capsule to regress and the cavity to be filled by bone or scar tissue.
With marsupialization the cyst epithelium and capsule are replaced
by oral mucoperiosteum. This may be incomplete with keratocysts where
patches of cyst epithelium persist, potentially giving rise to superficial
recurrent cyst formation. Where a cystic ameloblastoma is inadvertently
marsupialized the cavity becomes filled with proliferating ameloblastoma
epithelium.
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CLINICAL PRESENTATION

Many cysts are discovered on routine radiographic examination, often

before expansion of the jaw is noticed. However, a cyst should be suspected
where there is a smooth, rounded expansion of either mandible or maxilla.
Where resorption and deposition of subperiosteal new bone results in only a
thin layer of overlying new bone the surface can be indented with the
examining finger, fracturing the bone and producing the so called ping-pong
ball effect. When only microscopic amounts of bone remain beneath the
mucoperiosteum fluctuation can be elicited and the swelling may take on a
dark bluish appearance. If two fluctuant swellings are present in the same
jaw it may be possible to elicit fluctuation between them. This is a sign that
there is only one cavity, if not then there may be two cysts, or the lesion may
be multilocular. The fitting surface of a denture which has been made some
years previously may also provide evidence for the length of time the
swelling has been present.
Absence of a tooth from its place in the arch suggests the presence of a
dentigerous cyst, particularly in the young. In the older patient, perhaps
with a history that the tooth was extracted, a residual periapical cyst is more
likely. Suitable radiographs will help to confirm or refute these
deductions.
Dentigerous cysts tend to arise in relation to teeth subject to delayed
eruption, i.e. 3rd molars, 2nd premolars and maxillary canines, and less
often supernumerary teeth in the upper incisor region and the upper incisors
themselves. Displacement of adjacent unerupted teeth in a child’s jaw by a
cyst may be deduced if their follicular spaces and gubernacular canals
remain visible in radiographs.
A carious, discoloured, fractured or heavily filled tooth related to the
swelling suggests an apical periodontal cyst. In a high percentage of cases a
non-vital maxillary lateral incisor is involved because of caries, trauma or a
cingulum invagination causing pulp necrosis. Tilting of the crowns of
standing teeth indicates that their roots have been displaced by expansion of
the cyst. Palatal inclination of the maxillary cheek teeth is common where a
cyst expands to fill the antrum, whereas sideways displacement is seen
where the cyst develops interdentally, notably with dentigerous cysts in
children. Apical periodontal cysts arising from deciduous teeth are uncommon
probably because they do not have sufficient time to develop before the
tooth is shed, but when they do arise they often become quite large,
displacing the succeeding teeth. Indeed any cyst will enlarge rapidly in the
labile and responsive jaws of a child making prompt treatment essential.
Following the extraction of a tooth with a sizeable radicular cyst there
may be an escape of cyst fluid. Provided it does not become infected the
socket may still heal clinically leaving a residual cyst, but often a bony
defect persists at the site of the socket which is visible radiographically and
gives a clue to the source of the residual cyst.
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 ORAL SURGERY, PART 1

Infected cysts present as painful, tender swellings which may already

have developed a discharging sinus. Occasionally such cysts give rise to a
cellulitis, but only rarely an osteomyelitis. Pathological fracture of the
mandible in response to minor trauma is surprisingly unusual, mainly
because there is more compensatory subperiosteal new bone on the buccal,
lingual and inferior aspects than is readily apparent in the radiographs.
Furthermore, the remaining bone has a tubular arrangement which gives it
unexpected strength. However, social, sport or iatrogenic trauma may
reveal such a lesion by producing a fracture.

Investigations
It is necessary to pulp test all teeth associated with a cystic lesion in order to
help establish the diagnosis. If all the related teeth respond normally then a
dentigerous cyst, keratocyst, solitary bone cyst or cystic ameloblastoma
must be considered in the differential diagnosis, whereas the presence of a
pulpless tooth at about the midpoint of the cyst suggests an apical
periodontal cyst.

Radiology
A combination of rotational tomographic, periapical, occlusal and PA jaws
radiographs will help to define the site, size and marginal outline of the
cystic lesion. Good quality oblique lateral views of the mandible may add
detail not evident in a rotational tomogram and can still have a place in
difficult cases. Cysts arising in the premolar—molar region of the maxilla,
and from the upper lateral incisor with its palatally placed apex, tend to
enlarge upwards into the antrum and inferior meatus of the nose and
therefore additional radiographs such as the lateral sinuses and occipito-
mental views are important.
Cysts developing in bone of uniform density take on a spherical shape,
but otherwise tend to enlarge in the direction of least resistance. It is for this
reason that maxillary cysts enlarge into the antrum and expand buccally
before distending the tough, palatal mucoperiosteum. In the thickly
corticated body of the mandible cysts push through medullary bone for a
considerable distance to produce a sausage shaped cavity before pene-
trating the cortex at some point or points to produce a subperiosteal
swelling. This behaviour is seen with all large benign cysts of the mandible
and is not specifically characteristic of keratocysts. However, it also seems
that some dentigerous cysts and periodontal cysts cease to enlarge after
achieving a modest size.
Neurovascular bundles, particularly the inferior dental bundle, although
displaced by cysts, retard enlargement, as they are displaced more slowly
than the surrounding bone is resorbed, so they produce ridges on the cavity
wall and indentations at the periphery.
As with periapical bone destruction an increase in radiolucency is the
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result of cortical bone destruction, not cancellous bone destruction, and is
maximal when both plates are penetrated. Once there is complete
perforation a map-like radiolucency with a distinct margin is seen which is
obvious but which rarely coincides with the full extent of the lesion. An
absence of linear trabecular images without a change of radiolucency marks
the extent of medullary cavitation. The margin of the cavity within
cancellous bone is therefore indicated by an abrupt return of trabeculation,
but contrary to common opinion, rarely by a thin, peripheral, radiopaque
line. Ridges inside the bone cavity and that part of the subperiosteal new
bone which arises almost at right angles to the edge of cortical perforations
externally will produce white linear images if the X-ray beam passes
tangential to them. Both may give the false impression of a multilocular
cavity, particularly if there is also uneven resorption of the cortex. The sub-
periosteal bone can give the appearance of a white linear margin; its image
does not necessarily coincide with the periphery of the intrabony cavity.
Chronic infection of the sac can result in a noticeable zone of sclerosis
around the cyst, a feature which is enhanced if there is a sinus present.
Irregular resorption of the adjacent bone should arouse suspicion of a
malignant change, although this is a rare occurrence. Where maxillary
cysts extend into the antrum the margin of the intrusive opaque image forms
part of a sphere and has a thin, dense or white linear outline, unlike the
floppy shape, less dense margin of benign mucosal cyst of antral origin.
Sometimes difficulty arises in differentiating between a large antrum and
a cyst. Often the problem is resolved by sinus views in which the opaque
upper margin may be seen or by comparing the appearance seen in
periapical views of both sides. There is usually a considerable degree of
symmetry between the alveolar, palatal and tuberosity extensions of the
right and left sinuses so a marked asymmetry is likely to be significant.
Furthermore, the thin cortical bone of the antral wall normally forms a
continuous linear white image which fuses with the lamina dura covering
the tooth roots even if the antrum dips low between them. If the interdental
bone lacks a white cortical line on the sinus aspect and ends as a cut off
margin of cancellous bone the cavity is likely to be pathological and
probably a cyst. Particularly is this so if the upper end of the interdental
bone between several teeth ends in this way and the lamina dura is absent
over the intervening tooth roots. Where doubt persists a wide bore needle
can be introduced on a syringe through the anaesthetized cavity wall.
Aspiration will produce air if it is the antrum and cyst fluid if it is a cyst.
Provided the patient tips the head forward some sterile saline can be
injected as a last resort. If the cavity is the antrum the saline will run out of
the nose!
As periapical cysts tend to expand symmetrically, the apex of the tooth of
origin is often centrally placed in relation to the margin of the cyst. Further
evidence is the absence of the lamina dura over the apex and perhaps a root
canal which is wider than in adjacent teeth, or even narrower due to the
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deposition of secondary dentine prior to pulp death, and of course

incomplete formation of the root end where the pulp and dentine papilla
have necrosed before development of the tooth was complete.
As cysts enlarge they displace adjacent tooth roots and if radiographs are
examined critically in up to a third of such cases some resorption of the
roots will also be seen. With large benign cysts the resorption can be
substantial, although much resorption may arouse suspicion that the lesion
is an ameloblastoma. While concurrent bilateral dentigerous cysts can
occur, symmetrical cyst development around molar crowns suggests the
presence of pseudo-dentigerous keratocysts.
Keratocysts in the retromolar region tend to expand with an amoeboid
outline backwards into the ramus and up towards the coronoid process.
Despite the increased rate of turnover of their epithelium keratocysts are
relatively poor bone resorbers and are more readily confined to the
medullary cavity, with comparatively late expansion of the cortical
plates.
The point has been made already that irregular enlargement can produce
a ridged cavity radiographically simulating a multilocular cyst. More
keratocysts give the impression radiographically of being multilocular than
are actually multilocular. However, an outpouching of the wail forming a
significant part of a sphere suggests a daughter cyst and true multilocularity
is certainly suggestive of a keratocyst. Whenever multilocular cysts are
seen the differentiation between keratocyst and ameloblastoma becomes
important and aspiration of the cyst contents may be helpful (see
below).
The nasopalatine cyst presents as a central circular or occasionally
heart-shaped radiolucency in the anterior palate. Nasolabial cysts as stated
previously may resorb the thin margin of the inferior border of the nasal
pyriform fossa, in which case the double curved ‘bracket line’ seen on the
standard maxillary occlusal radiograph will be converted to a single
backwards curve on the affected side. There will also be an increased
radiolucency of the alveolar process over the lateral incisor and canine
which occurs due to resorption of the overlying cortex. If appropriate to
demonstrate the cyst’s full extent, the contents may be aspirated and an
aqueous radiopaque medium such as Triosil injected prior to further
radiography.
Because cysts are the most common benign, intra-osseous lesions of
the jaws, there is a tendency to describe any abnormal bone cavity seen in
a radiograph as a cyst or ‘cystic’. The features seen in several different
views should always be studied, in particular an occlusal view which shows
the lateral surface of the lesion where it is covered by subperiosteal new
bone is of importance. If the margin is not entirely smooth the lesion is
unlikely to be a simple cyst and may well be a solid, if benign, neoplasm.
Loss of marginal definition implies a malignant tumour, especially a
carcinomatous.
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Aspiration

Where concern exists as to the nature of a lesion in the jaws, aspiration may
be attempted using a wide bore needle and a 5 or 10 ml syringe after
infiltrating a small amount of local analgesic solution into the overlying
mucosa. It can facilitate aspiration if a narrow bore needle is also inserted
close to the other to avoid the creation of a painful reduction of pressure in
the cavity.
Dentigerous and periodontal cysts usually yield a clear pale straw-
coloured fluid containing varying amounts of cholesterol crystals. These
have a bright glistening appearance which can be seen if the syringe is held
under a beam of light or if some fluid is expressed onto a dry swab. When
haemorrhage into the cyst has recently taken place an opaque, dark brown
fluid will be aspirated. Odontogenic keratocysts contain a creamy white,
viscoid suspension of keratin.
Cyst fluid may be sent for electrophoresis, in which case dentigerous and
periodontal cysts will reveal quantities of albumin and globulin resembling
that found in serum with a total protein in excess of 4:0 g per 100 ml.
Keratocyst contents tend to have much less protein on electrophoresis,
most of which is albumin, but stained smears will show parakeratinized
squames. This may be done by spreading a drop of cyst fluid thinly on to two
cleaned slides, allowing them to dry and staining one with haemotoxylin
and eosin and the other with the rhodamine B fluorescence method. The
accurate diagnosis of a keratocyst may be achieved by a combination of the
electrophoresis and smear techniques, although occasional false positives
with other cysts and cystic neoplasms are possible.
The result of aspiration with an ameloblastoma depends upon the
physical type. Some form a single large cyst from which liquid is readily
aspirated, others are macroscopically multilocular, and if a largish cyst is
penetrated fluid can be withdrawn. Yet others are clinically solid, though
histologically have small cysts. In general the fluid does not contain
cholesterol crystals, though considerable quantities may be formed if the
ameloblastoma has been irradiated, as was the practice in some centres in
the past.
A failure to aspirate liquid from the bone cavity usually means that a solid
tumour is present, though this can happen if the needle is blocked by a
fragment of solid debris or cyst lining. Fresh blood can be aspirated from
vascular cyst walls, vascular solid tumours or from solitary bone cysts
where bleeding from the wall is easily provoked. The ready aspiration of
complete syringe-fulls of venous blood indicates the presence of an
intramedullary cavernous haemangioma. Aspiration of bright red blood
suggests an arterial or arteriovenous malformation, particularly if pulsation
can be appreciated. Uncontrolled haemorrhage from the last two lesions is
potentially life-threatening if full precautions are not taken. An angiogram
must be performed where doubt exists.
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Biopsy
Where there is any question as to the nature of the cyst it should be biopsied
under local analgesia prior to surgery in order to clarify the diagnosis and
surgical management. However, the site for biopsy needs to be chosen with
care if a trustworthy report is to be hoped for and the material sent to a
pathologist familiar with odontogenic lesions. Of course precautions should
be taken to place the biopsy incision so that it can be excised with the lesion
and to facilitate accurate closure so as to prevent infection which will delay
treatment.

TREATMENT
General Considerations
Untreated cysts tend to increase in size and become infected. The presence
of a large cyst within the mandible will weaken it. This makes it likely for a
pathological fracture to occur as the result of an accidental blow on the jaw,
or perhaps when a tooth is being extracted if the operator is unaware of the
intra-osseous lesion.
Where possible functional teeth should be preserved. This will require
the careful assessment of the vitality of all teeth related to the cyst. Pulpless
teeth should be root filled within 24 hours prior to the operation provided
the root canal can be maintained dry while the filling is placed and provided
there has not been a recent acute infection involving the cyst. Root filling the
tooth preoperatively shortens and simplifies the actual cyst operation.
Where these conditions cannot be fulfilled an orthograde root filling may be
placed during the operation and after enucleation of the cyst. To ensure a
good apical seal a large gutta percha point may be condensed so as to
protrude beyond the apex and trimmed flush with a hot plastic. Where this
is not possible because of the presence of a crown or abnormally narrow
root canal the tooth will require an apicectomy and a retrograde amalgam
seal.
Contrary to popular belief vital teeth whose apices are adjacent to the
cyst wall often retain their vitality if the cyst is enucleated with sufficient
care, either because a thin layer of bone remains covering the apex or
because in other cases gentle separation of the cyst sac may leave the apical
neurovascular bundle intact, even though the apex is denuded of bone. Ifthe
root has accessory canals providing a substantial blood supply again the
pulp may survive. In all cases it is important to monitor these teeth
subsequent to the operation by clinical examination, periapical radiography
and serial vitality tests until bone regeneration is complete and the vitality
of the teeth confirmed.
Where there needs to be a delay before operating upon an infected cyst
any acute episodes should be treated with antibiotics and drainage.
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Operative Procedures
Epithelium lined cysts of the jaws may be treated in one of two ways:
a. By marsupialization, which may be performed after removal of part of
the lining or after enucleation of the whole cyst sac;
b. By enucleation and primary closure.
It is the primary closure of the wound rather than the enucleation of the
sac which distinguishes the second procedure from the first, which simply
opens the cavity widely to the mouth or occasionally the maxillary sinus or
nose.

MARSUPIALIZATION
Marsupialization opens the cavity widely to the mouth. The wider the
opening, the shorter the time before undercuts and recesses are filled in as a
result of regeneration of bone and the easier the irrigation and cleansing of
the cavity. The cyst sac beneath the opening is removed so that the raw
margin between lining and oral mucosa soon heals. In the case of
dentigerous cysts the enclosed tooth starts to erupt towards the arch as the
cavity fills in. Where the whole cyst lining is removed and the flap of oral
mucosa is turned into the cavity it granulates, epithelializes and then
reduces in size in the same way.
Marsupialization of odontogenic cysts is probably successful because of
a variety of factors.
a. Once the liquid contents are released, there appears to be an inherent
tendency for the cyst lining to contract probably due to myofibroblasts in
their walls. This allows endosteal bone formation to take place.
b. As the cyst lining shrinks there is also a marginal ingrowth of normal
mucoperiosteum which replaces the capsule with its resorptive potential.
The ingrowing mucoperiosteum may provide additional bone regenerative
factors.
Following marsupialization the patient has a cavity which needs to be
irrigated free of stagnant food debris at regular intervals. It therefore
requires a pack or bung to obturate the opening and prevent premature
closure. If large and left uncovered it may alter the sound of the voice.
Regular follow up visits are necessary to see that the cavity is filling up in a
uniform fashion and to adjust the size of any bung or cyst plug. In a
proportion of cases usually involving the maxilla, the cavity may not fill in
completely and a supplementary procedure will be necessary to eliminate
the residual cavity if it is an inconvenience. In general therefore
marsupialization into the mouth is avoided wherever possible and primary
closure of the oral wound is preferred.
However, marsupialization is still indicated under the following
circumstances:
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1. In a young person, for a dentigerous or pseudo-follicular keratocyst
where marsupialization will permit the eruption of the enclosed tooth or any
underlying developing teeth which have also been displaced.
2. Where a cyst other than a dentigerous cyst has enlarged between
unerupted teeth and the oral cavity. In a child if development of the
displaced teeth has not progressed very far enucleation will expose and
damage the developing tooth germs.
3. Where a large cyst involves the apices of many adjacent erupted teeth
and where enucleation could prejudice the support and vitality of these teeth
or perhaps put at risk a major neurovascular bundle. As has been discussed
above, with care enucleation may be possible without damage to the blood
supply to the teeth even where radiographically it appears that their apices
are incorporated in the cyst capsule.
4. If there is concern that enucleation and primary closure of a large cyst
may lead to a pathological fracture. This is only true if marsupialization can
be accomplished through a more limited bony opening than enucleation,
and if the extraction of teeth, which might cause a fracture, can be
avoided.
5. This method has a particular application in the very elderly or for
patients who are unfit for a general anaesthetic because of advanced cardiac
or respiratory disease or where there are other serious problems such as
haemophilia. It may be feasible to make a modest opening under local
anaesthesia with, if appropriate, simple sedation, where enucleation and
primary closure would not be possible.

The Technique of Marsupialization

Where a substantial area of mucoperiosteum covered alveolar process is
expanded a simple window may be made, removing an oval of mucosa,
bone and underlying cyst wall. The opening must be made as large as
possible compatible with the preservation of adjacent structures and the
cavity packed. The specimen of cyst wall is submitted for histological
examination. If the opening encroaches on the sulcus mucosa it will retract
to expose a wide raw area but later it will contract, reducing the size of the
opening.
In such circumstances a preferable technique is to create an inverted
U-shaped flap based on the buccal sulcus which can be turned into the cyst
cavity covering the margin (Figs. 11.2a and 11.3a). The incision is made
around the anticipated outline of the surgical opening in the bone and cyst
sac. It should leave at least 0-5 cm of continuous gingival margin around
adjacent teeth or 1 cm between the incision and the crest of an edentulous
ridge. The mucoperiosteum is reflected, starting in the lateral corners of the
incision, over sound bone and working gently inwards over the central
bulge. Through an initial opening in the bone the cyst lining is separated
from the underside of the overlying bone (Fig. 11.26) which is to be
removed and the bone nibbled or cut away to form an adequate opening,
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Fig. 11.2. Diagrams illustrating marsupialization of a cyst. a, A U-shaped

incision over the margins of the future cyst opening. b, A mucoperiosteal flap
reflected to reveal a perforation in the cortex. c, Bone removed to uncover the
cyst lining which is incised from within outwards flush with the bone edge. d,
The lining is sutured to the edge of the mucosa. Often the apex of the tooth of
origin protrudes into the cavity and may be amputated flush with the lining. If
un-rootfilled, a retrograde root filling can be inserted. e, The flap is turned into
the cavity and packed into place with ribbon gauze soaked in Whitehead’s
varnish.

cutting the bone back to just underneath the still attached mucosa. A scalpel
is stabbed through the lining against the bone edge and an opening made
into the sac by cutting from inside the cavity out, against the bone margin
(Figs. 11.2c and 11.35). The specimen of lining is sent for histological
examination, the flap is turned in and the cavity packed with half or one inch
ribbon gauze soaked in Whitehead’s varnish or bismuth iodoform paraffin
paste (BIPP) (Fig. 11.2d). The latter is particularly effective in lubricating
the pack and reducing infection but the taste is objectionable and
occasionally produces a rash in those sensitive to iodine. All packs should
be secured by sutures.
It does not matter if the flap overlaps the lining as the cyst epithelium will
be destroyed. Surgical tidiness can be improved by running a continuous
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Fig. 11.3. Left. Marsupialization of a radicular (apical periodontal) cyst arising

from pulpless {1. Note the dark coloured crown. The gum has been incised anda
mucoperiosteal flap raised. Bone has been removed to uncover the cyst lining.
Right. The apex of [1 enters the cavity and has been trimmed exposing the root
filling. The displaced root of |2 is still covered by the cyst lining, the lateral half
of which has been cut away.

catgut suture round uniting the oral mucosa and flap edge to the cut margin
of the cyst before the pack is placed (Fig. 11.2d). Two weeks later the pack
is removed. The patient irrigates the cavity regularly with a disposable
syringe. Food may be kept out of the cavity and the opening prevented from
contracting by a bung fashioned from black gutta percha or a soft acrylic,
attached to a temporary plate.
Large cysts arising in the maxillary incisor region invariably perforate the
bone on the palatal side and the capsule fuses with the underside of the
mucoperiosteum. If such a cyst is marsupialized from the buccal aspect a
deep, narrow slit-like cavity results as the lining fails to separate from the
palatal mucosa. This may also prevent overlying teeth from erupting. In a
child where enucleation would put at risk unerupted teeth a palatal opening
may be made and kept patent by an extension on an acrylic palatal plate.
This usually results in satisfactory cyst regression, eruption of the
permanent anterior teeth and adequate regeneration of palatal bone.
About two-thirds of the cyst lining on average is left in situ by these
techniques, which raises the possibility that more serious disease may be
overlooked if the whole cyst sac is not submitted to the pathologist. Some
ameloblastomas form a single large cyst with the more obvious tumour
tissue in one or more nodules. However, although the whole lesion is an
ameloblastoma, the thinner part of the lining epithelium is most likely to be
mistaken for a keratocyst by an inexperienced pathologist. In all cases
before the cyst is packed the cavity is irrigated and aspirated dry and the
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 CYSTS OF THE JAWS
inner surface of the lining inspected for mural nodules. If one is seen it
should be removed for section. A marsupialized ameloblastoma will heal in
the same way as a benign cyst for a period of time, then fresh extension will
occur and fleshy tumour tissue will appear in the cavity.
Carcinoma arising focally in odontogenic cyst linings is recognized as a
very rare occurrence. It is most unlikely that malignant change would be so
localized that some indication would not be seen in a reasonable segment of
buccal cyst wall, nor indeed that the presence of a carcinoma would not
soon be apparent within the opened cavity.
Contrary to popular belief keratocysts will respond satisfactorily to
marsupialization and probably with a not much higher risk of recurrence
than after enucleation. Indeed this may be the treatment of choice where
enucleation would result in the loss of sound teeth or disturb erupting teeth
in a child. Should a recurrence occur it will be superficially placed in the
alveolus and may be spotted while still small if regular recall is practised,
and it can be dealt with quite simply by enucleation.

ENUCLEATION AND PACKING

Where enucleation of the cyst lining is undertaken but previous infection in
a large cyst suggests that primary closure of the wound would not be
successful, a flap is turned in and the cavity packed. The cavity heals with
granulation tissue until epithelialization is complete. Reduction in size
takes place as after marsupialization with retention of the deeper part of the
lining. Loose packing after enucleation is also used as a secondary measure
where the wound breaks down after an attempt at primary closure.

ENUCLEATION AND PRIMARY CLOSURE

Where enucleation and primary closure is performed, once the flap has
healed soundly the patient is often unaware of the healing cavity and
regeneration of bone takes place from all its aspects. Also infrequent follow
up appointments are required to monitor healing by radiography. Bone
regeneration is often complete within six months for small cysts and one
year for large ones. During this time also the vitality of adjacent teeth will be
confirmed.
Keratocysts of course need subsequently to be reviewed annually for at
least five years in order not to overlook recurrence. In general greater
surgical skill is required for successful enucleation and primary closure, a
greater volume of tissue will need to be anaesthetized if a local anaesthetic
is used, or alternatively a general anaesthetic will be required.
Successful primary closure requires a different design of flap to that
which is suitable for marsupialization so the decision as to the type of
operation to be performed must be made before the surgeon starts. A short
postoperative stage, less frequent follow up visits and a better contour to the
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Fig. 11.4. Diagrams illustrating the enucleation of a cyst and primary wound
closure. a, A three-sided flap is reflected. b, Bone is removed to uncover the cyst
and the lining separated from the bony cavity. c, The lining removed. The apex
of root-filledI] is seen. Note the broad zone of bone around the opening. d, The
flap is sutured into place.

healed alveolar process all make this the preferred procedure where it is
technically possible.
The operation can be performed under local or general anaesthesia,
almost always operating intraorally (Fig. 11.4). Where general anaesthesia
is available it is preferable for large cysts. If a general anaesthetic is used,
infiltration of the operative site with 1 : 100000 adrenaline in saline will
help to reduce haemorrhage and facilitate dissection. Buccal flaps are best
designed with a gingival margin incision, preserving the interdental
papillae. One or two relieving incisions extending as curved arcs into the
buccal sulcus will be needed to provide adequate access and are made on
sound bone. The gingival papillae facilitate replacement of the flap and
provide tough tissue for suturing. Where the ridge is edentulous the incision
is carried along the crest of the ridge.
In order to provide a broad zone of contact for the flap and a valve like
closure of the wound the incision should be planned well wide of the
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 CYSTS OF THE JAWS

a b

Fig. 11.5. a, A generous three-sided flap has been raised uncovering a

perforation in the expanded bone and the cyst lining. b, The bone has been cut
away to improve access and the cyst sac enucleated.

proposed opening in the bone. Reflection of the flap should commence

firmly under the periosteum of the anterior buccal incision, working parallel
to the gingival margin and undermining and detaching the papillae as the
elevator is pushed distally. Where the cyst has eroded the overlying bone
and become adherent to the underside of the flap, or at the site of a sinus or
previous drainage incision difficulty may be encountered in separating the
two layers. Patient pressure with the periosteal elevator close to the point of
reflection from the cyst lining, perhaps with a layer of gauze swab around
the periosteal elevator, will establish a plane of cleavage. Particularly
adherent spots will require sharp dissection with scalpel or dissecting
scissors.
Reflection should continue until sound bone has been reached all round
the intended bony opening. Should the overlying bone be intact an opening
should be made using chisels or a bur. A rose-head bur will cut out a disk of
bone without puncturing the cyst lining which makes separation of the sac
easier. The lining is separated with a Howarth’s rougine from under the
margin of the opening, which facilitates the removal of more bone with
rongueurs until adequate access for enucleation of the sac has been created
Cig ies):
Enucleation can be accomplished with a variety of instruments
depending upon access. In large cysts a Howarth’s rougine or a Ward’s
periosteal elevator are suitable. For smaller ones a Mitchell’s trimmer or a
large bi-angled spoon excavator, supplemented by curved Warwick James’
elevators are better. The edge of the instrument slides over the surface of the
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bone, with the convex back towards the lining, lifting it off. A two-handed
technique is particularly helpful peeling the capsule from the bone by using
a blunt ended fine surgical sucker like the Kilner and retracting it with a
periosteal elevator in the other hand. This ensures a bloodless field and a
clear view of the site of dissection.
In general difficult and adherent areas, such as where the lining is fused to
the nasal floor, are left to the last, if necessary emptying the sac to see the
bottom of the cavity. Care should be taken with mandibular cysts which
have resorbed the walls of the inferior dental canal. Separation of the lining
from the neurovascular bundle is usually straightforward if it is peeled off
along the length of the bundle, not across it. This also applies to large
maxillary cysts where blind, forceful dissection may not only damage the
infra orbital nerve, but produce an inconvenient and obscuring haemorrhage
from its vessels.
Some difficulty may also be experienced where the lining is adherent to
the periodontal membrane around the apices of teeth, hence the need to
apicect non-vital teeth. Teeth that prior to the operation respond to vitality
tests may remain vital if the lining is peeled off the apices along their length
without scraping either root or bone. If possible the sac is removed in one
piece as this ensures none is left behind. The bony cavity is irrigated and
inspected for any retained fragments of lining, then packed with saline
moistened ribbon gauze. This is removed after 5 minutes and the wound
checked for haemostasis. Any oozing patches are treated with Abseal.*
This way it is hoped the clot will be confined to the cyst cavity and the flap
will adhere firmly to the surrounding bone. The wound is closed with
care.
Where a maxillary cyst has produced a palatal swelling rather than a
buccal one a palatal flap may be raised from the gingival margin, an opening
made in the bone and the cyst lining enucleated from this aspect with less
risk of damage to the standing teeth. After the flap has been sutured back in
place a small piece of soft black gutta percha is applied to the fitting surface
of a previously made acrylic plate and pressed into place. The gutta percha
corrects the contour of the palate and the plate holds the mucosa close to the
bone around the margins (Fig. 11.6).
Large cysts of the maxilla invaginate the maxillary antrum and are
covered by a thin shell of subperiosteal new bone, between the cyst capsule
and the antral lining. When the cyst occupies most of one side of the maxilla
the antrum is reduced to a narrow slit above and behind the cyst from which
the drainage of secretions is impaired. The stagnant secretions are likely to
become infected from time to time. If a simple enucleation and primary
closure is performed remodelling will be prolonged. It is better to remove
the partition between the cyst and the residual antral cavity.

*Ethicon Ltd., P.O. Box 408, Bankhead Ave, Edinburgh EH11 4HE.

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 CYSTS OF THE JAWS

Fig. 11.6. Top. An apical, periodontal cyst from pulpless |2 is expanding

palatally. [2 has been root-filled preoperatively. The palatal mucosa has been
reflected and bone removed to uncover the cyst. Bottom. The cyst has been
enucleated and the flap sutured back into place. Palatal contour has been
restored and will be maintained by a gutta percha lined acrylic plate.

After enucleation of the cyst lining the partition is penetrated outwards

towards the zygomatic extension of the antrum. A Howarth’s rougine is
slipped into the antral cavity and the thin partition fractured away. The
antral lining which previously covered the partition should be left attached
by one margin, but the thin bone nibbled back flush with the wall. Then the
flap of antral lining can be pressed into contact with the bare bone of the cyst
cavity. A trochar and cannula or curved Spencer Wells forceps is passed
through the nostril, under the inferior turbinate and into the cyst cavity to
create an intranasal antrostomy for drainage and a length of Yeats drain
pulled through into the nose. It is secured by a stitch to the ala of the nose.
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 ORAL SURGERY, PART 1
The oral wound is carefully closed. This technique prevents the accumula-
tion of haematoma and ensures subsequent drainage from the new antral
cavity. The drain is removed after about 48 hours—it is easier and more
comfortable for the patient to draw out a soft plastic drain than the gauze
pack which is sometimes used.
If large cyst cavities are not partly decompressed after enucleation they
become overfilled by haematoma, creating tension on the suture line which
breaks down. Large mandibular cysts, i.e. those greater than 5cm in the
long axis, should be drained. The size of the dead space in the cyst cavity
should be reduced by removing as much as possible of the thinner and more
expanded wall, which is usually the buccal one, and a vacuum drain is
inserted, passing it down and out through the submandibular skin. The
intraoral wound must be closed with special care to evert the wound
margins and produce maximum contact between the raw flap surfaces.
Either interrupted vertical mattress sutures or a continuous horizontal
mattress, oversewn with a continuous plain stitch, will achieve a hermetic
seal. The drain should be left for at least 24 hours. If the cyst is in the ramus
the vacuum will pull the deeper part of the masseter into the cavity further
reducing the dead space.
A special comment is required for the keratocyst. Recurrences variously
reported as occurring following 10-62 per cent of operations are due to a
variety of causes. Because the cyst lining is thin and easily torn small
amounts of cyst lining may be left inadvertently in the bony cavity. Patience
and gentleness will help to reduce the chance of this and careful inspection
after irrigation should enable the operator to remove any remaining
fragments. The bimanual sucker and periosteal elevator technique aids
precise dissection. Not infrequently large cysts extend up the ascending
ramus into the coronoid process and become inaccessible. Stripping off the
temporalis tendon and performing a coronoidectomy with a fissure bur will
open the cavity to direct vision. All cyst linings are difficult to separate from
the periosteum where the bony wall is perforated. The thin keratocyst lining
is particularly adherent and careful, sharp dissection may be required.
It is possible that the microscopic daughter cysts which can be found in
the capsule may extend into the cancellous bone and be left behind when the
lining is enucleated. It is possible that the incidence of this type of
recurrence can be reduced by skimming off a shallow layer of bone from the
cancellous component of the cavity wall. This is accomplished with a large
round bur, using minimal pressure and cutting under a generous water
spray. Care must be taken not to damage adjacent structures, particularly
adjacent nerves, or to implant living cells into the freshly opened cancellous
spaces. The necrosis of an uncertain zone of wall with caustic chemicals or
cryosurgery is not in keeping with good surgical practice, particularly as ina
substantial percentage of cases no recurrence will occur even without such
treatment. Such imprecise methods may unnecessarily damage adjacent
structures.

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A small proportion of keratocysts are multilocular and develop

multicentrically from a zone of dental lamina. Provided that there are only a
modest number of cavities and that care is taken to enucleate all the cysts,
many will heal without further trouble. It should not be forgotten that new
cysts may arise in adjacent unstable dental lamina, but recurrence from this
cause will not be prevented by the drastic measures mentioned above. In
patients with the multiple cyst syndrome further cysts may arise anywhere
in the dental lamina and new cysts appear at any age though the maximum
incidence is during the second decade. Only careful long-term follow up will
permit these to be dealt with when small. They are not preventable.
Attention has been drawn to dental lamina residues in the mandibular
retromolar mucosa. In the case of ramus cysts this mucosa can be excised
before the wound is closed, but recurrences rarely arise superficially at this
site. The notorious reputation for the keratocyst to recur has also
encouraged some surgeons to excise the mandible where there is a large
lesion. This may be justified where there is a multitude of cysts which would
defy individual enucleation, but many large keratocysts are unilocular
despite their appearance in radiographs due to ridges on the wall.
Large cysts can be enucleated by gentle, diligent surgery, so that such
radical treatment for a non-malignant condition is generally unnecessary.
Careful follow up enables any small recurrences to be detected early and
removed, and the overall morbidity for the patient is considerably reduced.
Indeed in some cases where subperiosteal resection with bone grafting of
the defect has been carried out, recurrence within the graft has been
reported.
Where the cyst has penetrated out to the periosteum it is just as difficult to
separate the periosteum from the lining while resecting the mandible as
during enucleation of the lining from within the bony cavity. If patches of
lining are left on the periosteum then recurrence in the graft is virtually
certain to occur so that the more radical approach does not necessarily have
a therapeutic advantage.
Some recurrences have occurred down in the neck suggesting implanta-
tion of free fragments as a cause. Careful and copious irrigation of the
wound before closure and care to avoid soiling the wound with cyst contents
and fragments of lining should help to prevent this type of complication.

ENUCLEATION AND PRIMARY CLOSURE

WITH BONE GRAFTING
The highly vascular periosteum and endosteum of the jaws have remarkable
powers of bone regeneration so that large cavities are filled with little
evidence of the original defect except for a delicate radial pattern to the
bone trabeculae. This makes the grafting of these cavities with autogenous
cancellous bone chips largely unnecessary. The use of other materials such
as absorbable haemostatic materials or processed stored bone of various
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types as cavity fillers is contraindicated as they interfere with normal

healing. Just occasionally following enucleation there is a local loss of ridge
contour which will impair the success of a subsequent prosthesis, and under
such circumstances chip bone grafts may be justified, but there is always a
risk of wound breakdown and of their loss through infection.

PATHOLOGICAL FRACTURES
Intra- or postoperative fracture of the mandible following the removal of a
large cyst is uncommon because compensatory subperiosteal bone
deposition keeps pace with the expansion of such slow growing benign
lesions. Thus despite a dramatic, large, radiolucent cavity to be seen on a
rotational tomographic radiograph, there is invariably substantial amounts
of bone buccally, lingually and inferiorly to maintain continuity.
However, where the mandible is generally thin and fragile, splints or arch
bars should be prepared preoperatively and the patient warned of the risks
to be faced. Should a fracture take place, the cavity should be packed
with Whitehead’s varnish impregnated ribbon gauze and the mandible
immobilized.
Occasionally a pathological fracture occurs postoperatively, usually
when the oedema and discomfort have subsided and the patient chews more
adventurously, or is accidentally struck. Where there is no displacement,
satisfactory healing will often take place merely with a regime of soft diet
and reassurance. Otherwise apply intermaxillary fixation, open up the
operation site, reduce the fracture and pack the cavity to splint the
fragments in alignment.

NASOPALATINE CYSTS
These cysts are enucleated after the reflection of a palatal flap, incising
around the gingival sulci of any standing teeth. Avulsion of the vessels
entering the incisive fossa from the flap as it is raised usually leads to
retraction of their walls and spontaneous cessation of bleeding. If this is
delayed the vessels may be crushed with a mosquito artery forceps. The
cyst is then peeled from the cavity with a narrow periosteal elevator or the
curette end of a Mitchell’s trimmer. The terminal fibres of the long
sphenopalatine nerves are usually spread over the surface of the capsule.
These have to be divided to free the cyst sac and this can be painful under a
local anaesthetic. A few drops of solution injected in the top of the sac a few
minutes before this is done will help.
It is worth remembering that small ‘cysts’ (i.e. less than 7mm) seen in
radiographs often prove to be deep incisive fossae. In the absence of
swelling or symptoms, radiographic review is preferred to surgery. The
palatal flap may be sutured back with sutures between the palatal and
buccal gingival papillae. Some operators prepare an acrylic plate retained
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with cribs to prevent haematoma formation. If this has been omitted a small
stab incision made in the midline of the flap over the bony cavity will help to
prevent excessive distention of the flap.

SOLITARY BONE CYSTS

Surgical exploration should be carried out as described for enucleation in
order to confirm the diagnosis. It is wise to submit the segment of bone
removed to gain access to the cavity for histological examination.
Occasionally this has a structure resembling fibrous dysplasia. Currettage
of the bony walls leads to haemorrhage and disrupts the thin connective
tissue covering. Closure of the wound usually produces rapid healing.
However, these patients should be kept under review as occasionally a
recurrence takes place. Recurrence is not uncommon where the patient is a
child, but is unusual after skeletal growth is complete.

FISSURAL CYSTS
These rare cysts are best enucleated and of course submitted for
histological examination.

POSTOPERATIVE FOLLOW-UP
This will be required for:
1. Keratocysts in order to detect early and deal with any recurrence;
2. Associated teeth in order to ensure that latent loss of vitality does not
lead to an abscess or further cyst formation;
3. Unerupted teeth which may require exposure and orthodontic
treatment if their eruption has been disturbed.

SUGGESTED READING
Craig G. J. (1976) The paradental cyst: a specific inflammatory odontogenic cyst.
Br. Dent. J. 141, 9-14.
Harris M. (1978) Odontogenic cyst growth and prostaglandin-induced bone
resorption. Ann. R. Coll. Surg. 60, 85-91.
Harris M. and Toller P. (1975) Pathogenesis of dental cysts. Br. Med. Bull. 31, 2,
159-163.
Harvey W., Cuat Chen F., Gordon D. et al. (1984) Evidence for fibroblasts as the
major source of prostacyclin and prostaglandin synthesis in dental cysts. Arch.
Oral Biol. 29, 223-229.
Hodson J. J. (1957) Observations on the origin and nature of the adamantinoma
with special reference to certain muco-epidermoid variations. Br. J. Plast. Surg.
10, 38-59.
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 ORAL SURGERY, PART 1
Killey H. C., Kay L. W. and Seward G. R. (1977) Benign Cystic Lesions of the
Jaws, their Diagnosis and Treatment, 3rd ed. Edinburgh, London and New
York: Churchill-Livingstone.
Main D. M. G. (1970) Epithelial jaw cysts, a clinico-pathological reappraisal. Br.
J. Oral Surg. 8, 114-125.
Matejka M., Porteder H., Ulrich W. et al. (1984) Prostaglandin synthesis in dental
cysts. J. Maxillofac. Surg. 23, 190-194.
McHugh W. D. 91961) The development of the gingival epithelium in the monkey.
Dent. Practit. 11, 314-324.
Pindborg J. J. and Kramer I. R. H. (1971) Histological Typing of Odontogenic
Tumours, Jaw Cysts and Allied Lesions. World Health Organization.
Rule D. C. (1976) Dermoid cyst of the lower lip. Br. Dent. J. 141, 116-119.
Shear M. (1983) Cysts of the Oral Regions, 2nd ed. Bristol: Wright.
Toller P. A. (1948) Experimental investigation into factors concerning the growth
of cysts of the jaws. Proc. R. Soc. Med. 41, 681-688.
Tonge C. H. and Luke D. A. (1976) Dental anatomy—cleft palate. Dental Update
(May/June). 138-143.
Valdehaug J. (1972) A histologic study of experimentally induced radicular cysts.
Int. J. Oral Surg. 1, 137-147.

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 CHAPTER 12

SOFT-TISSUE SWELLINGS OF THE ORAL MUCOSA

SWELLINGS OF THE ORAL MUCOSA

A variety of superficial swellings can be found arising from and beneath the
oral mucosa most of which are inflammatory hyperplasias and granulomas.
A completely logical classification of the tumours on aetiological grounds is
not possible for reasons which will become apparent. A practical grouping,
however, can be made partly based on the site of origin of the lesion and
partly on the basis of aetiology and histological appearance.
As an initial step they can be divided into those which arise from the
mucosa covering the alveolar processes and those which arise elsewhere in
the oral cavity (see below). Some of those which arise from the alveolar
process mucosa have the word ‘epulis’ as part of their name, but others do
not. An epulis is a lump arising from the gingiva. Those which arise from the
masticatory mucosa on the alveolar process clearly fall into this group, but
those which arise from the masticatory mucosa of the palate are not
classified as epulides. Some lumps have different histological appearances
at various stages in their evolution so that a histological grouping can
contain several entities.
Despite their apparently benign character it is essential that all masses
which are excised should be sent for histological examination.

a. Swellings of the gingiva

i. Discrete (epulides)
Fibrous epulis
Denture-induced granuloma (denture hyperplasia)
Pyogenic granuloma
Pregnancy tumour
Giant cell epulis
Haemangioma
Neurofibroma
ii. Diffuse enlargement
Drug-induced
—diphenylhydantoin
—cyclosporin A
Fibromatosis gingivae
Fibromatous enlargement of the tuberosities
Sarcoid
Chrohn’s disease
Wegener’s granuloma
Zoi)
 ORAL SURGERY, PART 1
b. Swellings of the buccal and palatal mucosa
Fibro-epithelial polyp
Fibroma
Papilloma
Neurofibroma
Lipoma
Crohn’s Disease
c. Swellings of the tongue
Pyogenic granuloma
Fibro-epithelial polyp
Median rhomboid glossitis
Lymphoid nodules
Lymphangioma
Haemangioma
Granular cell myoblastoma
Amyloid

Fig. 12.1. A fibrous epulis arising in relation to periodontally involved

SWELLINGS OF THE GINGIVA

Fibrous Epulis
Most fibrous epulides arise from an interdental papilla. They arise as a
hyperplastic response to chronic irritation or trauma, usually where there is
poor oral hygiene. The irritant factor may be the sharp edge of a carious
cavity, or of an inadequately contoured restoration, or calculus, particularly
subgingival calculus, and plaque. As the inflammatory mass enlarges it
bulges out on either the buccolabial or palatolingual side and overlaps the
adjacent teeth and alveolar process (Fig. 12.1). Where there is a large
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approximal, carious cavity in a posterior tooth the mass may enlarge to fill
the cavity. It is then described as a gum polyp, in contrast to a pulp polyp
which develops from a widely exposed pulp.
Initially the inflamed hyperplastic papilla is soft and red and bleeds
easily. Even when the enlargement has become too great to be regarded
merely as a hyperplastic papilla the lump is still soft and vascular and
composed of immature, cellular, fibrous tissue supplied by many dilated
capillary blood vessels and infiltrated by mixed inflammatory cells.
Histologically at this stage it is indistinguishable from a pyogenic
granuloma. In the course of time the mass becomes larger, up to 1-5—2cm in
diameter, but rarely more than 2cm, pale pink in colour and firm.
Some fibrous epulides are sessile at first sight, but a blunt, periodontal
probe can be passed underneath the lump from various angles to define the
narrow point of attachment. Mature fibrous epulides become less vascular,
are covered with stratified squamous epithelium and are composed of a
mature collagenous fibrous tissue. Inflammatory cells are seen only in
relation to sites of irritation or ulceration.
From time to time fibrous epulides are abraded during mastication and
develop an ulcerated surface which may be sore enough to encourage the
patient to seek professional help. Sometimes the ulcerated and inflamed
mass resembles a malignant neoplasm at first sight. Woven bone develops
in the centre of long standing fibrous epulides and may increase in amount
until only a small zone at the periphery remains unossified.

Treatment
Simple conservative local excision is sufficient to remove the epulis. Where
it is attached by a narrow peduncle this is sectioned parallel with the
adjacent surface. Those attached by a broad peduncle or which are sessile
and involve the interdental tissues require incision down to bone
immediately around the attachment, and the mass with enlarged papilla
removed together.
The important aspect of treatment is to identify and remedy the source of
chronic irritation. This is usually obvious once the epulis is removed, if not
before. Failure to do this and to establish adequate regular cleansing of the
now open interdental space will result in recurrence. A periodontal pack is
usually needed to control ooze from the raw surface and to protect it until it
has healed.

Denture Induced Granuloma (Denture Hyperplasia)

A denture induced granuloma occurs as a hyperplastic response of the
underlying tissues to the flanges of a mobile, ill-fitting denture. The
hyperplastic mass may develop opposite just one part of the denture, such
as the lower labial flanges or in relation to the entire periphery. Mostly the
flanges dig into and irritate the sulcus tissues as a result of shrinkage of the
alveolar ridge. Occasionally a local expanding intra-bony lesion such as a
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Fig. 12.2. A denture induced granuloma 4-1| region. The denture flange fits in
the groove between the two components. The inner one fills the space between
the denture flange and the resorbed ridge. It is red, granular and infected with
candida. There is a large and small component to the outer part which fits over
the denture flange.

cyst, or even more rarely a carcinoma from the antrum, causes the denture
to rub and produce a hyperplastic mass which disguises the primary
lesion.
Where there has been ridge resorption the hyperplasia develops as two
adjacent and parallel masses with a groove in between in which the denture
flange fits. One mass occupies the space beneath the denture and the other
arises at the outer margin of the flange and overlaps it (Fig. 12.2).
Sometimes in the lower anterior region there are successive rows of
hyperplastic tissue extending from the ridge out into the sulcus and even
onto the inside of the lip. Each layer of tissue is pale pink in colour and firm,
sometimes with a granular surface. It is thicker in the centre but tapers
towards the ends and is attached at one edge to the sulcus mucosa by a long,
narrow, linear peduncle.
Similar lesions may develop across the palate at the posterior border of a
full upper denture and on the mucosa overlying a resorbed anterior
maxillary ridge which has been the subject of chronic trauma from lower
standing natural teeth.
The leaf like pedunculated fibro-epithelial polyps of the palate always
develop under a denture so can be looked upon as a form of denture induced
granuloma. They are attached by a small peduncle and presumably would
be spherical or pear-shaped were they not flattened by the palate of the
denture. When the plate is removed they are seen to lie in an indentation in
the palatal mucosa.
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ia 12.3. A pyogenic granuloma arising in relation to a recently erupted

4.

These lesions are primarily inflammatory in origin, perhaps developing

at the margin of sites of repeated ulceration, and the vast majority remain
quite benign. Occasionally areas of white or speckled leukoplakia develop
on a hyperplastic lesion which may be infected by Candida albicans.
Treatment is dealt with in Chapter 4.

Pyogenic Granuloma
Like the fibrous epulis this lesion arises in response to chronic irritation and
non-specific infection. Calculus, plaque, overhanging cervical margins of
restorations, food impaction in interdental embrasures and periodontal
pockets are common causes. They also arise where a deciduous molar has
recently been shed, but has left behind a sharp fragment of dentine and
enamel or a root. The deep crevice between the gingival margin and the
crown of an incompletely erupted tooth, if infected, can also give rise to a
pyogenic granuloma (Fig. 12.3).
Most lesions present as a sessile or pedunculated vascular mass with an
ulcerated surface. They are purplish-red in colour, painless and soft,
enlarge quite rapidly, but only occasionally exceed 1 cm in diameter (except
during pregnancy—see below). Histologically they are composed of
immature and very vascular fibrous tissue infiltrated with mixed acute and
chronic inflammatory cells. Typical lesions most often appear in children
and young adolescents where they are seen in circumstances similar to
those which produce fibrous epulides in older adolescents and adults.
Young, immature fibrous epulides, it will be remembered, are very
similar in clinical features and histological appearance but the typical
pyogenic granuloma will retain these features over a long period of time
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while achieving a size similar to the mature fibrous epulis. The justification
for describing this lesion as a separate entity is that some can retain their
vascularity and softness over several years, including examples seen in men
and non-pregnant women. On the other hand, it is also probable that some
of the lesions which start in childhood as pyogenic granulomas, subsequently
mature as fibrous epulides as the patient gets older.
Occasionally a vascular antral polyp may prolapse through an oroantral
fistula created by the extraction of an upper molar and may be confused
with a pyogenic granuloma. However, this lesion is initially very soft and
may be displaced upwards into the antrum again with a blunt probe. It is
important to remember that exuberant granulation tissue is seen over
infected sequestra and foreign bodies or at the entrance to discharging
sinuses which may be overlooked. These lesions rapidly regress if the
infected body is removed or if drainage from the sinus ceases.
Pyogenic granulomas can be looked upon as a form of exuberant
granulation tissue which proliferates to form a substantial mass, is covered
by stratified squamous epithelium and persists over a considerable period of
time.
A preoperative radiograph will confirm the presence or absence of a
retained root, a tooth fragment or an erupting tooth.

Fig. 12.4. A pregnancy tumour (epulis) in the lower incisor region. The mouth is
generally clean and the gingival margins healthy, but calculus has accumulated
on the teeth adjacent to the epulis and the local gingival margins are
inflamed.

Treatment
The lesion is infiltrated with local anaesthetic and excised, curetting away
any remaining fragments at the base. The resultant wound is dressed with a
periodontal pack. As with fibrous epulis the underlying irritant factors must
be dealt with and poor local oral hygiene corrected.
Some lesions in the premolar region in children tend to recur. This
usually ceases once the adult teeth have fully erupted. If the causative factor
is removed or corrected, but the epulis is not removed, both the pyogenic
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granuloma and the fibrous epulis tend to shrink, but rarely disappear
completely.

Pregnancy Epulis (Pregnancy ‘Tumour’ or Granuloma)

This lesion is a variant of the pyogenic granuloma which arises in pregnancy
and has similar clinical and histological appearances (Fig. 12.4). There is
an exaggerated inflammatory response to plaque in some pregnant women
which results in pregnancy gingivitis and which is thought to be due to
increased levels of circulating progesterone.
Pregnancy tumours tend to arise from the third month of pregnancy
onwards, but are most often seen in the last trimester. They may develop in
a patient who has a generalized pregnancy gingivitis or even where the oral
hygiene is good, but where there is some local irritative factor.
Patients with pregnancy gingivitis tend to abandon oral hygiene measures
as tooth brushing makes the gums bleed and is painful. A pregnancy tumour
also is vascular, ulcerates readily and bleeds in response to minor trauma,
so plaque and calculus soon accumulate locally, adding to the irritation.
Occasionally the pregnancy granuloma may develop into a sizeable
mass; however, even if untreated these florid lesions regress to a relatively
avascular fibrous epulis after delivery. Smaller lesions may disappear
completely.

Treatment
A professional scale and polish, the re-establishment of tooth cleaning with
a soft toothbrush and floss and plaque control with chlorhexidine dental gel
are the first measures in treatment. Irritant factors local to the pregnancy
tumour should be sought and removed.
Large and haemorrhagic granulomas which are a nuisance to the patient
should be excised under local anaesthesia. A unipolar cutting electrode as
used for gingival surgery is ideal and reduces haemorrhage which otherwise
can be quite brisk and on occasions profuse. A firm gingivectomy pack both
covers the raw wound and controls postoperative ooze. Any recurrence is
best left untreated until after delivery.

The Giant Cell Epulis

The term giant cell reparative granuloma was used to distinguish the
intraosseous giant cell jaw lesion from the osteoclastoma of long bones.
Histologically the epulis is remarkably similar to the intraosseous lesion
and has therefore been referred to as the peripheral giant cell granuloma.
This epulis is much less common than the fibrous epulis or the pyogenic
granuloma but also seems to arise in relation to local sources of gingival
irritation. They present as a pedunculated lesion, but usually with a broad
peduncle, and vary from a firm pink fibrous-looking lesion to a red,
haemorrhagic, or mottled purplish colour (Fig. 12.5). They are firmer than
a pyogenic granuloma but softer than a mature fibrous epulis, can enlarge
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Fig. 12.5. A giant cell epulis related to a retained root. It is dusky purple in
colour.

rapidly, but rarely exceed 3cm in diameter, and are more common in
females then males.
Radiologically there may be a localized shallow resorption of the surface
of the underlying bone. The lesion must be distinguished from the
subperiosteal form of the central giant cell granuloma, which is more often
seen in the canine premolar region in children and young adolescents at
puberty. The subperiosteal giant cell granuloma presents as a bulky
submucosal swelling which overlies a laterally spreading, intrabony lesion
which often involves the developing teeth. As the bone on just one aspect of
the alveolar process is destroyed the extent of the involvement may not be
obvious in radiographs. By comparison the epulis involves only the gingival
mucosa.
Histologically groups of osteoclast-like multinucleate giant cells are seen
in a spindle cell stroma which contains many thin walled vessels and
macrophages. Haemorrhage into the tissues as a result of minor trauma is
common. The lesional tissue is not encapsulated but demarcated by a
narrow zone of subepithelial connective tissue. At the base the lesional
tissue is usually in contact with the underlying, interdental bone. Small
amounts of woven bone may develop in the deeper and more mature
parts.
Giant cell epulides are occasionally a feature of hyperparathyroidism in
the same way as intrabony ‘brown tumours’ and so fasting serum calcium,
phosphorus, alkaline phosphatase and an immunoparathyroid hormone
assay, together with a 24-hour urinary calcium and hydroxyproline
estimation, are necessary to exclude this disorder.

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Treatment
Local excision, light curettage of the underlying bone and the application of
a surgical pack is adequate treatment, with of course removal of any irritant
factor.

Congenital Epulis
The congenital epulis is present in the neonate from birth as a pedunculated
mass which is large in proportion to the size of the mouth and attached to
one of the gum pads. The base of the peduncle is usually broad, but some
mucosa can be conserved from its margins to close the defect resulting from
its excision.
The histology shows large closely packed cells containing fine acidophilic
granules. The nature of the lesion is controversial and has been looked upon
as a form of granular cell myoblastoma, a fibroblastoma, or a dental
hamartoma (a malformation resembling a neoplasm caused by defective
tissue combination or maturation). A connection has been described with
the enamel organ of an underlying developing tooth. A rare type of
ameloblastoma features similar granular cells so this may be an analogous
change in cells of odontogenic epithelium origin.

Treatment
It is easily excised without risk of recurrence.

Haemangiomas
These occasionally present as a small localized sessile or pedunculated
hamartomatous gingival swelling. They may be excised for histological
examination, but if they recur can be treated by cryosurgery. They can be
distinguished from a pyogenic granuloma which they resemble by the way
that they can be emptied of blood with pressure. Incidently, gingival
pyogenic granulomas are sufficiently vascular that they may be reported as
a capillary haemangioma by a general pathologist unfamiliar with oral
lesions.
Diffuse Gingival Enlargements
Drug-induced Gingival Hyperplasia
A diffuse, firm hyperplasia of the gingiva may occur as a result of
anticonvulsant therapy with diphenylhydantoin (Epanutin, Dilantin
sodium). The incidence appears to vary from group to group and may be as
high as 50 per cent. The swelling, which starts with the interdental papillae,
is confined to the gingival margins of erupted teeth and tends to be pink and
firm and non-haemorrhagic, but occasionally bleeding and ulceration do
occur. The enlargement may become so gross as to cover the surfaces of the
teeth. The gingival mucosa is enlarged as a result of a substantial
proliferation of collagen fibres. The overlying epithelium features down-
growths of the rete pegs into the underlying corium. In approximately 12 per
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cent of patients root deformities such as apical resorption or spindly
narrowing are also seen as a result of the drug interfering with tooth
formation.
Treatment consists of surgical removal by gingivectomy to eradicate the
soft tissue mass which can be prevented from recurring by meticulous
plaque control. Unfortunately this may not be feasible with severely
affected epileptic patients incapable of personal oral hygiene. With the use
of alternative anticonvulsant drugs this unexplained phenomenon may be
avoided.
A similar gingival hyperplasia is induced by the use of cyclosporin A for
immunosuppression. This drug is often used in renal, bone marrow, liver
and heart transplantation, and some 25-30 per cent of kidney transplant
and 2 per cent of bone marrow transplant patients develop the gingival
enlargement. Once it commences it develops quite rapidly and is softer than
that seen in Epanutin hyperplasia where the hyperplasia evolves slowly.
Stringent oral hygiene measures effect only marginal control and
substantial haemorrhage can accompany gingivectomy. Interestingly,
hypertrichosis may also occur with the use of this drug.

Fibromatosis Gingivae (Hereditary Gingival Fibromatosis)

This is a rare condition in which there is a diffuse fibrous overgrowth of the
gingiva which may be limited to the posterior segments or involve the whole
gingival margin. The mode of transmission is usually a dominant trait,
although sporadic cases present. It may also be associated with hypertri-
chosis and mental retardation. The condition is rarely present at birth and
most commonly becomes apparent with the eruption of the permanent
dentition. The condition may be related to other benign but troublesome
fibromatoses occuring in childhood and adolescence elsewhere in the
body.
Treatment is by gingivectomy which in adult patients may be permanently
successful. In other cases the hyperplastic tissue recurs and may even
produce a thickening on the edentulous ridge after all the teeth have been
extracted.

Fibromatous Enlargement of the Maxillary Tuberosities

The enlargement affects the mucoperiosteum on the palatal and distal
aspects of the 2nd and 3rd molars more than the buccal tissues. It can
produce substantial, bilateral, hard, rounded fibrous masses which create
false pockets against the crowns of the adjacent molars. Similar, but less
bulky hyperplasia may affect the lower retromolar pad and the lingual
gingival tissues adjacent to the lower molars. While there is some similarity
to gingival fibromatosis there appears to be no connection with the
genetically determined generalized enlargement. The tuberosity masses, if
large may interfere with speech and swallowing and prevent the fitting of
dentures. In time true pocketing may develop as a result of food impaction

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between the enlarged gum and the molar teeth and accumulation of plaque.
For treatment see Chapter 4.

Fig. 12.6. A diagram illustrating the removal of a fibro-epithelial polyp from the
inner aspect of the cheek. A stitch is inserted into the polyp which is drawn
gently away to expose the pedicle. The pedicle is divided close to the lump and a
mattress suture inserted which deliberately picks up the tissues either side of the
vascular supply to the polyp so as to effect haemostasis.

SWELLINGS OF THE BUCCAL AND

PALATAL MUCOSA
Fibro-epithelial Polyps
Pedunculated fibrous hyperplastic lumps arising from the mucous
membrane lining the oral cavity are relatively common, but true fibromas
are rare tumours in the mouth.
The cheek lesions often develop on the buccal mucosa opposite a space in
the dentition into which they are sucked during deglutition. Some on the lips
and cheek appear to develop initially as a round, flat, fibrous, submucosal
scar where sharp opposing teeth traumatize the cheek. Again the suction of
deglutition or a chewing habit may raise the initial flat lesion into a
pedunculated swelling. Similar lumps develop on the tip of the tongue
opposite sharp incisal edges or a diastema but arise from a tiny peduncle.
The pedunculated, fibro-epithelial polyps of the hard palate have already
been described under denture induced granuloma. They tend to be pale pink
in colour. Some are quite soft, while others are firm.
Histologically they possess a normal stratified squamous epithelium
which may be hyperplastic or ulcerated in response to trauma. The bulk of
the lesion is composed of a vascular and cellular fibrous connective tissue
with varying degrees of inflammation. True fibromas are reputed to be less
vascular and to possess a distinct capsule.
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Fig. 12.7. A papilloma on the inner aspect of the lower lip.

Treatment
They are readily excised. A suture is passed through the lump and acts as a
handle to control it. Too much tension should not be applied as this pulls the
adjacent tissues out into the peduncle. An elliptical incison is made around
the peduncle close to the base to remove it, and the defect sutured with one
or more interrupted resorbable sutures. Sometimes a horizontal mattress
is needed to pick up and control the divided blood supply to the polyp
(Fig. 12.6).

Papilloma
Papillomas are uncommon benign tumours of the oral mucosa, but
probably occur with equal frequency on the cheek, soft palate, fauces and
tongue. They tend to occur in children and young adults and may be viral in
origin. Papillomas are usually white or pinkish and pedunculated,
consisting of a delicate polypoid mass of keratinized epithelium on a
connective tissue base (Fig. 12.7). Occasionally several may arise in
different parts of the mouth. An important differential diagnosis in an older
patient is a verrucous carcinoma.

Treatment
The lesion is excised at its base with a narrow margin of normal mucosa.
Haemorrhage can be controlled by a mattress-suture bringing the under-
mined edges of the mucosa together. Alternatively, electrocautery may be
used and the wound allowed to granulate.
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Neurofibroma
Neurofibromas are uncommon in the mouth and present as soft pedunc-
ulated swellings of the cheek, tongue or palate, or as sessile masses on the
gingiva. Deeper lesions produce a fusiform swelling often soft and lobulated
in the substance of the cheek, tongue or palate, and may be mistaken for a
lipoma. It is important to examine the skin for other swellings and for brown
(café-au-lait) patches which make up von Recklinghausen’s neuro-
fibromatosis. Lesions arising from the inferior dental nerve will enlarge the
bony canal or even create a significant intra-osseous radiolucency. There is
no associated neurological defect.
Plexiform neurofibromatosis may affect the head and neck region. In
these unfortunate patients, a whole plexus of nerves is thickened producing
a marked deformity due to the soft redundant mass within the facial tissues.
The effect is that of a hemifacial hypertrophy.
Histologically there is a proliferation of the Schwann cells of the nerve
sheath producing ‘schwannomas’ or ‘neurilemmomas’ or ‘neurinomas’.
Occasionally the nerve is displaced and the tumour can be shelled out but
in many cases there is no separation between the connective tissue mass
and the nerve fibres.
Neurofibrosarcomas are rare.

Treatment
Treatment is excision where necessary but the involvement of related
nerves presents obvious technical problems and a likelihood of nerve
damage. Incomplete removal, as for instance with plexiform neurofibro-
matosis, will lead to a recurrence.

Lipoma
Lipomas are rare in the mouth, usually arising in the cheek from the buccal
fat pad or in the floor of the mouth. They are soft and fluctuant, and may
appear yellowish through the mucosa.

Treatment
Extracapsular excision.

SWELLINGS OF THE TONGUE

Fibro-Epithelial Polyp and Pyogenic Granuloma
Fibro-epithelial hyperplasias (fibro-epithelial polyps) may arise on the
tongue, usually on the lateral border, whereas pyogenic granulomas may
occur on the dorsum and contain food particles. Similarly, the less common
lesions such as neurofibromas, fibromas and even lipomas may be found.
However, the most characteristic swellings are median rhomboid glossitis,
lingual lymphoid tissue, lymphangiomas and haemangiomas and the
granular-cell myoblastoma.
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Median Rhomboid Glossitis

This presents as a smooth or nodular oval mass on the mid-dorsum of the
tongue just anterior to the junction of the anterior two-thirds and posterior
third. It is devoid of papillae and tends to have a purple-pink hue.
Although considered, for many years, to be a developmental defect due
to the failure of the lateral lingual swellings to fuse over the tuberculum
impar, this explanation has been questioned. It is now thought to be a form
of chronic hyperplastic candidiasis. However, the infection with candida
may be secondary to the presence of an abnormal mucosa. Treatment of the
candidiasis does not result in the disappearance of the nodular, non-
papillated lesion. It is painless and treatment is usually unnecessary,
although in some cases patients develop a cancerophobia, especially if
examined by a non-dentally qualified clinician.
A simple V resection may be used to eliminate bulky lesions. Before
excising a lesion be sure it lies anterior to the foramen caecum. Lingual
thyroids present at and behind the foramen caecum and may be the patient’s
only thyroid tissue.

Lingual Lymphoid Tissue

This may be found where the lateral border of the tongue fuses with the
faucial pillars. The smooth lobulated red and occasionally vascular tissue is
both normal and desirable. However, it may also give rise to cancerophobia
in a neurotic or hypochondriacal patient especially when a psychogenic
pain has drawn attention to the area.
Firm reassurance that this is normal tissue is essential. Sometimes the
foliate papillae, found at the same site, become inflamed and tender.
Topical gentian violet 1 per cent solution for a few days usually brings about
resolution.

Lymphangioma and Haemangioma

Lymphangiomas present as fine nodular semi-translucent lesions which
tend to persist with growth of the normal tongue. Excision of circumscribed
lesions usually presents no problems. Some are ideally removed with a
cutting laser. Others require wedge resection correcting at the same time the
macroglossia which the lesion causes. Significant postoperative swelling
must be expected, but subsides within 2 weeks.
Cavernous haemangiomas may be solitary or part of a widespread oro-
facial vascular malformation. The tongue has an irregular bluish enlarge-
ment. Rarely this may be found to contain the concentric opacities of
phleboliths when radiographed. If discrete and troublesome, excision under
general anaesthetic with careful haemostasis using diathermy and deep
sutures is advisable. Where a large volume of the tongue is involved by a
cavernous malformation, demarcation with selective angiography and
embolization with particles of polyvinyl alcohol (Ivalon) is the treatment of
choice.
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Amyloid
Diffuse firm enlargement of the tongue is produced by amyloid infiltration.
This is often a manifestation of latent or known myelomatosis. Histo-
logically the tongue is infiltrated with eosinophilic hyalinised material
especially around blood vessels. This is a complex glycoprotein which gives
a green birefringence on light microscopy when stained with congo red.
Myeloma paraproteins should be detectable in the plasma and urine and
a radiological skeletal survey may reveal widespread punched out
radiolucencies.

Granular-cell Tumour (Myoblastoma)

This rare lesion may present as a smooth symptomless swelling in the
dorsum of the tongue. It is usually pale, firm and non-tender. The origin of
the lesion is considered to be the Schwann cell and local excision is
invariably successful. The histological appearance is of large polyhedral
cells with small central nuclei and eosinophilic granular cytoplasm. The
overlying epithelium shows pseudoepitheliomatous hyperplasia which in a
superficial biopsy can lead to a mistaken diagnosis of carcinoma.

OTHER CONDITIONS PRODUCING

SOFT-TISSUE SWELLING
Sarcoid
Sarcoid may produce a localized swelling or a diffuse, tender hyperplasia of
the gingiva. Biopsy will reveal a tuberculous-like non-caseating epitheloid
and giant cell granuloma. The condition occurs in young people, often
negroes, and involves the eyes, skin, lymphoid tissue and cranial nerves.
The cause is unknown.
Orofacial manifestations include lymph node enlargement which may be
firm, non-tender and occasionally considerable in size, swollen salivary and
lacrimal glands and uveitis. A chest X-ray will reveal enlarged hilar lymph
nodes, the Kveim skin test is usually positive, and the serum angiotensin
converting enzyme is raised.
A biopsy of the mucosa of the hard palate or gum is also said to be
diagnostic in about 40 per cent of cases.

Treatment
The sensitive gingival lesions can be treated with topical steroid gel (0-1 per
cent triamcinolone in Orabase). Grossly enlarged lymph nodes are easily
removed for aesthetic reasons. Uveitis and extensive pulmonary disease
require systemic corticosteroids.

Crohn’s Disease
This is an uncommon, idiopathic, granulomatous condition of the
alimentary canal which occasionally affects the mouth. Lesions are often
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red granulomatous areas on the gingiva or irregular ‘cobblestone’ patches

on the buccal mucosa. The lip may swell suggesting angio-oedema except
that the swelling is persistent and does not respond to antihistamines.
Crohn’s disease may not be suspected unless there is a history of lesions
elsewhere in the gut. A biopsy will reveal granulomatous areas consisting of
macrophages, lymphocytes and multinucleate giant cells, resembling a
foreign body reaction or sarcoid.
No specific treatment is required for the oral lesions although topical
steroids may be useful. An unsightly persistent swollen lip may require
local steroid injections or even systemic steroids.

Note: The Melkersson—Rosenthal syndrome is usually considered to be a

combination of swollen lips (cheilitis grandularis apostomatosa, or cheilitis
granulomatosa), scrotal tongue and facial palsy. It is often difficult to
establish the diagnosis if all the features are not present. When it occurs
with facial palsy the condition is probably sarcoid, but without the cranial
neuropathy, cases may be Crohn’s disease or merely angio-oedema.

Malignant Granuloma (Wegener's Granulomatosis)

This may present as a haemorrhagic hyperplastic pale granular gingival
overgrowth which is usually localized or occasionally diffuse or multifocal
within the mouth. This diagnosis should be suspected if there is substantial
destruction of the underlying bone and in particular the presence of lesions
on the nasal mucosa or within the antrum. It is important to establish
whether the condition is the localized destructive granuloma (Stewart’s) or
the generalized Wegener’s variety which will lead to fatal renal failure if not
treated early.
Histologically the dense infiltration of lymphocytes and plasma cells
associated with necrosis may be difficult to diagnose unless the character-
istic vasculitis is evident. Apart from a raised ESR there may be no other
specific features and a careful search for lesions elsewhere must be
made.

Treatment
Local lesions may be arrested with radiotherapy but this is not invariable,
and progressive destruction of the face may lead to death through aspiration
pneumonia. The systemic disease is treated with corticosteroids and
azathioprine.

SUGGESTED READING
Barker B. S. and Lucas R. B. (1967) Localised fibrous overgrowths of the oral
mucosa. Br. J. Oral Surg. 5, 86-92.
Lee K. W. (1985) Colour Atlas of Oral Pathology. Philadelphia, Lea
& Febiger.

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 SOFT-TISSUE SWELLINGS OF THE ORAL MUCOSA
Rateitschak-Pluss E. M., Hofti A. and Rateitschak K. N. (1983) Gingival-
hyperplasie bei Cyclorsporing A Medikation. Acta Paradontoligica 93,
57-65.
Sunderland E. P., Sunderland R. and Smith C. J. (1983) Granular cells associated
with the enamel organ of a developing tooth. J. Oral Path. 12, 1-6.
Tyldesley W. R. and Potter E. (1984) Gingival hyperplasia induced by cyclosporin
A. Br. Dent. J. 157, 305-309.

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 CHAPTER 13

THE DIAGNOSIS AND MANAGEMENT OF

OROFACIAL PAIN

Pain is an unpleasant emotional experience due to either physical or

psychological trauma. Most cases of facial pain are easily recognized as
being toothache, sinusitis, trigeminal neuralgia, or even the more rare
conditions such as facial migrainous neuralgia. However, the greatest
difficulty in the management of facial pain is the failure to appreciate the
common occurrence of psychogenic pains and the means of diagnosing and
treating them.

THE HISTORY
The patient’s account of the pain is of the utmost importance. Indeed where
there are no other associated symptoms and no detectable physical signs the
patient’s history is the only evidence upon which the clinician can base a
diagnosis.
Dentists, like other practically inclined and surgically trained clinicians,
tend to spend too little time taking a history and may even feel
uncomfortable if they do not promptly offer practical help to the patient.
Where the diagnosis is straightforward, treatment can be prescribed
immediately. For many patients who present with pain the clinician may
not be certain of the diagnosis after the first consultation and inappropriate,
empirical treatment may hinder and complicate the diagnostic process.
It often takes time to persuade the patient to tell all of his or her story, to
sort out the details in chronological order, establish valid relationships and
separate out the accumulation of beliefs and assertions of the patient’s
relatives, friends and professional advisors.
At the first visit patient and clinician meet as strangers and it may not be
until a subsequent consultation that enough rapport is developed for
important details to be revealed. Sometimes a female patient may confide
the essential clue to the surgery assistant. Not infrequently patients censor
certain pieces of information on the grounds that they are not the business of
a dentist!
Pains due to local disease processes have a recognizable pattern, but
more importantly there are usually other associated symptoms and physical
signs to be uncovered by appropriate investigations. Also, as the disease
progresses the clinical picture evolves accordingly. Patients who have a
remittent or continuous pain, unchanged in character over many months or
years and without the appearance of new symptoms or signs, are most

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unlikely to have either an occult infection or a malignant neoplasm and, at

least, can be reassured on that point at the first visit. There are, however,
pains which follow a similar pattern and are probably due to an ill-
understood physical disease process, even though there is little in the way of
physical signs. Examples of such pains are migraine and trigeminal
neuralgia. Finally there are the psychogenic pains which are difficult to
recognize without experience, and whose underlying mechanisms are still a
matter of speculation.
The site of origin of a pain from a superficially placed disease process is
usually accurately located by the patient, often with one finger, except when
the pain is referred from a site innervated by an adjacent branch of the same
nerve. In the latter case the site of complaint is non-tender. Such pains are
often sharp and intense, but a dull, burning pain subsequently spreads out
from the original focus, involving eventually a wide area. It is important
therefore to determine where the pain started. If on physical examination a
cause is found consistent with the patient’s history ‘the causal relationship’
is assumed, but it is helpful, and indeed may be important, to find
confirmatory evidence of current activity of the disease which would
account for the complaint of pain. Some psychogenic pains may be
experienced at a particular site to which consistently the patient points. The
finding of a heavily filled tooth, unresponsive to vitality tests but without
evidence of active infection, is not conclusive. Similarly many innocent
impacted wisdom teeth or retained roots are wrongly incriminated. The
clinician should reserve judgement that this is the sole cause, or even the
likely cause, of the complaint, unless the symptoms match the signs.
Pains which arise from a focus of disease in the depths of the tissues are
less well localized. Ifthe pain is due to nerve involvement then the pattern of
neurological signs may give a clue to the anatomical site of the lesion. If
there are sensory changes involving more than one branch of the trigeminal
nerve the appropriate division is likely to be involved. If more than one
division is affected the lesion is at or inside the base ofthe skull. Lesions just
outside or inside the skull may also involve other cranial nerves. Long tract
signs usually mean a lesion within the brain or several disseminated
lesions.
Important management problems relate to the further investigation of the
patient and the use of empirical treatment as a therapeutic test. It is
necessary to investigate a patient with sufficient thoroughness to avoid
overlooking a detectable and treatable cause. On the other hand the
indiscriminate use of investigations subjects the patient to avoidable
discomfort, inconvenience and perhaps even complications. Indeed some
investigations are not only hazardous, but expensive and the thoughtless
use of diagnostic resources adds to the cost of health care and can even
delay the investigation of more urgent cases.
Trying the effect of treatment where a plausible cause of the pain has
been found may well be justified, but in the absence of certainty as to the
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diagnosis may increase the patient’s symptoms and impede progress

towards a correct understanding of the case. Both inappropriate investiga-
tion and inappropriate treatment may confirm in the mind of a patient with
psychogenic pain the presence of serious physical disease which the
clinician has not found or is concealing from the patient. Examples of these
problems will be given when discussing specific entities.
In order to diagnose any pain and in particular distinguish between
organic and psychogenic pain it is essential to take a history which includes
the following information.
1. The character of the pain—is it sharp, dull, throbbing, burning or
stabbing?
2. The site at which it is felt and any radiation. This should be recorded
as a line drawing.
3. The timing—when the very first attack occurred and the frequency
and duration of subsequent attacks. It is important to consider the timing of
attacks during the day, whether the pain is worse in the morning, afternoon,
evening or night, and if it prevents or disturbs sleep.
4. Provoking factors—these may include hot, cold, sweet and sour food
and drinking, biting, chewing, yawning or talking, and bruxism—nocturnal
or diurnal. But also establish the effect of anger, anxiety or alcohol.
5. The relieving factors—is it controlled by analgesics, alcohol, the
application of heat, or does the pain disappear spontaneously?
6. What are the associated clinical features—swelling, unpleasant
taste, trismus, nasal obstruction, loss of facial sensation, epiphora, anxiety
or depression?
7. It is necessary to establish whether the patient suffers from pain or
discomfort elsewhere in the body, such as headaches, migraine, neck or
back pain, chest, abdominal or pelvic pain and pruritus. The timing,
duration and management of these pains should be recorded. In this way it
can be seen whether or not the facial pain belongs to a whole body
syndrome.
8. The current and past general medical history, including drug
therapy.
9. It is important to establish the patient’s emotional history and
determine whether the patient has suffered periods of anxiety or
depression.
10. Astandard family history, including the ill health or death of parents,
brothers and sisters, spouse and children, is of crucial importance and often
forgotten.

CLINICAL PRESENTATION
The Teeth—Odontalgia
Pulpal pain—irritation or inflammation of the dental pulp—arises from
caries, loose or lost restorations and the latent split tooth. A transient sharp

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pain as a response to acid, sweet and thermal changes is a feature of

uninsulated dentinal tubules. However, once the pulp becomes inflamed,
the sharp pain becomes more severe and lasts for perhaps 10 or 20 minutes
following contact of the tooth with cold or sweet food. Spontaneous
episodes of sharp pain herald the onset of a persistent throbbing pain which
is characteristically worse following stimulation and when lying down at
night. It may be well localized, particularly on biting and chewing, but
occasionally the pain becomes diffuse or is referred to the opposite jaw and
may also be obscured by painful ipsilateral reflex muscle spasm.
All teeth must be carefully examined with a mirror and probe and
percussed for sensitivity. Electrical and thermal pulp testing may also prove
valuable in localizing a hypersensitive or non-vital tooth. Additional help
may be obtained by injecting a local anaesthetic solution at the considered
source of the pain. If the pain persists despite good analgesia alternative
teeth should be re-examined.
The diagnosis of the split tooth can be difficult but the possibility should
be considered, especially with heavily filled upper premolars or lower Ist
molars. Sharp pain may only be provoked by getting the patient to bite
firmly on a wool roll placed buccolingually over the tooth. A small
fibreoptic light source is invaluable and removal of the restoration usually
reveals a crack through the base of the cavity.
Toothache in the absence of appropriate physical and radiological
signs—atypical odontalgia—is a psychogenic vascular pain which may
mimic common dental pain and is discussed in detail later in this
chapter.
Radiographs should include bitewing and periapical films of the
suspected teeth. Where there is difficulty in establishing a diagnosis,
especially with root-filled teeth, two long cone periapical projections taken
obliquely in the horizontal plane to reveal the individual apices of
multirooted teeth are invaluable. For pain arising in the upper dentition, an
occipitomental view of the antrum is essential, to eliminate the possibility of
sinusitis or, occasionally, a carcinoma.

Periodontitis
Pain from the inflamed periodontal membrane is invariably dull and
continuous, and initially relieved by clenching the teeth, but later on is
aggravated by this action. Periodontitis may be as a result of primary
infection of a pocket due to food impaction, or secondary to an apical pulpal
infection, or occasionally due to a longitudinally split root.
The treatment will depend on the cause. If a primary acute periodontal
abscess is present, drainage of exudate and irrigation of the pocket with an
antiseptic such as povidone-iodine or alcoholic tincture of iodine has a
soothing effect which may be assisted by grinding the tooth out of occlusion.
Unless periodontal surgery is carried out, the condition will recur. A
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secondary periodontitis can be treated only by removal of the infected pulp
or tooth.

Bone Pain
The principal causes are alveolar osteitis (dry socket), infected cysts,
fractures, osteomyelitis, and primary or secondary malignant tumours.
(These are dealt with in detail in the appropriate sections.)
The pain varies from a dull, continuous ache to a severe throbbing which
is relieved by antibiotics and analgesics. Inflammation producing throm-
bosis in the vasa nervorum or the infiltration of the inferior dental
neurovascular bundle by a malignant tumour will give rise to mental
analgesia. A rare cause of mandibular pain with mental anaesthesia is a
sickle cell crisis.
Radiographs taken in either two or three planes will help to determine the
exact site and extent of the disease.
As metastatic carcinoma may mimic an area of inflammatory bone
destruction, where there is any doubt about the diagnosis, the lesion should
be explored and a specimen taken for biopsy.

PRIMARY ORGANIC JOINT DISEASE

Traumatic Temporomandibular Joint Arthritis
This follows damage to the capsule and meniscus due to direct trauma and
may follow a blow on the mandible or subluxation. The pain may be
moderate to severe, is well localized and aggravated by movements of the
mandible which are restricted. The mandible will deviate towards the
painful side on attempted opening and a tender joint effusion may be visible
and palpable.
Radiographs should include a rotational tomogram which can give the
clearest picture of the condylar head and fossa. In addition, the
transpharyngeal view is valuable, particularly if the mandible can be
opened. The traditional superior oblique transcranial radiograph is difficult
to interpret and gives a distorted view of the joint surfaces. Where an
unreduced anterior dislocation of the meniscus is suspected to be the cause
of the problem, an arthrogram will visualize the displaced meniscus.
Treatment consists of resting the joint and relieving pain with adequate
analgesia such as aspirin | g, or ibuprofen 400 mg, t.d.s., 4-6-hourly.
Persistent pain despite conservative therapy will be discussed under
chronic dysfunction.
Acute arthritis of a non-traumatic aetiology is rare. Children may suffer
juvenile rheumatoid arthritis (Still’s disease) or an arthritic reaction to
rubella immunization. In adults, acute rheumatoid arthritis is part of a
systemic disease and is usually readily diagnosed. Rarer causes include
psoriasis, gout and infective arthritis.
Investigations will include serological tests for rheumatoid arthritis,
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serum uric acid for gout and aspiration of any effusion for microscopic and
microbiological investigation. Treatment will be determined by the
underlying cause.

Osteoarthritis of the Temporomandibular Joint

This is a degenerative condition of the joint which occurs commonly
without symptoms in the elderly, but has been observed clinically and
radiographically in younger patients when it may follow long-standing
untreated facial arthromyalgia. Immediately this creates the problem of
diagnosis where it appears that a functional psychosomatic disorder may
give rise to a structural organic lesion. Even in older patients where
degenerative joint changes occur together with repetitive chronic
mechanical insult (such as may follow using inadequate dentures),
emotional tension can be an important predisposing factor and result in
painful symptoms.
Since the degenerative changes in the joint cannot be reversed, attention
must be diverted to correctable factors. Prolonged vigorous movements as
may accompany singing or the use of old, ill-fitting dentures, particularly if
they are worn continuously day and night, may be contributory factors.
Lack of adequate occlusal support from the posterior teeth may transfer
chewing stresses to the anterior ones with increased leverage on the joint
tissues.
The pain is well localized to the affected joint and is provoked by chewing
and other jaw movements. On examination, there is tenderness and both
palpable and sometimes audible crepitus in the joints. When acutely
inflamed, an effusion with periarticular swelling may be seen. If the pain is
sharp and severe in an elderly patient, the differentiation from a paroxysmal
trigeminal neuralgia can be difficult. Furthermore, it would appear that
temporomandibular joint osteoarthritis can be a trigger for a true
paroxysmal neuralgia in some patients.
The radiographic changes are best seen on the transpharyngeal and
rotational tomographic views of the joint and include a loss of cortical
definition, erosions and subarticular cysts together with calcific or osseous
metaplasia at the insertion of the lateral pterygoid tendon, which together
produce flattening and an angular beak-like remodelling of the condylar
head.

Treatment
1. Correction of the occlusion with adequate dentures is of primary
importance.
2. A course of an anti-inflammatory analgesic, such as ibuprofen
400 mg, 3 times a day with meals, or naproxen 250-500 mg once or twice a
day, is useful, especially where there is an acute painful effusion.
3. Where an element of tension or depression is provoking bruxism an
anxiolytic antidepressant drug such as 25-50mg of dothiepin is of great
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value. The tricyclic antidepressant drugs also have a synergistic effect on

analgesics for pain relief.
4. Persistent pain may respond to one or two intra-articular injections of
an anti-inflammatory steroid, such as I ml of triamcinolone (40mg) or
dexamethasone 1 ml (4mg). Unfortunately, it is impossible to be certain
whether intra-articular steroids have any long-term beneficial effects over
that of the oral non-steroidal analgesic. Repeated intra-articular injections
of steroids can induce resorption of the condylar head so, if there is no
benefit from one or two injections, further doses are not advisable.
5. Smoothing of the condylar head by open surgery. The high condylar
shave is advocated by some authors for cases with persistent, intractable
pain. However, although immediate relief is achieved in some patients, the
long-term value is uncertain. Simple smoothing of discrete osteophytes is
preferred. The benefit of meniscectomy is short lived and further severe
degenerative changes in the condylar head follow. Where there is gross
degeneration of the meniscus, or in cases that have undergone previous
surgery, a conservative smoothing operation with the insertion of a 2mm
silicone elastomer membrane suspended from the condylar fossa and
overlying the eminence is the treatment of choice, in combination with the
analgesic regime.

FUNCTIONAL TEMPOROMANDIBULAR
JOINT DISORDERS
Because the mandible is bent into a U shape with the joints at either end in
the same plane both must move together and in harmony with one another.
Any abnormality in the movement of one TM joint imposes an abnormal
movement on the other. Thus a patient may complain of pain and perhaps
clicking in one joint in which the condyle is found to be moving forwards to
the point of subluxation when the jaw is opened while the opposite condyle
merely rotates and does not translate, hence the excessive movement of the
other.
Movement of the condyles must also be guided by the muscles so that
when the teeth articulate and move against one another in function they do
so without discomfort. This must be managed despite the fact that few
dentitions permit unimpeded movements of the jaw. Indeed some joints
may act at a distinct mechanical disadvantage because of abnormal
occlusal relationships. For example, where there is marked mandibular
retrognathism the mandible must be protruded to incise food so that a
closing force is exerted with the condyle held far forward on the articular
eminence.
Such factors alone do not usually cause symptoms, but predispose the
joint to disturbed function, pain, clicking and limitation of movement if
other insults are added such as prolonged active opening during dental
treatment. When the new factor can be reversed, or one of the predisposing

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factors eliminated, symptomless function may be restored. In some cases

the underlying or precipitating factors are psychogenic in origin and the
failure to recognize or treat such a problem may lead to chronicity.

PSYCHOGENIC PAIN
Psychosomatic disturbances are now recognized as being a common
category of illness. When emotional strain gives rise to disturbances in the
cardiovascular system, gastrointestinal tract or skin, the identifiable
physical changes, such as increased blood pressure, tachycardia, peptic
erosion or eczema, make the diagnosis respectable to the clinician and
acceptable to the patient. Unfortunately, if the clinical presentation is
simply pain, then there is often a failure to appreciate on both sides that real
pain may arise in peripheral organs as a result of a central emotional
disturbance. The pain usually arises in tense muscles or dilated blood
vessels and is rarely the peripheral referral of a central disturbance, i.e. a
conversion symptom, or an hallucination.
Psychogenic pain may arise in a variety of situations:
1. As a result of a stressful life event in a previously normal
individual.
2. As a manifestation of transient emotional illness such as anxiety,
neurosis or depression.
3. As an abnormal personality trait which will persist throughout life.
This may be hypochondriacal or hysterical in character.
4. As the manifestation of psychosis.
The first two groups are by far the most common and most amenable to
treatment.
As with all pain problems the history is the key to the diagnosis, and the
following areas should be explored:
a. General pain symptoms. Symptoms of other psychosomatic conditions
which occur simultaneously or sequentially with orofacial pain, e.g.
migraine, tension headaches, neck and back ache, pelvic pain, especially
dysmenorrhoea often associated with menorrhagia, irritable (spastic)
colon, pruritus and non-allergic vasomotor rhinitis. By establishing the
positive relationship of these conditions with orofacial pain, not only is the
diagnosis clarified, but the patient is reassured that unexplained pain or
continuous illness that has been a trouble for years with fruitless
investigations and operative procedures can be explained in a more rational
way.
b. Family history. As stated, a detailed family history is often a crucial
key to diagnosis. Features of importance include a history of emotional
disturbance in the parents or siblings, bereavement immediately prior to the
onset of the condition or the occurrence of a congenital deformity or chronic
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illness often in a child or spouse. Weddings and pregnancies in the family

which normally are a source of joy are sometimes the cause of distress or
anxiety.
c. Social history. Psychosomatic pain can arise in the first decade in
children who adapt poorly to school, or who have difficulty tolerating
sibling rivalry. In older children the pressure of examinations can be a
cause. Vocational pressures in adults including unemployment and marital
problems such as alcoholism or sexual maladjustment are important. Later
still, social isolation or responsibility for a chronic invalid produce
psychosomatic illness.
In summary, the dental clinician has no difficulty in establishing the
patient’s general medical history, but is often reluctant to ask if the patient
suffers from ‘worry or depression’ or has been treated for these conditions,
and often overlooks the need to explore the family medical history and
social history.
Clinical presentations of psychogenic pain include:
—Facial arthromyalgia (TMJ dysfunction, myofascial pain dysfunction
syndromes).
— Atypical facial pain (atypical facial neuralgia).
— Atypical odontalgia.
—Oral dysaesthesia.
—Factitious ulceration.

Facial Arthromyalgia
(The Temporomandibular Joint Dysfunction Syndrome)
(The Myofascial Pain Dysfunction Syndrome)
After toothache the most common facial pain arises in the temporo-
mandibular joints and facial muscles. There is still reservation amongst
some clinicians as to the principal cause of temporomandibular joint pain.
The overwhelming evidence is that this joint and its associated musculature
are commonly the sites of psychogenic dysfunctional pain and that pure
organic causes are considerably less frequent. (See Primary organic joint
pain above.)

Clinical Presentation
The condition may vary from clicking and sticking of the jaw joint on
chewing, talking and yawning to a severe, continuous dull ache in one or
both temporomandibular joints associated with trismus. Although the onset
may be acute, the pain commonly radiates up into the temporal region,
down to the angle of the mandible and is often associated with occipital,
sternomastoid and cervical pain.
The patient can describe the pain as being an earache and may suffer
from a stuffy sensation or popping noises within the ears and tinnitus.
Questioning will usually reveal a history of headaches, migraine, cervical

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and back pain, in addition to abdominal and pelvic pain and pruritic skin.
Thus the patient will have been treated for what is often diagnosed as a
slipped disc, irritable colon, dysmenorrhoea and eczema.
Although referral is often due to a recent exacerbation, it is important to
determine previous episodes of pain which may have occurred intermittently
over many years.
The pain may be present on waking together with trismus and tend to
improve during the day, in which case there may be a history of nocturnal
bruxism or jaw clenching. Other patients tend to develop the pain during the
course of the day, especially when tired and stress is discernible as a related
factor. Bruxism and comparable oral habits such as nail, pencil or pipe
biting and cheek or lip chewing are frequently associated features.
After establishing whether the patient is aware of bruxism or facial
tension, it is important to ask whether they suffer from anxiety of
depression. Many patients will be reluctant to reveal a previous psychiatric
history, at least at the first interview. Other important factors which often
arise in the absence of any emotional disturbance are adverse life events.
These include, in children, difficulties with school examinations or sibling
rivalry, a history of bereavement or family illness which may include
congenital malformation in a child, or alcoholism in a husband, marital
disharmony, and professional stress. These factors can only be elicited by
taking a detailed family history.
On clinical examination, there is usually tenderness in one or both joints
and also in a variety of facial muscular sites, including the temporalis and
masseter muscles. Trismus may be present and there is usually deviation of
the mandible on opening towards the most painful side. Intraorally, ridging
of the buccal mucosa and tongue margins is pathognomonic of a persistent
clenching habit and bruxism may also be seen in the worn facets of the
anterior teeth. It is, of course, important to examine the dentition for carious
lesions, pulpitic teeth and gross occlusal defects.
The pain appears to be a combination of a traumatic arthrosis due to
bruxism and painful muscular vasodilatation. The poor response to
analgesics and effective control by tricyclic antidepressant drug therapy
suggest that the intensity and persistence of the painful symptoms may also
be due to failure in a central amine pain suppressor mechanism.
Much emphasis has been placed on malocclusion as the prime aetiology
of this condition, despite the fact that no clinical trial has been able to
establish malocclusion as the cause or occlusal equilibrium as a consistent
cure of the condition. Acute or subacute forms may be provoked by an
inflamed tooth, or gross occlusal disturbance such as a recent badly
contoured dental restoration or a sudden loss of posterior occlusal support.
However, most cases do not display any gross malocclusion and in some
the dental disorder appears to trigger off, or localize, a chronic pain
problem.
Some 60 per cent of patients appear to be suffering from either a neurotic
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or depressive illness, while the remaining 40 per cent, although psychia-

trically normal, often give a history of stressful life events. Although the
patients who attend for treatment are predominantly adult married females,
there is a wide age range extending from the first decade upwards, and it
would appear that many men suffer a mild form of the condition but do not
attend for treatment. In children the condition is misdiagnosed as
earache.
The pain is best considered to be part of a whole body psychosomatic
syndrome in patients who are often competent individuals with obsessional
perfectionist traits, particularly those who hold responsible positions.

Treatment
1. All dental disease must be eliminated, includiag carious cavities,
periapical abscesses and pericoronitis. There is no evidence that minor
occlusal disharmony or partially and unerupted wisdom teeth are
responsible for the condition. Major restorative dental procedures aimed at
modifying the occlusion can make the patient worse, producing severe
intractable pain so that there is difficulty in separating the original problem
from the secondary somatopsychic disturbance.
2. An appreciation of the underlying stress is important to the patient
who responds well to the reassuring explanation that emotional tension
expressed as bruxism can create joint pain and with painful dilated blood
vessels, muscle spasm. It is important to emphasize to the patient that the
pain is a ‘real pain—comparable to migraine’ and is not imaginary.
3. Tricyclic antidepressants such as nortriptyline, starting with 10mg at
night and increasing to 30mg at seven days and then maintaining this
regime for three weeks will produce marked relief of both local and general
symptoms. Where pain persists the patient should be encouraged gradually
to increase the dosage to a maximum tolerated level which may be 100mg.
Side effects such as drowsiness and a dry mouth soon wear off especially as
the drug is taken at night before retiring. Where there is no remission small
doses of a phenothiazine appear to be beneficial and are used as a combined
medication with the tricyclic, e.g. trifluoperazine, 24mg in the morning. A
useful and well tolerated drug combination is Motival (fluphenazine 0-5 mg
and nortriptyline 10mg), one to two at night. Again this dose should be
increased gradually as required. Flupenthixol 0-5—1-5 mg twice daily is also
a useful alternative regime where a tricyclic drug fails.
It may be necessary in severe, persistent cases to use a monoamine
oxidase inhibitor such as Parstelin (tranylcypromine 10mg and trifluo-
perazine Img) I t.d.s. at 8, 12 and 4 p.m. with 2-5 mg diazepam at night to
prevent insomnia.
It is important to stress that the medication is being used for its centrally
acting muscle relaxant analgesic effect and not as an antidepressant.
4. A bite-guard may be used either at night or during the day, between
meals, to discourage bruxism and may be effective in a number of cases.
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However, many patients quickly cease to use or even lose the bite-guard
and its value appears to be a placebo effect and is therefore best used in
young patients and those who are reluctant to take psychotropic drugs.
5. Severely disturbed and intractible cases invariably benefit from a
psychiatric consultation and if necessary, treatment. Unfortunately, many
patients are reluctant to be referred to a department of psychological
medicine and not all psychiatrists show interest in psychosomatic facial
pain.
6. The role of surgery is controversial. Although a blind condylotomy
has been shown in one retrospective series to be of value, many patients
have gradually relapsed. The diagnosis of internal derangement of the joint
with anterior dislocation of the meniscus has become fashionable since the
increased use and understanding of temporomandibular joint arthrography.
Anterior dislocation of the meniscus without reduction can produce both
chronic pain, erosion of the anterior surface of the condylar head and even
condylar remodelling with loss of ramus height and an anterior open bite.
However, many of these cases respond to conservative therapy, that is
reassurance, analgesic and antidepressant drugs. Even so, an increasing
number of patients are being subjected to a high condylotomy and posterior
re-attachment of the meniscus as an open procedure. There is no controlled
published work to establish the degree of success ofthis surgical procedure,
and many cases can be seen in time to become either worse or develop
marked degenerative changes with osteophyte formation of the condylar
head.
In summary, the authors do not support the need for surgery except in
extreme cases, which may be determined by the following criteria:
a. Where the patient has had longstanding pain and trismus unrelieved
by conservative drug therapy for a minimum of 12 weeks.
b. Where an arthrogram or computerized tomogram or arthroscopy
confirms anterio-medial or posterior dislocation of the meniscus, adhesions
or gross osteophytes of the condylar head.
At surgery the joint space is opened up by a Juniper joint distractor. If a
displaced disk can be freed and repositioned it is sutured to the posterior
capsule. Grossly adherent and torn menisci are probably best removed and
replaced by a2mm Dow Corning disk prosthesis suspended from the fossa
by fine wire ligatures. Adhesions may be divided by arthroscopy without
open surgery.
It is important to remember that following longstanding trismus a
temporalis contracture may develop which will give rise to an extra-
articular ankylosis and prevent opening under a general anaesthetic. This
can only be treated by bilateral temporalis myotomies or coronoidectomies.
Vigorous postoperative exercises are essential.
Finally, one important feature of all psychosomatic conditions is that the
vulnerability of the patient persists throughout life, predisposing to relapse
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and recurrence. The patient should be made aware of this and given
instructions as to how they can cope, for instance, by returning to their
former course of medication. It has also been shown that medication is
required for at least a year for many patients with longstanding joint and
facial pain. Shorter periods of treatment lead to relapse often within 3-4
weeks. (See also sections on Atypical facial neuralgia and Atypical
odontalgia below.)

Atypical Facial Pain

(Atypical Facial Neuralgia)
Although this painful condition may occur alone, it frequently presents
sequentially or even simultaneously with facial arthromyalgia and would
appear to be a non-muscular, non-joint variant of the facial psychogenic
pains.
This is acommon form of facial pain, often described as a continuous dull
ache with intermittent excruciating throbbing episodes. It is character-
istically localized to non-muscular, non-joint areas, such as the facial
bones, alveolus and teeth, where the localized variant, atypical odontalgia,
will be discussed separately. It may be bilateral and is not provoked by any
identifiable factors such as temperature changes or jaw movements and is
not relieved by analgesics. Like facial arthromyalgia it is associated with
pains elsewhere in the body. A common feature is a sensation of nasal
stuffiness or obstruction. This is a non-allergic vasomotor rhinitis and is
usually firmly described as a history of chronic sinusitis.
The pain episodes may be intermittent or continuous over a period of
many years. Quite often there is a history of a placebo response to
antibiotics which, as a result, may be prescribed frequently but without
obvious reason. Dental treatment also can provoke or potentiate the pain. A
frequent additional complaint is of swelling and redness of the face, or
redness of the oral mucosa. There may indeed be slight oedema and redness
of part of the face or minimal hyperaemia of the oral mucosa. Such
appearances may form the basis for the use of antibiotics but without
regression of the swelling.
Infiltration of the painful site with local anaesthetic may give temporary
relief, but has no diagnostic value. The association with migraine and
vasomotor rhinitis suggests that the pain mechanism is vascular with
intermittent or perhaps persistent vasodilation giving rise to the release of
local pain producing substances. Although the absence of physical signs
and the difficult history may tempt the clinician to assume the problem is
imaginary, this is unhelpful and will obscure the true nature of the condition
and impair management.
Another difficult feature of many patients is their extreme reluctance to
accept a diagnosis of psychogenic pain, even when it is sympathetically and
emphatically explained that the pain is nevertheless a real and distressing
one. These patients will often insist in an obsessional way that there is a

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physical cause giving details of the supposed anatomical disturbance and

demand surgical treatment. This should be completely resisted as the
extraction of teeth and exploratory operations complicate the picture.
While surgery often produces short-lived relief, it is usually followed by an
exacerbation of the problem. Such treatment adds an additional failure of
clinical expertise to some patients’ log book, indeed some hypochondriacal
patients give the impression of competing with the clinician. This has been
described as the pain game, and unfortunately, the tendency to manipulate
and dominate may, in aggressive and paranoid patients, become a basis for
medicolegal attack. However, if the patient is treated firmly with repeated
assurance that surgery is both unnecessary and harmful, and that only
medical drug therapy is suitable, the majority of patient’s problems can be
controlled. In a few cases, however, the pain persists. Severe and persistent
pain, or a marked emotional disturbance, are indications for referral to a
psychiatrist.
There are good reasons for maintaining these patients under continuous
review, which should include regular careful neurological examination.
While with experience and care the clinician may have confidence in the
diagnosis, continuing observations will ensure that the first clinical
manifestations of physical disease will not be missed. Any suggestion of
sensory change indicates the need for a CT scan. In any case the patients
benefit from a regular supportive interview with someone they have come to
trust, and finally it avoids the beginnings of a new disease being overlooked
because the symptoms are looked upon as new manifestations of the old
complaint.
The treatment is the same as facial arthromyalgia.

Atypical Odontalgia
(Idiopathic Periodontalgia)
Pulpitis and periodontitis are common recognized causes of orofacial pain.
However, an atypical odontalgia with identical features consisting of
persistent or throbbing pain provoked by biting, chewing and thermal
changes can arise without any detectable structural lesion. The condition
becomes more readily recognizable if teeth in more than one quadrant are
affected. However, should a single, heavily filled tooth become painful,
there is a strong temptation to remove first the filling, then the pulp, and then
after root filling and apicectomy, extract the tooth, even without any clear
clinical indication. An additional complicating factor is that atypical
odontalgia is commonly precipitated by a dental procedure such as the
fitting of a crown or bridge or an extraction and is made worse by further
active treatment.
The important differential diagnosis in these cases is the latent split tooth.
The history is therefore one of pain in the teeth followed by repeated dental
procedures, including pulp extirpations and extractions, followed by a ‘dry
socket’ from a mouth where certain of the residual teeth, although sound
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and vital, are still tender to percussion and hyper-responsive to other

stimuli.
In other cases the patient complains of pain in a completely sound tooth.
Extraction of the tooth relieves the pain, but several months later the patient
returns with a similar complaint about a further blemish-free tooth. This
cycle can be repeated until four or five normal teeth have been removed and
the clinician’s suspicions aroused.
Like atypical facial neuralgia, the pain appears to be vascular in origin
and is related to other pains of a similar nature. Although many patients
reveal significant emotional problems, some do not, and attempts to force a
psychiatric diagnosis on these patients are of no therapeutic advantage.
However, it is important to stress to the patient that the pain is a real pain
and is best considered to be a ‘dental migraine’ which will respond to drug
therapy. Apicectomies, refilling or extracting teeth where there is no
clinical indication of the need for such treatment should be avoided at all
costs.
The treatment is that of facial arthromyalgia and atypical facial
neuralgia.

Oral Dysaesthesia
This group of conditions tends to be non-painful and more commonly occur
in the elderly with latent or overt problems of bereavement and loneliness.
In some cases there may be evidence of an organic psychosis due to cerebral
ischaemic changes. The most common presentations are:
1. Burning tongue—glossodynia or glossopyrosis.
2. Dry mouth in the presence of saliva ‘salivary sand’.
3. Denture intolerance.
4. Phantom bite syndrome.
5. Abnormalities of taste, including the obesssional fear of halitosis or a
conviction of a ‘discharge’ from a particular corner of the mouth.
1. The burning tongue, glossopyrosis or glossodynia, is probably the
most common and may also extend to involve the gingiva, lips and palate.
The patient is often middle-aged and female, but can be of any age or sex.
The discomfort is not present on waking, but gradually increases during the
course of the day, until, towards the evening, it becomes intolerable.
Nevertheless, it never prevents or disturbs sleep. An important diagnostic
feature is that it is usually, but not invariably, relieved by eating and
drinking, which distinguishes this from organic disturbances, such as
vitamin B,, or iron deficiency, or benign or malignant ulceration. Although
the condition is often attributed to a fungal infection, there is rarely any
evidence of this. A secondary problem is cancerophobia, which is often
confirmed in the patient’s mind by a bright red tongue, with scalloped
margins. This appearance is due to compression of the tongue against
clenched teeth.

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2. The problems of a dry mouth sensation or ‘sand in the saliva’ occur

despite adequate salivary flow, and investigations of salivary gland
function, including tests for Sjégren’s disease, prove to be negative.
3. In the same way, some patients have prosthodontic problems which
appear to have no physical justification in that there are good ridges as a
foundation for dentures. The suspicion is borne out by the large bag of
dentures, each made by one of a number of competent clinicians, and which
the patient usually carries with her. The underlying complaint is usually of
oral mucosal hypersensitivity such that even pressure with a finger, let
alone the dentures, is not tolerable.
4. The phantom bite syndrome is the situation where a patient cannot
find a position of comfort despite having worn dentures for many years. The
disturbance is invariably precipitated by the provision of new dentures to
correct the loss of fit and occlusal height in the old set! Here a neurotic or
even psychotic reaction is triggered off by a disturbance in orofacial
posture. In addition the patient may develop an obsessional concern for
some single feature, be it the shape of the teeth or the appearance of the
tongue or the colour of a crown. These conditions are best described as 4
mono-symptomatic hypochondriacal neurosis. If the symptoms become
more bizarre and obsessional in character, then it is a hypochondriacal
psychosis. The phantom bite syndrome may also occur in the dentate
patient following occlusal rehabilitation.
5. A variant form of mono-symptomatic hypochondriacal neurosis is the
complaint ofperversion oftaste, i.e. cachageusia. The patient may describe
a constant acid or foul taste or be obsessed with having halitosis. Clinically,
there is no evident cause and in most cases fruitless investigations of the
sinuses, chest and stomach have usually been carried out. Treatment
should be strong reassurance, simple instructions on oral hygiene including
cleaning the dorsum of the tongue with a soft wet toothbrush, supplemented
by the following medication. These patients respond better to a pheno-
thiazine and related drugs than the tricyclic antidepressants. Flupenthixol.,
commencing with 0-5 mg bd, and increasing the dose as required to 3mg a
day. An alternative is trifluoperazine 2—4 mg as slow release spansule twice
a day.

Factitious Ulceration
Painful factitious (self-inflicted) ulceration may be difficult to recognize,
particularly if the lesion resembles an aphthous ulcer or a stomatitis. The
mucosa may be abraded with either finger nails or the application of a
corrosive substance such as aspirin. Patients invariably deny causing the
lesion and the diagnosis has to be made on the basis that the site and
presentation do not fit a recognizable, pathological entity. In addition, there
is usually a history of emotional disturbance. Conversely, where lesions
appear to be bizarre or resemble some rare disease, a diagnosis which is not
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 ORAL SURGERY, PART 1
e, a self-inflicted
borne out by the microbiological or histological evidenc
lesion should always be conside red.
of stress, a
As these lesions appear to be an unconscious manifestation
be tried with a
phenothiazine, e.g. trifluoperazine 2-4mg a day can
psychiatric assessment or treatment as necessary.

OTHER SITES OF PAIN

The Tongue
Lingual pain may be sharp or burning and can be referred to the ear. When
the cause is an organic lesion, it is provoked by spiced or hot food or drink,
and by swallowing.
The benign mucosal causes include aphthous and viral ulceration,
erosive lichen planus, bullous lesions, and the atrophic glossitis of iron
deficiency or vitamin B,, deficiency. Occasionally, the enigmatic
geographical tongue will give rise to discomfort.
The possibility that an ulcer may be malignant is an important
consideration. Carcinomas which arise at the posterior end of the lateral
border, in the vallecula and on the posterior third of the tongue may cause
pain as the first symptoms and can be particularly difficult to detect while
still small. In all cases, the tongue should be examined carefully by drawing
it forward and holding it with a dry gauze swab. Some skill in using a
laryngeal mirror is necessary to see down as far as the epiglottis. If any
doubt persists in the clinician’s mind an examination under anaesthesia
with biopsy should be arranged.
The most common cause of lingual discomfort is the burning tongue of
glossodynia or glossopyrosis. This has been discussed in detail above—see
p. 327. Investigations will include biopsy, easily done under local
anaesthetic, serum iron and iron binding capacity, serum Bi2 and folate.
Each condition will require specific therapy. However, persistent pain
due to an inoperable carcinoma of the posterior third of the tongue may be
relieved by the division of the glossopharyngeal nerve in the tonsillar
fossa.

Salivary Glands
Pain is variable in character, often intermittent and dull, but well localized
and associated with a swollen gland which usually enlarges whilst eating.
With infection, pus can be expressed from the opening of the secretory duct,
the mouth of which will be seen to be inflamed. Intermittent swelling due to
obstruction can be provoked clinically by lemon juice.
The important differential diagnosis is mumps where the swelling usually
becomes bilateral and the patient is febrile and ill and may develop
inflammation at other glandular sites such as the testes, pancreas or breast.
With mumps the serum should be screened for S and V antibodies when the
patient is first seen and again ten days later.

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Obstructive causes for sialoadenitis include calculi, which are usually

seen in the submandibular gland and occasionally in the parotid. Calculi
can be diagnosed by plain radiography or may need to be confirmed by
sialography which should be done after an acute inflammatory phase has
been brought under control with antibiotics. Occasionally, the cause of
obstruction may not be seen, especially in the parotid, and is attributed to a
mucous plug, buccinator spasm or stricture of the duct. Just occasionally,
salivary gland tumours produce obstruction.
The persistent tender nodule in the parotid may be an adenoid cystic
carcinoma.
Many patients complain of persistent or intermittent pain and swelling
of the parotid area, occasionally strongly supported by the evidence
of family or friends which after careful consideration and investigation
proves to be psychogenic joint pain—facial arthromyalgia. The history is
usually of several months duration with pain provoked by eating and not
drinking and no actual swelling of the gland is seen despite repeated
examination.

The Maxillary Antrum

Acute sinusitis presents as a dull and often severe maxillary pain, either
unilaterally or bilaterally, which is characteristically worse on bending.
Unfortunately, the diagnosis may be obscured by sensitivity in one or more
of the premolar and molar teeth which can be exquisitely painful on
percussion, giving the impression of a pulpitis. However, the patient has
usually suffered a recent upper respiratory tract infection with nasal
obstruction and an anterior and posterior nasal discharge. The cheek is
tender to pressure and occipitomental radiographs will show an opaque
sinus often with a fluid level.
Chronic sinusitis consisting of intermittent nasal obstruction with
radiographic changes showing mucosal thickening and polyp formation
rarely gives rise to facial or dental pain. The condition may require active
treatment, or the persistent mucosal changes justify biopsy in case they
represent a carcinoma. An ENT surgeon will advise if this is so. In the
absence of clinical evidence of active disease the changes may be no more
than residual fibrosis of the mucosal thickening.
Where the patient is in fact suffering from persistent psychogenic pain
repeated medical and surgical treatment on the basis of such radiographic
appearances alone may be harmful rather than beneficial.
Carcinoma of the antrum tends to remain painless until late in its
development and patients are more likely to present with nasal obstruction
with epistaxis, facial enlargement, loose teeth, epiphora and elevation ofthe
eye. Pain is usually due to invasion ofthe nerves in the wall of the sinus So is
often associated with impaired sensation in the distribution of the maxillary
nerve.
All patients with otherwise unexplained maxillary pain should have an
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occipitomental radiograph as part of their investigation to exclude

carcinoma, particularly as a rotational tomograph may not reveal such a
lesion if it lies in part of the antrum outside the sharp plane of the tomogram.
An opaque soft tissue mass associated with bony erosion is the
characteristic radiological appearance.

The Ears
A painful otitis externa due to a furuncle, impacted wax or a fungal infection
may occasionally be referred to the mandibular area. The pain, however,
can be elicited by rotating the pinna and examination with an auroscope will
reveal the site of inflammation. Treatment by the GP or ENT surgeon is
directed towards the cause. Middle ear infection is associated with an
inflamed or ruptured tympanic membrane and requires urgent specialist
care.

Tonsils
The peritonsillar abscess (quinsy) occasionally presents as pain in the
maxilla with trismus, which the patient misinterprets as toothache.
However, on examination the palate is seen to be swollen between the uvula
and tonsillar fossa.
Treatment is with antibiotics, incision and drainage of the abscess. This
may be done in suitable patients in the upright position, anaesthetizing the
swelling first with topical, then with a submucosal injection of a local
analgesic. The alternative is to use a short-acting intravenous anaesthetic
with the head of the patient well extended in the supine position and a good
sucker to prevent inhalation of the pus.

The Elongated Styloid Process (Eagle’s Syndrome)

Painful dysphagia may follow fracture of the styloid process. Eagle’s
syndrome is pain arising from an elongated styloid process where a
diagnostic feature is said to be tenderness on palpation in the tonsillar fossa.
Whether an elongated styloid process is really the cause of such pain is
questionable. Radiographs reveal elongated styloid processes in many
middle-aged and elderly patients and pain of an acute nature in the
pharyngeal area should be considered to be a glossopharyngeal neuralgia, a
nasopharyngeal tumour or possibly psychogenic atypical facial neuralgia in
the first instance.

Pain in the Region of the Eyes

Acute glaucoma has been described as presenting with an ill-defined, acute
facial pain. However, the association of blurred vision and a palpably hard
eye should establish the diagnosis. A patient considered to have acute
glaucoma should be referred as an emergency to an ophthalmic surgeon.
Treatment consists of pilocarpine and surgery.

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 THE DIAGNOSIS AND MANAGEMENT OF OROFACIAL PAIN

Angina Pectoris
Occasionally, a manifestation of ischaemic heart disease is angina pectoris
referred to the angle of the left mandible or even the premolar region via
their common autonomic sensory innervation. The pain is provoked on
effort and will be associated with ischaemic changes on an electro-
cardiogram. Instances are known, however, where patients with a cardiac
infarct have presented with continuous severe pain in the left mandible
which they have attributed to a bad tooth. An extraction under these
circumstances would clearly have serious consequences.

PRIMARY NEURALGIAS
The most common paroxysmal neuralgia arises in the trigeminal nerve.
Occasionally, the condition also affects the glossopharyngeal nerve or
superior laryngeal branch of the vagus nerve. The aetiology of this pain is
unclear and has been attributed to viral damage within the ganglion,
demyelination of intracranial nerve roots due to nerve compression by
small vascular loops, by dural bands or by narrowing of the nerve foramina,
and even to ill-defined foci of chronic osteitis within the jaws.

Paroxysmal Trigeminal Neuralgia (Tic Douloureux)

Usually affecting the middle aged and elderly. The patient presents with a
sharp, often severe stabbing pain lasting seconds which is provoked by
talking, chewing, swallowing or by touching a specific area called the trigger
zone. However, rapidly repeated attacks at intervals throughout the day
may lead the patient to describe the pain as continuous. Women are more
often affected than men. The most common sites involved are the
mandibular mental and maxillary canine areas. The ophthalmic distribution
of the trigeminal nerve is rarely affected.
Attacks do not occur during the night except when the patient suffers
from insomnia. Although periods of remission are well recognized, the
condition tends to recur or persist throughout the patient’s remaining life
without any objective neurological signs appearing. The diagnosis may be
complicated by the fact that the pain can be provoked by an osteoarthritic
temporomandibular joint. The patient justifiably becomes depressed and in
between episodes of trigeminal pain may present with a persistent ache or
burning sensation which is usually an atypical facial neuralgia.
The pain can also be an early manifestation of disseminated sclerosis, or
of an intracranial neoplasm (see later under secondary neuralgias). The
development of fresh symptoms or detectable neurological signs therefore
calls for prompt further investigation.

Treatment
The anticonvulsant carbamazepine (Tegretol) 100-400mg_ taken
immediately on waking and 5—6-hourly, i.e. three times a day in all, controls
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the condition in most cases. It is important to introduce the drug gradually

to avoid nausea, drowsiness and ataxia. With time, these symptoms tend to
decrease, although in some patients the onset of an allergic dermatitis may
necessitate its withdrawal. Unfortunately, there is no equally potent
alternative drug, although phenytoin 200-400mg twice a day may be
useful. Clobezam 10mg three times a day may also be of value as a
supplement to carbamazepine or phenytoin. Contrary to earlier reports,
agranulocytosis, due to carbamazepine, is very uncommon.
Where drug therapy is inadequate, or immediate relief is essential, good
control can be achieved by injecting 1ml of 60 per cent or 90 per cent
alcohol into the mental or infraorbital foramina, taking care to avoid
entering a blood vessel by aspirating before the injection. The alcohol can
also be infiltrated in the region of the mandibular foramen at the lingula. In
all cases, 2ml of 2 per cent lignocaine should be given five minutes before
the injection to avoid unnecessary pain. The immediate relief is valuable in
distressed patients and may last for 6-12 months, although as with all
peripheral blockades recurrence in adjacent areas, that is displacement,
often arises sometimes within a matter of a few days. Peripheral
neurectomy and cryotherapy at these sites have comparable results. With
cryotherapy, an early return of sensation before recurrence of the pain is
said to be an advantage.
Intraganglionic alcohol injection or radiofrequency thermocoagulation
performed through the foramen ovale under radiographic control is
necessary when medical or peripheral measures fail. The advantage of
thermocoagulation is that the destruction of the nerve fibres may be
modulated to include principally the unmedullated pain fibres, preserving
some sensation and reducing paraesthesia.
Finally, an intracranial preganglionic section of the mandibular or
maxillary nerve trunk or division of the mandibular and maxillary nerve
fibres in the nerve root may be required where all other measures fail.
Intracranial vascular loops that compress the trigeminal nerve may be
divided and this may relieve the pain.

Glossopharyngeal Neuralgia
Glossopharyngeal neuralgia is brought on by swallowing and the pain
shoots both down into the throat and into the ear. The treatment is
analagous to that of trigeminal neuralgia above.

SECONDARY NEURALGIAS
Secondary neuralgias arise from irritation of the trigeminal ganglion or
nerves by some identifiable lesion and may either mimic exactly the
primary paroxysmal pain, or present as a less specific disturbance.
Important differentiating features are the associated local sensory, reflex
or motor impairment which may or may not be present when the patient first

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THE DIAGNOSIS AND MANAGEMENT OF OROFACIAL PAIN

presents. The lesion causing the disturbance can arise either extracranially,
within the cranial base, or intracranially.

Extracranial Lesions
Two mental nerve syndromes may give rise to neuralgia, commonly in
elderly patients. The more common arises from the pressure of a lower
denture flange which compresses a mental nerve which has become
superficial as a result of alveolar bone resorption. The pain may be elicited
by digital compression at the appropriate site and radiographically the
mental foramen is seen to be at the alveolar crest. Treatment in the first
instance may consist of relieving the denture over the origin of the nerve or
inserting a soft lining. However, in many cases, the nerve will have to be set
down surgically below the buccal surface of the residual alveolar process.
A less common mental nerve neuralgia is due to entrapment arising from
narrowing of the mental foramen itself and this may give rise to a
paroxysmal pain indistinguishable from a true tic douloureux. The
diagnosis is made easier if the patient is not a denture wearer and the
alveolar process is well preserved, in which case radiologically there is
evidence of a narrow foramen. Treatment consists of decompression of the
mental nerve by the careful removal of a ring of bone around the margin of
the foramen.

Causalgia
Causalgia is pain arising at the site of a nerve injury. Despite extractions
and frequent operative procedures to the mandible and maxilla, true
cauSalgia appears to be very rare. Its presentation may be a well localized
persistent burning or throbbing pain at the site of a traumatic surgical
procedure. This is commonly the upper lateral incisor or the lower 3rd
molar and relief can only be obtained by a complete local analgesic
blockade of all sensory pathways from the relevant jaw.
Some causalgias have been attributed to traumatic neuromas but,
unfortunately, excision of these discrete painful areas of mucosa has only
provided relief of pain in 50 per cent of patients. It is important to consider
the alternative diagnosis of atypical facial neuralgia which is probably a
vascular pain precipitated by an emotional disturbance.
Some cases of causalgia appear to arise following repeated irrelevant
surgery for the treatment of atypical facial neuralgia, and it may be possible
to convert the psychogenic vascular pain into an intractable causalgia in
this way. It is typical of causalgia that exploration of the injured site and
excision of scar tissue results in relief of the pain, but the pain returns as
healing is completed and new scar tissue forms.

TREATMENT
In the first instance the case is best considered to be an atypical facial
neuralgia, exploring the patient’s history and using an appropriate
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antidepressant drug therapy. With a true causalgia, nerve blocks will

provide immediate, reproducible and long-term relief. However, with
atypical facial neuralgia, if relief is achieved it is invariably of a short
duration—often no more than 10-20 days—and the pain will recur despite
persistent loss of sensation. For this reason, nerve section or ganglion
blocks should be withheld until the diagnosis appears to be certain.
In order to avoid irreversible nerve damage, cryotherapy to the
appropriate nerve, which is usually the inferior dental, will enable the pain
to be abolished without irreversible sensory loss. It may be repeated, or if
necessary the nerve itself avulsed.
Avulsion of the inferior dental neurovascular bundle is best done under a
general anaesthetic when it is identified at the lingula. The lingula should
then be removed using a chisel or an osteotome parallel to the lingual
cortex. This enables a satisfactory length of bundle to be grasped. Two
resorbable ligatures are best passed around the entire bundle and tied before
the bundle is divided. The nerve is then exposed at the mental foramen and
sectioned and avulsed by applying traction to the proximal end.
Intracranial root sections must be avoided in these patients as the
recurrence of pain and hence uncertainty about the diagnosis is high.
Therefore, rather than expose the patient to unnecessary surgical
morbidity, a better alternative is to prescribe a continuous course of
appropriate analgesics such as diflunisal or pentazocine.

Frey’s Auriculotemporal Syndrome

This condition arises following parotid or rarely temporomandibular joint
surgery or trauma. Occasionally it may arise spontaneously in cases of
diabetic neuropathy or following cervical sympathectomy.
The patient may complain of a burning sensation in the temporal or facial
region associated with flushing and profuse sweating on eating. Occasionally
there is persistent hyperalgesia between attacks. Cases have also been
reported provoked by certain foods, including cheese.
The syndrome is attributed to parasympathetic secretomotor fibre
reinnervation of the cut ends of sympathetic vaso and sudomotor nerves.
However, recovery in the post-surgical group and spontaneous onset in
those cases that arise following diabetic neuropathy suggest that the cause
may be a lack of inhibitory sympathetic tone. In some cases, the symptoms
appear to remit spontaneously after one or two years, although paradoxi-
cally many cases also arise suddenly a long interval after surgery.
Conservative therapy with parasympathomimetic blockade using poldine
methyl sulphate 2-4mg 3 times a day has varying degrees of success but
may produce an uncomfortable dry mouth and constipation. Nerve
avulsion including the auricular temporal nerve or intracranial section of
Jacobsen’s nerve is usually unhelpful. The topical application of an
anticholinergic such as 2 per cent glycopyrrolate or hyoscine cream may
336
THE DIAGNOSIS AND MANAGEMENT OF OROFACIAL PAIN

produce relief lasting up to 48 hours, and therefore can be repeated on a

daily basis.

Herpes Zoster
The pain in this condition invariably precedes the vesicular eruption which
may affect any peripheral nerve. However, in the head and neck region, the
ophthalmic division is commonly involved. The infection is thought to arise
due to activation of the varicella virus resident in the nerve ganglia, which
can occur at any age but is more common in the elderly and following some
debilitating disease, radiotherapy or steroid therapy. Where the virus has
also involved the geniculate ganglion the patient will have a facial palsy, the
so called Ramsay Hunt syndrome. Unfortunately, if the pain is initially
localized to a tooth, this may be extracted unnecessarily.
The vesicular eruption is best treated with the topical application of 0-1
per cent aqueous idoxuridine to oral mucosal lesions and a 5 per cent
suspension of idoxuridine in dimethylsulphoxide to the cutaneous lesions.
This must be done four times a day for four days, but needs to be applied
early in the course of the eruption to be beneficial. Acyclovir, which can be
given as tablets systemically as well as applied topically to the lesions, may
prove to be more effective.

Post-herpetic Neuralgia
This unfortunate complication may arise following untreated herpes zoster
and presents as a persistent burning pain in an area of diminished sensation,
hence the term ‘anaesthesia dolorosa’. It is attributed to the destruction of
the large myelinated sensory fibres by the zoster virus which abolishes their
modulating inhibitory effect at the posterior horn substantia gelatinosa gate
mechanism. The pain usually diminishes in six months to two years.
Treatment consists of analgesics such as ibuprofen 400mg, 4—6-hourly,
which may be supplemented with a tricyclic antidepressant drug such as
nortriptyline 10-100mg. Occasionally, stronger analgesics such as penta-
zocine will be necessary. Entonox, 50 per cent oxygen and nitrous oxide, is
useful during the acute attacks. The condition is not amenable to nerve
block, cryotherapy or surgery.

Nasopharyngeal Carcinoma (Trotter’s Syndrome)

Nasopharyngeal carcinoma is more common in South-East Asia, affecting
principally the Chinese, but it also appears to be a common lesion in
Alaskan Eskimos. It may arise in young people and is thought to be related
to the oncogenic Epstein-Barr virus.
The classical lesion arises in the fossa of Rosenmiiller behind the opening
of the eustachian tube and obstructs its aperture producing conductive
deafness. As the tumour infiltrates laterally, the mandibular and maxillary
divisions of the trigeminal nerve are involved giving rise to a combination of
facial pain, cutaneous analgesia and wasting of the masseter muscle. Direct
oF
 ORAL SURGERY, PART 1

invasion of the soft palate and the medial pterygoid muscle produces
ipsilateral elevation of the uvula, dysphagia and trismus. Extension towards
the base of the skull will eventually involve other cranial nerves.
The lesion may be detected by mirror inspection of the nasopharynx,
particularly under anaesthesia, and by lateral pharyngeal soft tissue
radiographs, but computerized tomography provides the best means of
visualization.
Treatment is by radiotherapy and cytotoxic drugs.
Cranial Base Lesions
Petrous Temporal Osteitis (Gradenigo’s Syndrome)
Very rarely, infection of the middle ear may spread through the petrous
temporal bone so that the osteitis reaches the meninges and involves cranial
nerves such as the abducen nerve and trigeminal ganglion. This produces a
lateral rectus palsy and facial pain usually with cutaneous analgesia. This
rare presentation is usually an extension of the so-called malignant otitis
externa in which an ischaemic necrosis arises in cases of diabetic
vasculopathy.
Treatment consists of careful debridement of the infected bone, a course
of metronidazole and vascularization of the dead space with a temporalis
muscle flap.

Cholesteatoma
A cholesteatoma may present with chronic facial pain and hypoaesthesia.
This is a slow growing lesion within the petrous temporal bone. The
diagnosis is made by computerized tomography, and the treatment is
surgical removal.

Other Cranial Base Lesions

Other cranial base lesions involving the cranial nerves include fractures,
paragangliomas nasopharyngeal tumours extending upwards, intracranial
lesions extending downwards and metastatic lesions from remote areas.
Rarely, Paget’s disease may lead to platybasia, compressing nerves in their
foramina. However, these conditions usually give rise to important physical
signs in other parts of the body.

Intracranial Lesions
Tumours of the Posterior Cranial Fossa
The classical example is the schwannoma (acoustic neurinoma) arising on
the VIII cranial nerve in the cerebellopontine angle. The trigeminal, facial
and vestibulo-acoustic cranial nerves are enclosed in the narrow triangular
space between the pons, cerebellum and medial surface of the petrous bone.
Thus the enlarging neuroma produces trigeminal pain and sensory loss,
deafness and ataxia. These together with nystagmus and a reduced corneal
reflex may be observed clinically. Further investigations should include
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 THE DIAGNOSIS AND MANAGEMENT OF OROFACIAL PAIN

radiography of the internal auditory canal and computerized tomography

(CT). Although this is a benign lesion, early removal is essential to reduce
operative and postoperative complications.

Middle Cranial Fossa Lesions

These include pituitary tumours and aneurysms of the internal carotid
artery. The latter enlarges within the cavernous sinus. Both ultimately exert
pressure on the optic chiasma and the nerves contained in the cavernous
sinus which include the ophthalmic division of the V and the III, IV and VI
cranial nerves. Thus tumours in this region produce facial pain, cutaneous
analgesia together with disturbances in vision and in extra-ocular
movements. Investigations will include plain skull radiographs, angio-
graphy and a CT scan.

Multiple Sclerosis (Disseminated Sclerosis)

This condition can occasionally present as a tic douloureux which is
indistinguishable from the idiopathic form. However, most cases have
accompanying neurological disturbances, such as loss of taste, disturbance
in facial sensation and neurological deficits of a sensory, reflex or motor
character elsewhere. These symptoms may remit or change, giving rise to
the characteristic dissemination in time and space, that is the pathological
features come and go in varied anatomical sites.
The condition should be suspected when a paroxysmal neuralgia occurs
in a young person. However, there may be a latency of many years before
the spread of the demyelinating disease becomes apparent.
The treatment is as described for the primary neuralgia. In the absence of
specific treatment for multiple sclerosis, a failure to make the diagnosis
during the patient’s first presentation is not detrimental and does not affect
the prognosis.

VASCULAR PAINS
Migraine
This is a recurrent unilateral throbbing headache associated with visual
disturbances, nausea and ataxia. The pain is intensified by sneezing,
coughing and movements of the head. It appears to be due to painful
pulsatile extracranial vasodilatation associated with intracranial vasocon-
striction. There are a multitude of precipitating factors which include
hormonal and emotional disturbances, hypoglycaemia, alcohol and foods
containing vasoactive amines such as cheese (tyramine) and chocolate
(beta-phenylethylamine). Migraine may also be associated with tension
headaches, facial arthromyalgia and atypical facial neuralgia.
Many patients achieve relief with simple analgesics which include aspirin
600-1200mg, paracetamol 0-5—1-0g, and mefenamic acid 500mg. A
continuous course of a sedative tricyclic antidepressant such as fluphenazine
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0-5 mg with nortriptyline 10mg (Motival, Squibb) can be highly effective in

preventing frequent attacks.
The vasoconstrictor ergotamine tartrate is widely used, either 2mg
sublingually, 0:36-O-72mg by inhaler or 0-25mg intramuscularly or
subcutaneously. However, ergot preparations have to be given as early as
possible in the attack for satisfactory relief, and can add to the malaise and
nausea of the attack if repeated too frequently. The drug should be avoided
in pregnancy and in patients with vascular disease, for whom simple
analgesics and prochlorperazine 5mg are recommended.
Pizotifen is an antihistamine and anti-serotonergic drug related to the
tricylics and may also be used prophylactically. Dose is 0-5-3 mg nocte,
increased slowly toavoid drowsiness and anticholinergic effects.

Facial Migrainous Neuralgia (Also known as Horten’s Syndrome,

Sluder’s Syndrome, Cluster Headaches, Histamine Cephalgia,
Spenopalatine Neuralgia, Vidian Nerve Neuralgia, Alarm Clock
Headache, etc.)
The many names for this condition reflect the problems associated with its
diagnosis and treatment. As with other types of migraine, the pain is
attributed to spastic dilatation of blood vessels, which in this condition are
the maxillary branches of the external carotid artery. It affects principally
men and classically occurs at night, waking the patient in the early hours,
hence the name ‘alarm clock headache’. It is an intense, throbbing pain,
usually lasting about half an hour, and the patient may notice that his eye is
red and his nose feels congested on that side. The attacks occur at regular
intervals and are sometimes repeated as a Series over a week or more before
they subside. Occasionally alcohol or coffee are precipitating factors.
The attacks may be prevented with ergotamine suppositories used nightly
before going to sleep until a phase of remission occurs. As with simple
migraine tricyclic antidepressant drugs are a valuable prophylactic.
However, there appears to be a strong clinical association between facial
arthromyalgia, migraine, facial migrainous neuralgia and atypical facial
neuralgia, suggesting that they all represent related vascular pain
mechanisms. Thus when conventional migraine therapy has been ineffective
or where there is a history of anxiety or depression the therapeutic regime
for atypical facial neuralgia is often successful.

Giant-cell Arteritis (Temporal Arteritis)

Arteritis of the superficial temporal artery presents as a headache or local
pain. However, the condition can affect other branches of the external
carotid with varying sites of pain. When the maxillary artery is involved, the
pain may present as intermittent claudication in the masticatory muscles on
chewing. If the lingual artery is involved ulceration and necrosis of the
tongue can occur. The great danger is involvement of the ophthalmic artery
with retinal infarction and blindness.
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Occasionally the arteritis is associated with polymyalgia rheumatica in

which the patient complains of widespread stiffness and joint pain. The
patient is usually elderly, and may also suffer from diabetes mellitus. The
erythrocyte sedimentation rate may be high and rheumatoid serological
tests positive.
If a superficial artery, such as the superficial temporal or facial, is
accessible for biopsy, the diagnosis may be confirmed by histology.
Where the condition is suspected, systemic steroids beginning with
prednisone 60mg or dexamethasone 10mg a day should be commenced
immediately to prevent blindness. The doses will be maintained for ten days
and then reduced until the condition is under control.

SUGGESTED READING
Blau J. N. (1982) How to take a history of head or facial pain. Br. Med. J. 285,
1249-1251.
Fienmann C., Harris M. and Cowley R. (1984) Psychogenic facial pain,
presentation and treatment. Br. Med. J. 288, 436-438.
Fisher F. J. (1982) Toothache and the cracked cusp. Br. Dent. J. 153,
298-300.
Griffiths R. H. (1983) Report of the President’s Conference on the examination,
diagnosis and management of temporomandibular disorders. J. Am. Dent. Assoc.
106, 775-777.
Guralnick W. (1984) The temporomandibular joint. Br. Dent. J. 156,
353-355.
Rosen H. (1982) Cracked tooth syndrome. J. Prosthet. Dent. 47, 36-43.
Seldin E. B. (1983) The emperor’s new meniscus. J. Am. Dent. Assoc. 106,
615-616.
Speculand B., Hughes A. D. and Goss A. N. (1984) Role of recent stressful life
events experience in the onset of TMJ dysfunction pain. Community Dent.
Oral Epidemiol. 12, 197-202.
Sutton R. B. O. (1982) The problem of obscure facial pain. Dent. Update 9,
159-164.

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 CHAPTER 14

DRUGS AND ORAL SURGERY

When a patient attends the practice for the first time the dentist will usually
take a full history, recording the details in the patient’s records. Such details
as:
a. The present state of the patient’s general health;
b. Past illnesses and accidents;
c. Current and, where appropriate, past medication, particularly thera-
peutic drugs received during the past twelve months; and
d. Allergies to drugs, dressings and other substances,
will all be included. Some of these factors may modify the patient’s dental
management and will be discussed in this chapter. Where the patient is
allergic to certain drugs or dressings or is taking drugs which are likely to
interact with those the dentist may administer or prescribe, or suffers from a
chronic disease relevant to the conduct of dental treatment, the fact should
be noted in a special, prominent location at the front of the notes or record
card.
Not infrequently patients do not know the names of drugs which they
have obtained from their medical practitioner. They may also claim allergy
when in fact the untoward reaction was either a manifestation of the actual
illness or an idiosyncrasy, i.e. the drug’s normal side-effects occurring at a
much lower dose than usual, or even a placebo reaction. Placebo responses
are those endogenous changes stimulated by the act of taking a drug, by the
clinician’s attitude and management, and by the environment. This
response may be positive—as will be discussed in pain control—or even
negative. A patient experiencing side-effects such as drowsiness and
dizziness when unknowingly given an inert tablet is a form of placebo
response. It is because of these complex and often unpredictable reactions
that the therapeutic value of any drug treatment can only be established by a
controlled trial.
Before each new course of treatment enquiries should be made about any
change in the state of the patient’s health, current medication, or any new
allergies, and fresh entries made on the front of the records if appropriate. If
during the course of treatment drugs are to be prescribed a further brief
question about allergies is an additional safeguard.
There will be a basic range of drugs which the practitioner will use
frequently and with which he or she will be thoroughly familiar. In the case
of all other drugs it is worthwhile referring to a formulary to check dosage,
the size of tablets or the concentration of solutions, etc., available from the

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pharmacist, and the usual total quantities prescribed. Formularies, like the
British National Formulary and the ABPI Data Sheet compendium will
also have a paragraph about special precautions, drug interactions and side-
effects under each entry.

PAIN CONTROL
This important area provides the best examples of the complexity of drug
usage (see review by Seymour and Walton 1982). For instance, the placebo
response in pain control, which explains the great variations in pain
response to surgery, appears to be dependent on the release of endogenous
analgesic substances in the central nervous system. These so called
endogenous opioids include the enkephalins and endorphin. This system
provides an important protection against pain and, although readily
activated in acute situations such as war and sports injuries, clinically it can
only be stimulated by careful patient control. Therefore a basic formula for
pain control is a combination of confident and reassuring management
enhanced by the use of sedation and a rational use of analgesics.
If pain does not respond to analgesia ensure that:
a. The patient is receiving an adequate dose at appropriate intervals. For
example, for optimum analgesia opiate analgesics should be used in
moderate amounts at short intervals or on demand, whereas aspirin needs to
be prescribed in large doses at less frequent intervals.
b. The underlying disease has been appropriately dealt with, i.e. pus has
been drained, infected roots removed, all fractures detected and immobil-
ized, and exposed soft or hard tissues dressed.
c. The pain is not psychogenic in origin. Psychogenic pain will not
respond well to analgesics and requires antidepressant drug therapy, e.g.
dothiepin hydrochloride (Prothiaden) 25—150mg nocte. Tricyclic anti-
depressant drugs also appear to have a centrally acting analgesic effect
which potentiates simple analgesics and opiates.
d. The pain is not a paroxysmal neuralgia such as trigeminal neuralgia
which responds only to an anticonvulsant type of drug such as carba-
mazepine (Tegretol) 100—200mg 3 or 4 times a day.

Non-steroidal Anti-inflammatory Analgesics

This group of drugs which includes aspirin act by the inhibition of
prostaglandin synthesis in damaged and inflamed tissues. The prosta-
glandins amplify the local effects of pain mediators. Therefore analgesics
should be used where possible prophylactically, commencing therapy
before the onset of anticipated pain and continuing it at regular intervals to
prevent pain becoming established. Simple analgesics used in this way are
highly effective following most surgical procedures and only cease to be
useful when too little is taken too late.
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Aspirin (Acetylsalicylic Acid)

Aspirin remains the most important analgesic and possesses antipyretic
and anti-inflammatory effects.

PREPARATIONS AND DOSAGE

The optimum analgesic dose is 600-900 mg aspirin for an adult, every 4-6
hours if necessary. It may be prescribed as soluble tablets or enteric coated
tablets each of 300mg, or as aspirin 400mg and codeine phosphate 8mg
which is available as soluble tablets and taken dissolved in water up to 4
hourly if necessary.
Because there is evidence that aspirin may be a contributory factor in the
causation of Reye’s syndrome (an acute encephalopathy with fatty changes
in the liver following a viral infection) aspirin should not be given to children
under the age of 12 years. (Committee on Safety of Medicines, letter
MEF 490/140 dated 10 June 1986.)
Adverse reactions include nausea, abdominal discomfort or gastric
erosion and bleeding, and therefore the drug must be avoided in any patient
who has peptic ulceration. All anti-inflammatory analgesics are best taken
after meals. Allergy may produce asthma, angioedema, urticaria and
rashes. By inhibiting platelet thromboxane synthesis aspirin can interfere
with platelet aggregation and produce haemorrhage and is therefore
contraindicated in any patient with a bleeding disorder or on anti-
coagulants. Also its protein-binding effect displaces inactive albumin-
bound anticoagulant, therefore amplifying the anticoagulant effect.
Tinnitus is not uncommon with the continuous use of high doses. Aspirin
should be avoided in patients with renal damage, which may be increased
by the drug, especially if excretion is impaired.
Tablets containing mixtures of aspirin, paracetamol and codeine
probably offer more analgesic effect with reduced individual side-effects,
e.g. aspirin and codeine or aspirin, paracetamol and codeine. Where a
codeine-containing preparation is used, constipation may be produced.

Paracetamol
Taken 500mg-1g, 4—6-hourly, paracetamol is probably less potent an
analgesic than aspirin with less anti-inflammatory effect, and where
inflammation is the underlying cause of pain, aspirin may be preferable.
Severe liver damage may result from taking 10g (20 tablets) at once.
However, the drug is useful in patients with peptic ulceration or bleeding
disorders and is suitable for infants.
Paracetamol is also available in combination forms, paracetamol 325 mg
and dextropropoxyphene 32-5 mg (a soluble preparation is available), or
paracetamol 500mg with codeine phosphate 8 mg, 2 tablets 3 or 4 times a
day. In both cases the adult maximum dose of 8 tablets in 24 hours must not
be exceeded.

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Propionic Acid Derivatives

This large group of drugs are analgesic with mild to moderate anti-
inflammatory reactions but with less adverse effects than aspirin, hence
they are used where chronic medication is required such as musculoskeletal
disorders as well as for short-term pain control.

Mefenamic Acid
Taken 500mg t.d.s. after meals, mefenamic acid may produce diarrhoea
and rarely haemolytic anaemia but gut blood loss is low. The drug will
increase anticoagulant effects.

Ibuprofen
Taken 200-400 mg, 6-hourly, ibuprofen does not appear to displace and
potentiate anticoagulants. Available as a suspension 100 mg/5 ml.

Narcotic Analgesics
This group, sometimes termed major analgesics, are centrally acting and in
most cases produce dependency when used for prolonged periods of time.
However, for short-term management of surgical patients this is no
disadvantage compared with their important analgesic effect. A more
immediate problem is their emetic effect and it is therefore advisable to
combine the analgesic with an anti-emetic such as perfenazinel 4mg by
mouth or 5 mg by injection, or metoclopromide 10mg i.m. or i.v.

Codeine (Methyl Morphine)

Codeine may be injected as the phosphate 30mg up to 4-hourly, to a
maximum of 200 mg in 24 hours. Although not as potent as morphine, it is a
useful mild postoperative analgesic in cases where head injury or surgery
may predispose to a latent intracranial bleed as it does not interfere with
pupillary reflexes and produce meiosis.

Pethidine
Dosage is orally 50-100mg, intramuscularly 25-100mg, intravenously
25-50 mg, lasting 3-4 hours. Pethidine is more potent than codeine but less
so than morphine. It also has a shorter effective analgesic duration but little
hypnotic effect. The pupils are not constricted and it does not tend to cause
constipation. However, it may cause vomiting and has an atropine-like
effect producing dry mouth.

Pentazocine
Adult doses are orally 25-100mg, 3—4-hourly after food, i.m. or i.v.
30-60 mg, every 3-4 hours. It is a potent analgesic when injected but less so
when taken by mouth, with a lower tendency than other narcotics for
producing dependency. In addition to the common adverse effects of
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nausea, vomiting, dizziness and sweating, it may produce hallucinations or

unpleasant dreams in some patients. Despite this, the drug has considerable
value in the management of benign, intractable facial pain with apparently
minimum side effects, for which up to 500mg a day may be required in
divided doses.

Morphine
Dosage of 10-20mg subcutaneously, intramuscularly or intravenously
produces potent analgesia and euphoria and is valuable in the control of
severe pain. However, in addition to its depression of the cough reflex, it
depresses respiration, stimulates vomiting, produces miosis, bronchospasm
especially in the asthmatic, and spasm of the gut muscle. An important
postoperative effect of morphine may be delayed micturition due to spasm
of the bladder sphincter. In some patients this may lead to severe urinary
retention requiring catheterization.

Papaveretum (Omnopon)
This is a reconstituted mixture of purified opium alkaloids which probably
does not differ substantially from the effects of morphine.

Buprenorphine (Temgesic)
Dosage is 0-3—-0-6mg intramuscularly or by slow infusion intravenously,
6-or 8-hourly. It can also be taken sublingually 0-2-0-4mg 6-8-hourly.
This is a new potent synthetic analgesic with rapid onset and prolonged
duration and little disturbance of respiration, cardiovascular function and
minimal dependency. However, in all other respects it resembles the
opiates and may have a potent emetic effect with some patients.
Remember that prolonged opioid analgesia after major surgery,
especially where the patient is confined to bed, may produce constipation
leading to faecal impaction and inflamed haemorrhoids. This may be
avoided by giving liquid paraffin and magnesium hydroxide mixture in
small doses or dioctyl sodium sulphosuccinate starting 24 hours before the
operation. For established constipation give a suitable laxative such as
bisacodyl (Dulcolax) given orally 5-10mg or as a suppository in the
morning.

Special Analgesic Considerations

Diamorphine (Heroin)
This is a potent opiate producing a high degree of dependency and is
therefore reserved for terminal cancer patients. Its value is analgesia and
euphoria when administered by mouth, commencing at 5—10mg as heroin
hydrochloride in various mixtures, e.g. Brompton or Saunders mixtures,
and is used for comforting the dying. In these cases the analgesic should be
given frequently and adjusted to the patient’s needs, e.g. 3-4 hourly,
preventing rather than suppressing pain. The addition of a tranquillizer or

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antidepressant and anti-emetic is preferred to cocaine as in the traditional

mixtures and helps with the control of the emotional aspects of pain.
The dying require a sense of security and companionship which may best
be provided at home but when necessary the essential symptomatic
treatment and medical nursing will have to be arranged in an appropriate
hospice. It is important also to remember that relatives also require support
and even antidepressant therapy.

Fentanyl
This is a synthetic opiate which is more potent but shorter acting than
morphine. It is used as an adjuvant agent intravenously or together with
droperiodol, a major tranquillizer, for so called neuroleptanalgesia. This
combination enables the patient to be sedated and analgesed rapidly but
remain cooperative. However, respiratory depression readily occurs and
administration should be slow and well controlled with spontaneous
respiration.
Dosage is 50-200ug then 50ug every 20-30 minutes as required;
children 3—ug/kg. With assisted respiration doses of up to 600ug may be
given to adults and 10-15 g/kg to children.

Phenoperidine
This an alternative choice to fentanyl. Adult dose is 0-5-5 mg i.v.

PREMEDICATION AND SEDATION

Premedication is intended to produce sedation, amnesia and analgesia and,
where appropriate, inhibition of parasympathetic activity, such as reduced
salivation, bronchial secretion and vagal inhibition. In an anxious patient
sedation may be required days before the procedure. In ambulant patients
diazepam 2—5 mg nocte with a further dose an hour before entering hospital
for out-patient surgery is very useful. Children may be given 2 mg as a small
pill or syrup, or alternatively trimeprazine forte syrup 1-2 mg per kilogram
body weight.
Diazepam used as intravenous sedation has proved to be both safe and
effective. Slow intravenous administration of up to 10mg is adequate for
most patients. The use of higher doses such as 2mg per stone body weight
produces the onset of ptosis, the Verril sign, and is often close to a hypnotic
level with loss of patient control. As diazepam is slowly excreted, even
though the patient is conscious and appears co-operative, he or she should
always be accompanied home. A common problem is thrombophlebitis at
the site of the injection which may now be avoided by using a diazepam
emulsion (Diazemuls—Kabi Vitrum).
Like diazepam, midazolam (Hypnovel-Roche) can be used to produce
sedation for the ambulant patient by intravenous injection. It has the
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advantage that it is water soluble and hence less likely to cause

thrombophlebitis. Both the onset of sedation and initial recovery are rapid,
but like diazepam residual effects may last for 8 or more hours and patients
should not drive cars or handle machinery until the next day. It is supplied
in5ml ampoules, each containing 10mg midazolam; 1-75 ml of the solution
containing 3-5m of midazolam is given initially, then after a pause of
2 minutes further increments of 0-25ml (0-Smg) can be given with
appropriate pauses to assess if sedation has been achieved. Adult dose is
usually between 2°5mg and 7:5mg.
The control of secretions and the prevention of vasovagal effects are
achieved with atropine 6mg or hyoscine 4mg subcutaneously or intra-
venously one hour before the operation. Promethazine hydrochloride
(Phenergan) 25mg is also used because of its sedative anti-emetic and
atropine like qualities.
The inhalation of 30 per cent to 50 per cent nitrous oxide with oxygen, the
proportion of nitrous oxide carefully graduated to need, is also useful as a
sedative-analgesic.

POSTOPERATIVE MEDICATION
As stated, postoperative analgesics such as pethidine or morphine should
be given in adequate doses at frequent intervals if pain demands it. The
combined emetic effect of the anaesthetic, the accumulation of blood and
gastric secretions within the stomach, as well as the action of opiate
analgesics, can be controlled by anti-emetics such as metoclopramide
(Maxolon) 10mg i.m. or perphenazine (Fentazin) 10mg. Both drugs may
produce extrapyramidal symptoms such as distonia with facial spasm or
torticollis, although the adverse effect occurs in only about | per cent of
cases. In high dosage tardive dyskinesia may occur.

NIGHT SEDATION
The following drugs help the many patients who have difficulty in sleeping
in hospital, especially the night before an operation.

Dichloralphenazone (Weldorm—S & N Pharm.)

Available in 650mg tablets the dose is 2—3 tablets taken with water nocte.
Also available as a syrup 225 mg in 5 ml which should be taken well diluted
with water.

Nitrazepam
Dosage is S—10mg and may produce hangover with drowsiness during the
following day.

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Chlormethiazole Edisylate (Heminevrin—Astra)

Available in 192mg capsules, the dose is 2 capsules nocte. This drug
produces less hangover and is less cumulative than nitrazepam.

DIABETES MELLITUS
The principal problem of the diabetic is control of the carbohydrate
metabolism, but a sufferer is also at risk because of vascular disease
affecting the heart, kidneys and lower limbs, and neuropathies which may
impair cardiorespiratory reflexes. Hence, apart from minor procedures, the
diabetic patient requires preoperative medical assessment.
Overweight, middle aged and elderly diabetics are normally treated by
diet alone in the first instance. Oral hypoglycaemic agents may be
prescribed if control is not established, despite adequate weight loss and an
appropriate dietary regime. Children and young adults and underweight
diabetics usually need injections of insulin to achieve control and permit
normal development.
Hypoglycaemic coma develops if the normal dose of hypoglycaemic
agent is taken, but a meal is missed. Sometimes hypoglycaemia follows the
rapid absorption of an injection of insulin, an error in the dose administered
by the patient or substantial unexpected exercise. Most patients recognize
the premonitary symptoms and will have learnt to take some sugar. These
symptoms may be mistaken by an observer for apprehension or even the
effects of alcohol. Once unconscious the patient will be cold and wet with
perspiration. Initially the hypoglycaemia could be easily confused with a
faint, but the patient does not respond rapidly to being put flat. The
hypoglycaemic state should not be allowed to persist in case permanent
brain damage results. When the premonitory symptoms are experienced or
observed 3—4 lumps of sugar dissolved in a squash drink can be given by
mouth. Once consciousness has been lost up to 50 ml of 50 per cent glucose
for injection is given intravenously. It should be given slowly into a large
vein.
The patient will usually recover consciousness during the injection.
Sterile saline 5—1O0ml for injection should be given through the same
needle to prevent the concentrated sugar damaging the vein wall and
causing thrombosis. Where venepuncture proves difficult an injection of
glucagon can be given and can be particularly useful in children, 0-5-1 unit
(0-5-1 mg) being given by the intravenous, intramuscular or subcutaneous
route.
Glucagon is normally produced by the cells of the islets of Langerhans
and mobilizes liver glycogen, raising the plasma glucose level. Either a 5
per cent dextrose intravenous infusion should be started or sugar should be
given orally as soon as the patient recovers consciousness until a stable
blood sugar is achieved. Blood sugar levels can be determined by doing a
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Dextrostrip blood sugar on a capillary blood sample and reading it with an

Ames Glucometer. Diabetic patients who have been unable to eat normally
because of a painful and tender tooth are at risk of hypoglycaemia if they
have taken their normal insulin. So also are those who arrive as an
emergency expecting a general anaesthetic and who have starved
themselves in anticipation.
Minor surgical procedures under local anaesthesia should not interfere
with meal times and require no change in the patient’s insulin or drug
regime. It is important to confirm that diabetic patients have had sufficient
food with their insulin and if not to provide a glucose drink before
commencing surgery. It is also important to stress that normal food or the
equivalent in replacement carbohydrate should be taken postoperatively,
later in the day.
Diabetic coma comes on gradually and insidiously and will not present as
a sudden emergency. However, infection increases the requirement for
insulin and a patient with an acute dental infection may be out of control
with incipient ketosis. Patients admitted as a casualty or trauma case may
also present with this complication. There is an obvious risk to
administering a general anaesthetic in such a situation. In general dental
practice if it is suspected that the patient is hyperglycaemic or ketotic the
general medical practitioner should be contacted urgently, or failing this the
patient taken to the casualty department of the local hospital.
For all routine dental treatment (except when a general anaesthetic or a
substantial period of sedation is involved) diabetic patients can be treated in
the same way as other patients. They should of course conform to their
normal dietary habits and treatment regime. An injection of a local
anaesthetic solution containing adrenaline may result in the transient
release of glucose from liver glycogen into the blood stream, but as this does
not lead to ketosis, it is of no importance.
Diabetics are more prone to infection than other patients so that any
infections should be treated vigorously and special care taken to avoid
postoperative infection.
There are two problems associated with the administration of general
anaesthetics to diabetics. The obvious one is the problem of maintaining
control of the diabetes when, as a result of the surgery, the demand for
insulin may vary, and of course, the supply of sufficient carbohydrate to
avoid hypoglycaemia. Hypoglycaemia is a particular hazard in the already
unconscious patient where pallor and sweating may be the only clinical
indication of its onset. The other problem relates to the proneness of
diabetics to cardiovascular disease and special attention should be given to
the patient’s status in this respect.

Procedures under General Anaesthesia

For short anaesthetics on an out-patient basis patients on oral hypolycaemic
agents simply omit the drug on the morning of the operation. Patients on
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insulin may do likewise, subsequently injecting a suitable proportion of the

daily requirement as soon as they are able to eat after the anaesthetic.
Alternatively, where just a single extraction is required the patient may
have the normal insulin and breakfast, then receive the anaesthetic a short
period before the next meal is due. The calorie equivalent of the next meal
must be consumed as soon as possible after recovery from the
anaesthetic.
As a general rule diabetic in-patients are better admitted to hospital at
least 24 hours prior to the anaesthetic, and put on a routine 3-hourly
diabetic observation chart which includes fasting and postprandial blood
sugars. With unstable diabetics admission 2—3 days prior to surgery is
essential to put the patient on a soluble insulin regime 3 times a day, and
stabilize their blood and urinary sugar.
Where possible diabetics should be operated on in the morning, and a
fasting blood sugar (a venous blood laboratory test if possible) should be
done in the ward preoperatively.

Preoperative Management
All patients are starved overnight. No hypoglycaemic agents are given on
the morning of the operation and a fasting blood sugar done. If the blood
glucose level is more than 5mmol/l the premedication is given and the
patient sent to the operating theatre.
If the blood sugar is less than 5 mmol/] an intravenous infusion of 5 per
cent dextrose is started before the premedication is given.

Intraoperative
In the operating theatre all insulin-dependent diabetics have an intravenous
drip of 5 per cent dextrose.
During the operation the blood glucose level is monitored every hour
using the glucometer and insulin or glucose given as necessary. If the blood
sugar is more than 10mmol/I, 10 units of a rapidly acting neutral insulin
such as Actrapid insulin is given i.v., and if less than 3mmol/1, 50ml of 50
per cent dextrose is given i.v. It is advisable to maintain the blood sugar
around 8-10mmol/I during the operative and postoperative periods.
When close monitoring of the patient is possible before, during and after
the operation an intravenous infusion of soluble insulin may be given at
arate of 1 to 2 units per hour and balanced by 5 per cent glucose and 4 per
cent glucose-saline infusions. Potassium supplements may be needed. The
amounts of insulin given are monitored by frequent blood sugar estimations.

Postoperative
It is essential to avoid hypoglycaemia during this period and therefore
insulin is avoided until the blood sugar level is above 10-12mmol/I. It
would be prudent to maintain an intravenous drip of 5 per cent dextrose for
24 hours after the operation in all labile and insulin dependent diabetics.
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 ORAL SURGERY, PART 1

During this period the blood sugar is checked 3-hourly, and a regime of
soluble insulin, 2 units per mmol blood sugar, is continued 6-hourly until the
patient is fit enough for his normal regime, and can be fed by mouth.
For afternoon surgery a light breakfast may be given and treatment is
then as before.
Operative stress and infection in diabetics will increase their insulin
requirements hence antibiotic cover to eliminate and prevent infection is
essential.
All confused and unconscious patients admitted with maxillofacial
injuries should have a urinalysis for glucose and ketones and a blood sugar
estimation. Rarely a hyperglycaemic state may predispose to an accident
and may be confused with excess alcohol consumption. Blood should then
be taken for an accurate estimation of glucose, electrolytes and pH and the
patient is rapidly rehydrated with saline. Insulin should be given 20 units
intramuscularly immediately and then 6 units/hour as an intravenous
infusion. Potassium loss requires correction in these patients and medical
advice should be sought.
Where emergency surgery is necessary the blood sugar should be
maintained between 8-5 and 10mmol/I (150—180mg/100ml).

CORTICOSTEROIDS
Following an injury, either accidental or planned in the form of surgery, a
serious infection, or during a general anaesthetic, the adrenals are
stimulated by ACTH to secrete a greatly increased amount of the adrenal
glucocorticoids, cortisone and hydrocortisone (cortisol). Failure of this
response results in a fall in blood pressure and blood volume. There are two
circumstances in which this may occur: on the one hand where there is
damage to the hypothalamus or a lack of functioning adrenal or pituitary
tissue, and on the other where secretion has been suppressed as a result of
the therapeutic administration of corticosteroids.
The adrenals may be destroyed as a result of a vascular catastrophy, by
an autoimmune mechanism as is often the case in Addison’s disease, or by
diseases such as tuberculosis or amyloidosis. Therapeutic bilateral
adrenalectomy is an important cause and hypophysectomy has a similar
effect by removing the stimulation of the adrenal cortex by ACTH.
Diseases involving the hypothalamus or anterior pituitary also interfere
with the hypothalamic—pituitary—adrenal axis. Aminoglutethimide is given
to post-menopausal women with metastatic carcinoma of the breast
because of its ability to inhibit the conversion of androgens to oestrogens
in the peripheral tissues. However, it also inhibits adrenal steroid
production.
In all these circumstances the patients will be receiving maintenance
doses of corticosteroids, and following an accident, or surgery, or a severe
infection with toxicity, additional corticosteroids will be needed to simulate

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the normal response to such stress-producing experiences. A suitable

regime for such patients is 100mg of hydrocortisone sodium succinate
given intravenously 6-hourly, starting 1 hour preoperatively, and with the
amount halved daily until the normal oral maintenance dose is once more
achieved. Although the doses involved are large they are given for short
periods of time only and consequently the anti-inflammatory and
immunosuppressive activity of the steroids can be ignored.
Where major surgery has been undertaken involving many hours under a
general anaesthetic it may be necessary to maintain the administration of
100mg hydrocortisone sodium succinate 6-hourly, at first intravenously
and then intramuscularly, for up to 72 hours from the time of pre-
medication. This high dose again given i.m. will be maintained even longer
if complications like serious infections supervene, particularly if the patient
is unable to take or retain oral preparations.
For routine oral surgery procedures lasting, say, up to two hours under a
general anaesthetic 100mg hydrocortisone sodium succinate given 8-
hourly intramuscularly starting with the premedication and then for the first
24 hours is likely to be sufficient. The normal oral maintenance dose is
continued thereafter.
For minor surgical procedures under a local anaesthetic as an out-patient
a single dose of 100mg hydrocortisone sodium succinate intramuscularly
given | hour preoperatively is usually adequate, or alternatively twice the
normal oral dose for 36 hours followed of course by the normal oral
maintenance dose.
All operative procedures for these patients are best scheduled for first
thing in the morning so that the initial postoperative observations are made
while the full day staff are still on duty. The blood pressure should be
measured every 15 minutes during the initial postoperative period, until the
patient’s condition is considered stable, then hourly up to 12 hours in the
case of routine cases and 2—3-hourly for the remainder of the period when
the maximum dose is judged appropriate for major cases. (However, a
balance must always be achieved between adequate, safe levels of
observation, the consequent disturbance of the patient’s much needed rest
and the demands made upon nursing and resident staff.)
Patients who have had exodontia or minor oral surgery under local
anaesthesia as out-patients should be kept under observation for several
hours before they return home. They and their relatives should be warned to
report promptly to a practitioner in the event of any nausea, vomiting,
feeling of faintness, etc.
The other group of patients at risk in this category are those with partial or
complete suppression of adrenal cortical activity as a result of the
therapeutic administration of steroids. The drugs are given for their ability
to suppress the manifestations of various inflammatory and hyper-
sensitivity reactions. If circulating concentrations of glucocorticoids at or
above physiological levels are achieved corticotrophin releasing factor is
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not produced by the hypothalamus to stimulate secretion of ACTH by the

anterior pituitary. As a result either partial or complete atrophy of the
adrenal cortex occurs. Where relatively small doses are involved atrophy
can be minimized by giving them on alternate days and to coincide with the
early morning circadian peak of normal steroid secretion.
Supplementary hydrocortisone sodium succinate should be given
whenever a therapeutic regime has been continued for a week or longer.
Mostly topically applied preparations and inhaled aerosol spray do not
result in a sufficient systemic effect to warrant supplementation. However,
high doses of aerosol spray and potent preparations applied topically under
occlusive dressings may produce a negative feedback effect on the pituitary.
Where substantial doses are involved similar regimes to those given above
are required. Where small doses are involved and onlv partial atrophy is
likely a single intramuscular dose of 50-100 mg of hydrocortisone sodium
succinate for out-patients, and a similar dose 8-hourly for 24 hours for in-
patients, should be sufficient.
It must be remembered in such cases that the manifestations of the
underlying disease are merely suppressed by the steroids not cured, and
potential complications of the disease itself in the face of surgery should be
given due weight.
Withdrawal of the steroid is usually effected once spontaneous remission
of the underlying disease seems likely. This is done in stages over a
substantial period of time. Even so it takes months for full recovery of the
adrenal cortex to occur. A single dose of 100mg of hydrocortisone sodium
succinate should be given within 6 months of a prolonged course of
treatment or 3 months of a short course.
Postoperative patients who suffer an unexplained, rapid fall in blood
pressure should be treated with a further intravenous injection of
hydrocortisone sodium succinate as a matter of urgency. However, once
this has been done other causes of shock such as a cardiac infarct,
concealed haemorrhage, or a septicaemic infection should be excluded.
Indeed serious infections may occur without the normal obvious physical
signs. Patients who have been on prolonged therapeutic regimes may not
gain wound strength at the normal rate, bone healing may be delayed and
they are susceptible to postoperative infections. These factors must be
taken into account in planning the surgery.
All patients who are receiving corticosteroids should carry a steroid card.
This will record who has prescribed the drug and the dosage and advises
patients to show the card to the dentist. It also warns that the treatment
should not be stopped without medical advice and that additional steroid
may be appropriate in case of infection, accident or operations. It is both
helpful and courteous to discuss the proposed steroid supplementation with
the doctor prescribing the steroids.
The synthetic anti-flammatory steroids dexamethasone and betametha-
sone have been shown to reduce significantly postoperative swelling under

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controlled conditions without any evidence of delayed healing, infection or

other morbidity. Dexamethasone 4mg given intravenously with the
anaesthetic induction agent and repeated the following day, orally or
intramuscularly, has no detectable effect on plasma cortisol or electrolytes,
but only reduces the swelling to about 85 per cent of the controls and does
not affect trismus. Dexamethasone 10mg used in this way will produce a
detectable plasma cortisol depression to the lower limit of the normal range,
gradually recovering over 3-5 days. However, there is a significant
reduction in swelling ranging from 66 per cent on day | through to 15 per
cent of controls on day 7. This dose also reduces postoperative trismus.
Wound infection and healing were unaffected. Therefore some clinicians
use for minor oral surgery 10 mgi.m. with the premedication (or i.v. with the
anaesthetic) and 10mg i.m. or orally 24 hours later. For maxillofacial
procedures dosage is as follows:
Day 1 10mg Dexamethasone with premedication
Day 2 10mg Dexamethasone 1|2-hourly
Day 3 5mg Dexamethasone 12-hourly
Day 4 5mg Dexamethasone mane
Used with discretion, these regimes are valuable. However, it must be
emphasized that the routine administration of these steroids should not be
necessary if tissues are handled gently, haemostasis is obtained before
wounds are sutured and vacuum drains placed in all major wounds,
particularly where there is a potential dead space. If gross swelling results
as a routine the operator’s surgical technique should be reviewed.

ORAL ANTICOAGULANTS
Immediate and short-term anticoagulation is produced by intravenous
heparin and withdrawal of the drug is usually sufficient in the event of
unwanted bleeding. Phenindione (dindevan) and coumarins, particularly
warfarin, are used for sustained or long-term anticoagulation. These drugs
are given orally and antagonize the effects of vitamin K by substrate
competition. Warfarin is currently the most popular drug.
Anticoagulants are prescribed to prevent intravascular clotting, propaga-
tion of thrombus and embolism. They are prescribed for deep vein
thrombosis, patients with prosthetic heart valves and those with poorly
controlled atrial fibrillation. There is a long period of 36-48 hours before
warfarin is fully effective and it is during this period that heparin is given if
immediate anticoagulation is required. Because of the serious nature of the
complications which anticoagulation seeks to prevent, stopping the
treatment completely is usually avoided. Further sudden stoppage may lead
to a rise in factor VIII levels to above normal. Patients are usually
maintained with a prothrombin time between 2-0 and 4-0, British
Comparative Ratio (BCR), at which level spontaneous haemorrhage is
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 ORAL SURGERY, PART 1

usually avoided. The equivalent thrombotest level is 5-15 per cent

prothrombin activity.
If oral surgery is necessary for a patient taking oral anticoagulants the
patient’s physician is contacted, a full medical summary obtained and a
suitable regime agreed. Patients on anticoagulants should carry an
anticoagulant treatment card which records the dose of warfarin and the
BCR each time tests are done. This will give an indication of the level of
anticoagulation normally achieved.
The current prothrombin time is determined. At a BCR of 2-0 it is
normally safe to perform routine extractions, a few at a time, or limited
minor oral surgery. If the BCR is greater than 2-0 a dose or doses of warfarin
are omitted to let the prothrombin time reach a safe level. Because of the
delay before warfarin is fully effective a normal dose should be taken
immediately after the operation.
Where a more rapid return to the anticoagulated state is desirable 5000
units of sodium heparin may be injected subcutaneously starting as soon as
stable haemostasis is ensured and 1 2-hourly until the patient is ambulant or
can be re-established on an oral regime. Small doses of heparin activate
antithrombin II which inhibits factors X and thrombin. Particular care
must be taken with haemostasis and drains inserted where necessary.
Surgicel is inserted in the sockets, or for larger bone cavities, surgicel
soaked in Russel viper venom (Stypven) and the wound carefully sutured.
Excess bleeding as a result of surgery and the coumarin anticoagulants can
usually be controlled in an emergency by packing and suturing. If it is
serious the patient should be fully investigated, i.e. haemoglobin, full blood
count, prothrombin time or thrombotest, whole blood clotting time
(WBCT), thrombin time (TT) or activated partial thromboplastin time
(APTT). With controlled anticoagulant therapy, the WBCT and TT are
2-3 times normal and the APTT 1-2 times normal. Serious or severe,
continued bleeding may require further reversal of the anticoagulation. This
can be done by giving phytomenadione (vitamin K,) 2-5-10mg by slow i.v.
injection. However, this will take up to 12 hours to be effective and will
disturb further anticoagulant therapy for days or weeks. Therefore in such
an emergency fresh frozen plasma will provide more immediate control.
These measures are not without risk of precipitating venous thrombosis. It
should be rare that oral surgical haemorrhage cannot be controlled by local
measures.
Aspirin, and other protein binding drugs, alcohol, co-trimoxazole,
metronidazole, etc., potentiate the effects of warfarin. Some drugs which
increase liver microsomal activity like barbiturates antagonize the effect of
warfarin. A formulary should be consulted before prescriptions are given to
these patients.
Deep vein thrombosis with embolism is rarely a complication of head and
neck surgery although it can be encountered with multiple injuries involving
the pelvis and femora. If the risk is anticipated, especially in patients over
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50 years and heavy smokers, again a prophylactic subcutaneous heparin

regime should be used (5000 units s.c. 12-hourly).
If deep vein thrombosis is detected then a full anticoagulant regime is
required as follows: a loading dose of 5000 units of heparin intravenously
followed by a continuous infusion of 40000 units over 24 hours or 10000
units intravenously every 6 hours. Simultaneously the patient is started on
warfarin 10mg daily for 3 days then adjusted to the maintenance dose of
3—10mg a day maintaining a prothrombin time of 2-3 times the control. It
should be measured daily from the fourth day of treatment.
Warfarin is teratogenic and should not be used in the first trimester of
pregnancy.

ORAL CONTRACEPTIVES
Oral contraceptive tablets contain either a mixture of oestrogen and
progestogen or progestogen alone. The oestrogen/progestogen tablets vary
in the amount of oestrogen which they contain from 20 yg oestrogen to 50 ug
oestrogen. One of the side-effects of both types of contraceptive pill is
venous thrombosis and thrombo-embolism. The risk is less the lower the
oestrogen content but is also a potential problem with the progestogen only
preparation. In the case of the lower dose oestrogen combined preparation
and the progestogen only tablets precise adherence to regularity and timing
of doses is important if they are to be effective. Many women using this form
of contraception now take tablets containing 30-35 wg oestrogen.
Deep vein thrombosis starting in the calves and propagating upwards is a
possible complication of surgery or even confinement to bed and the risk of
this is increased by the contraceptive pill. Pulmonary embolism from such
thrombi is serious and is a potential cause of sudden death in the
postoperative period. Permanent damage to the venous return of the leg can
result also. Smoking increases the risk of venous thrombosis for women
using the pill.
Patients who are to have elective in-patient surgery preferably should not
take oral contraceptives for 4 to 6 weeks preoperatively and of course
should be advised to use alternative methods of contraception during the
next (postoperative) menstrual cycle. Some women do not admit to taking
contraceptive pills for a variety of reasons. Often they are part of their
normal way of life and not considered medication. Sometimes they feel that
the environment at consultation prior to admission is not private enough. To
avoid having to delay a major elective procedure these factors should be
considered at preoperative visits.
Quite a proportion of women due for more minor in-patient surgery will
only disclose their use of the contraceptive pill at the time of admission.
Where the procedure will not last longer than, say, 1-2 hours and where the
patient will be fit enough to get up and move around the next day experience
shows that the risk of venous thrombosis is very small. In all such cases the
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 ORAL. SURGERY, “PART 1

pill should be stopped on admission and until the appropriate starting day in
the next cycle and an alternative method of contraception used until after
the fourteenth tablet in the next cycle. Preferably the patient should consult
the doctor or clinic prescribing the tablets for expert advice.
Some patients will attempt to maintain the course of tablets despite the
anaesthetic and surgery from their own supplies. This is to be discouraged
as a failure to take the tablets regularly or at the correct time or if one is
vomited up it can lead to a lack of effectiveness and an unwanted
pregnancy.
Certain drugs interfere with the effectiveness of oral contraceptives. Of
particular importance to dentists is the interaction of antibiotics, particularly
ampicillin, barbiturates and carbamazepine. A formulary should be
consulted before drugs are prescribed for patients on the pill.
Oestrogens may be prescribed for other reasons, for example, during the
menopause, for men with metastatic carcinoma of the prostate and
occasionally for women with carcinoma of the breast. Discussions with the
doctor prescribing the oestrogens is indicated to evolve an appropriate
regime.
Support at the ankles by plastic foam wedges during the surgery to
prevent pressure on the calves, leg exercises and early mobilization are
general measures to reduce deep vein thrombosis. Low-dose heparin can be
used as a prophylaxis against venous thrombosis and pulmonary embolism
and can be used where the patient has not stopped taking the contraceptive
pill at the proper time and where delay to the operation is not appropriate,
or where a risk seems possible even with a short procedure. Heparin
5000 units is given subcutaneously and repeated every 12 hours until the
patient is ambulant. However, heparin even in this dose will increase the
amount of oozing at operation and can produce unsightly haematomas at
the site of the injection. Haemostasis can usually be effected with care in
soft tissue wounds, but postoperative oozing from cut bone and consequent
haematoma formation is a risk.

SMOKING
Patients should be encouraged to reduce the amount they smoke before
operation and if possible to stop completely for some days beforehand, a
week or ten days if possible. Smoking increases the incidence of
postoperative chest infection, venous thrombosis and embolism, and can
increase vascular spasm or reduce the blood supply to pedicle and free
flaps.

HYPOTENSIVE AGENTS
A variety of drugs are used to control hypertension either singly or in
combination. They control the blood pressure by a number of different

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mechanisms. At one time it was considered best to withdraw hypotensive

treatment before a general anaesthetic because the peripheral vasodilata-
tion induced by the anaesthetic drugs could increase the fall in blood
pressure. With currently used drugs it is mostly safer for patients to
continue with their medication, rather than to present the anaesthetist with
an uncontrolled hypertensive. Indeed, withdrawal of some drugs results in
rebound hypertension. In general such patients are best referred to hospital,
even for a short general anaesthetic, so that they can receive the care of an
experienced anaesthetist.
The use of local anaesthetics in normal quantities is not contraindicated
but prilocaine with felypressin may be preferred and local anaesthetic
solutions containing noradrenaline should be avoided. Hypertensive
patients of course tend to ooze more than normotensive individuals during
surgery and hypertension can be one cause of postoperative haemorrhage.

TRICYCLIC ANTIDEPRESSANTS
Noradrenaline is released as a neural transmitter at postganglionic
sympathetic nerve terminals. Part of the released noradrenaline is
inactivated by catechol-ortho-methyltransferase and some escapes into the
circulation, but 85 per cent is taken up again into the nerve terminal to be
used again. This active pump mechanism is inhibited by competitive
binding by tricyclic antidepressants, leading to an increase in circulating
noradrenaline.
A large number of tri- and tetracyclic antidepressants are available.
There is a risk of ventricular dysrhythmias and of a rise in blood pressure if
injections containing adrenaline or noradrenaline are given to these
patients. Hypertension is a particular hazard with noradrenaline and this
vasoconstrictor particularly should be avoided. Local anaesthetic solutions
containing felypressin may be used with safety for these patients.
Withdrawal of tricyclic antidepressives before a general anaesthetic is
usually not in order because the effects of the drug persist for 2-3 weeks. Ifit
is withdrawn for such a period of time, relapse of the depression is likely and
there will be a further period of 10-14 days before control is re-established
after recommencing treatment.

MONOAMINE OXIDASE INHIBITORS (MAOI)

Monoamine oxidase modulates the release of noradrenaline at sympathetic
nerve terminals by inactivating noradrenaline within the terminal. It is also
present in the liver and gastrointestinal tract where it detoxicates dietary
amines such as tyramine. It is for this reason that certain items of food
precipitate headache and hypertension in patients taking monoamine
oxidase inhibitors. Because of the dietary restrictions required MAOI have
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declined in popularity and have been partly replaced by tricyclic

antidepressives.
Adrenaline in local anaesthetic solutions does not present a hazard for
patients taking MAOI. However, noradrenaline is released and in large
amounts by sympathomimetic amines like amphetamine, ephedrine,
phenylephrine and isoprenaline and these substances must not be
prescribed. Tricyclic antidepressants also must not be given with
MAOI.
Morphine and other opioids can also precipitate a hypertensive crisis and
pethidine results in severe hypotension. The inactivation of monoamine
oxidase by MAOI is irreversible and persists for up to 14 days after
withdrawal of the drug so that prescription precautions apply during this
time. These patients often carry a treatment card which indicates which
drug they are taking and a series of precautions which the patients must
follow.

LITHIUM
Certain lithium salts are prescribed for patients with manic-depressive
illnesses. The therapeutic range is quite narrow and special care is required
to avoid toxicity. Sodium depletion and vomiting can potentiate the effect of
lithium and result in toxicity. Short out-patient procedures are unlikely to
require changes in medication but the anaesthetist may require the drug to
be discontinued a week before major in-patient surgery. The patient’s
psychiatrist or physician prescribing the lithium should be consulted.

ANTICONVULSANT DRUGS
There is a great temptation to stop anticonvulsant therapy for epileptics
when undergoing surgical procedures, particularly if they have no recent
history of fits. Unfortunately both the procedure and the abrupt withdrawal
of the medication may precipitate a seizure postoperatively. Epileptics are
normally continued on their anticonvulsant regime for an operation under
general anaesthesia. The preoperative dose is given orally as usual with
minimum water and then parenterally until the patient can swallow without
being sick postoperatively. Despite the administration of sedation or
anaesthetic drugs fits are more likely to occur in the postoperative
period.
Epileptic patients who have taken their tablets should be treated
normally for oral surgery under local anaesthesia. Even so, occasionally a
patient will have a fit as a result of the stress of attending. Recovery is
usually spontaneous with general care and a rubber ring between the teeth
during clonic contractions prevents tongue biting. Should status epilepticus
supervene, intravenous diazepam may be given slowly (not methohexitone
or thiopentone which excite the motor cortex). However, respiratory arrest
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may ensue as the fits are controlled and it must be possible to give controlled
ventilation with oxygen.

PORPHYRIA
This is an inborn error of porphyrin synthesis which occurs in several forms.
Sufferers normally carry a warning card. It is particularly important not to
give either thiopentone or methohexitone to them.

HEREDITARY RED CELL ABNORMALITIES

Certain abnormalities of red cells are important to the oral surgeon because
either drug therapy or anaesthetics can present particular problems.

ENZYME DEFICIENCY
Glucose-6-phosphate dehydrogenase (G6PD) is the first enzyme in the
hexose monophosphate shunt of the Embden—Myerhoff glycolytic pathway
from which erythrocytes gain most of their metabolic energy. This shunt
services the enzymes glutathione reductase and glutathione peroxidase
which protect erythrocytes against oxidation damage. If G6PD is absent
this protective mechanism is reduced and certain drugs in substantial
concentration can injure the red cells. High doses of sulphonamides,
antimalarials and aspirin, phenacetin and chloramphenicol taken during
infective illnesses can result in haemolysis. It is an X-linked recessive
disorder affecting mainly negroes and particularly those in East and West
Africa where the incidence may reach 20 per cent in males and 4 per cent in
females.

HAEMOGLOBINOPATHIES
Haemoglobin is composed of two pairs of polypeptide chains and four haem
molecules. Each polypeptide chain is folded to enclose one of the haem
molecules. During fetal life and the first few weeks after birth, human
erythrocytes contain haemoglobin F.
The globin in haemoglobin F is composed of 2 apolypeptide chains and
2y chains (a2y2). Normal adult haemoglobin comprises mostly haemo-
globin A, formed by 2@ and 2f chains (#282) with some A2 (a@262).
In one group of conditions certain amino acids in the polypeptide chains
of some abnormal haemoglobins are substituted by others. There are
several hundred such variants, only a few of which are of clinical
significance. They are either designated by a capital letter of the alphabet or
the name of the locality where they were discovered. Sickle-cell anaemia is
the most important of this group in respect of therapeutic hazards.
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In another group the gene for one type of polypeptide chain is either
missing, or defective, or its translation is defective. Consequently one pair
of polypeptide chains is either absent or incomplete. The f and a
thalassaemias are the most frequently encountered examples of this
group.

Sickle-cell Disease
A normal adult has the haemoglobin genotype A,A. Sickle-cell trait, the
heterozygous state, has the genotype A,S and homozygous sickle-cell
disease, S,S. Some patients, heterozygous for the sickle-cell conditions,
have haemoglobins other than A present, such as C, D and E. Haemoglobin
synthesis is inherited from both parents and expressed as a mozaic. Thus if
both parents are heterozygous a quarter of the offspring are likely to be
normal, a further quarter will have sickle-cell anaemia and the remainder
sickle-cell trait.
When haemoglobin S is deoxygenated, the molecules of haemoglobin S
becomes cross-linked to form elongated pseudo-crystalline “tactoids’ which
distort the red cell into the ‘sickle’ shape. Although the change is reversible
with reoxygenation, permanent deformation of the red cell envelope occurs
after repeated sickling. The presence of haemoglobin F strongly inhibits
tactoid formation but the presence of C as haemoglobin SC facilitates their
formation. The change is likely to occur in sinusoidal vessels or capillaries
where blood flow is sluggish. Sickle cells render the blood more viscous and
they obstruct capillaries resulting in infarction.
Trait patients may appear healthy. As the presence of HbS confers a
degree of resistance to malaria (which is not enhanced by the homozygous
state) this accounts for its prevalence in the areas in which this disease is
endemic and its persistence in negroes. However, even trait patients may
experience sickling with relative anoxia occurring, for example, during the
induction of general anaesthesia, in inadequately pressurized aircraft or ina
limb prepared for bloodless field surgery by the use of a tourniquet.
Two major complications face homozygous sickle-cell disease patients: a
severe haemolytic anaemia and infarction crises. Normally the patients
have only 8-10g/dl haemoglobin. Episodes of sequestration of red celis
lead to rapid further falls in haemoglobin level. Viral infections can even
precipitate an aplastic anaemia. The spleen and liver are enlarged and red
marrow hyperplasia enlarges medullary spaces and produces bossing of the
skull. Infarction crises in bone or spleen result in severe pain, fever, malaise
and jaundice. Secondary infection in bone infarcts results in osteomyelitis.
Infarction of renal papillae leads to haematuria, and mesenteric infarction
to an abdominal emergency.

Investigation
A simple blood film from an homozygous patient is likely to contain a few
sickle cells, but a film from a ‘trait’ patient will be normal. However, blood
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from a heterozygous patient mixed with a sodium metabisulphate solution

and allowed to stand, covered with a coverslip, for twenty minutes will show
sickling. The Sickledex test is done using blood from a finger prick in small
tubes, one containing the test specimen and the other acting as control.
After 5 minutes, with a positive result cayenne-pepper-like clumps of red
cells can be seen when the tube is viewed against a white background. This
is convenient as a surgery screening test.
Neither the Sickledex test nor the slide test differentiate between
haemoglobins AS, SS, SC, SD, SE or S thalassaemia. Positive patients or
patients about whom the clinician is suspicious on clinical grounds should
be referred to a haematologist and a haemoglobin electrophoresis
performed which will distinguish these various conditions. The patient
should be issued with a card stating the exact abnormality to avoid repeated
investigation and near relatives should be investigated where this has not
already been done. A simple haemoglobin estimation to determine the
degree of anaemia should not be forgotten.

Treatment
Both sickle-cell trait and sickle-cell disease patients can be treated under
local anaesthesia, but large volumes of solution containing the higher
concentrations of adrenaline which might cause appreciable tissue cyanosis
should not be used.
Where a general anaesthetic or inhalation sedation is required referral to
hospital is advisable, so that an experienced anaesthetist can give the
anaesthetic. Inhalation sedation or a short general anaesthetic with
adequate oxygenation is usually safe for trait patients on an out-patient
basis. Homozygous patients are usually admitted and the haemoglobin
level checked. In some still ambulatory patients it can fall as low as 5 g/dl as
these patients become habituated to a relative anaemia. Preoperative
transfusion will then be necessary.
Special precautions to ensure pre-induction oxygen saturation and to
avoid any episodes of restricted oxygen intake are important. Anaemic
patients may not exhibit clinical cyanosis as the amount of reduceable
haemoglobin may be insufficient to produce a colour change. Dehydration
and electrolyte depletion must also be avoided.

B-Thalassaemia
The condition is found commonly in the Mediterranean area and
particularly among certain island populations. In B-thalassaemia part or all
of the B polypeptide chains are not synthesized. The heterozygote
thalassaemia minor produces a mild anaemia but little disability. The
homozygous condition is serious as the patient is unable to synthesize
haemoglobin A (a2£2) because PB chains cannot be formed. There is a
profound anaemia from soon after birth with increased destruction of
abnormally shaped red cells. Production of haemoglobin F (a2 y2) which
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contains no f chains, continues beyond the neonatal period and increases to

form 30-40 per cent of circulating haemoglobin. Despite red marrow
hyperplasia the child cannot survive for long unless transfused, but repeated
transfusion soon leads to haemosiderosis. There is bossing of the skull due
to subperiosteal haemopoiesis and massive hepatosplenomegaly.
Diagnosis
There is almost always thalassaemia among the other members of the
family. Thalassaemia minor patients have a mild iron refractory hypo-
chromic anaemia. A blood film will demonstrate microcytes and red
cells are resistant to osmotic lysis. On electrophoresis there is a raised
haemoglobin A2 (a@262) fraction. The thalassaemia major patients are
small for their age, are obvious chronic invalids and almost always already
under the care of a haematologist or paediatrician. They are anaemic,
indeed profoundly so. A blood film will demonstrate severe red cell
dysplasia and erythroblastosis. Haemoglobin electrophoresis will reveal an
absence of haemoglobin A and raised haemoglobin F. Both parents will
have thalassaemia minor.
Heterozygous patients can be treated normally in practice but multiple
extractions and oral surgery other than the removal of the roots of a single
tooth or straightforward impaction are best undertaken in hospital. General
anaesthetics are best given at a hospital.
Routine restorative work can be managed in practice for the homozygous
patient. They are particularly susceptible to infection and present obvious
difficult management problems so that admission for any oral surgery is
essential.

a-Thalassaemia
This condition is encountered mainly in South-East Asia. Two variants
occur, one with severe and the other with mild inhibition of achain
production. Heterozygotes rarely present a clinical problem. Homozygotes
of the mild form require management in hospital. Homozygotes of the
severe disease die in utero.

DRUG ALLERGY
Hypersensitivity to drugs is likely to occur in patients with a history of
general allergy, i.e. atopy which usually takes the form of hay fever, asthma
or eczema. The most common sources of drug reaction are penicillin,
sulphonamides, aspirin and antitetanus serum, but few drugs are free of
allergenic potential.
In all cases the medication must be stopped and the patient treated as
follows:
1. For skin rashes which are urticarial, maculopapular, morbilliform,
vesicular, bullous or eczematous an oral antihistamine should be given such
364
 DRUGS AND ORAL SURGERY:

as chlorpheniramine maleate 4mg, 3-4 times a day. Very irritant lesions

may also be treated with 1 per cent hydrocortisone cream.
2. For erythema multiforme, consisting of conjunctival, orolabial and
urethral inflammation together with the cutaneous target lesion rash should
be treated immediately with high doses of corticosteroids, e.g. dexametha-
sone 4mg or prednisone 20mg, 8-hourly, reducing the dose gradually after
seven days.
3. Angioedema can be treated with an oral antihistamine or 10-20mg
chlorpheniramine maleate by intramuscular or slow intravenous injection.
If severe and involving the respiratory tract adrenaline 0-5—1 ml of 1 : 1000
(equivalent to 0-5-1 mg) should be given intramuscularly. Simultaneous
intravenous hydrocortisone sodium succinate 100mg should be given.
Where the airway remains obstructed tracheal intubation or even a
tracheostomy will be required.
4. Asthma can be treated with salbutamol which is a beta 2-
adrenoreceptor stimulator producing bronchodilatation and can be given by
aerosol inhalation 100—200 ug (1-2 puffs) 4-hourly, by tablet 2-4 mg, again
4-hourly, or by slow intravenous injection of 250g. If not available
aminophylline 250-SOOmg may be given by slow intravenous injection
over 15 minutes or a 360mg suppository may be tried. For severe asthma,
100mg hydrocortisone sodium succinate must be given intravenously
together with oxygen.
5. Serum sickness consisting of fever, arthralgia, rashes and lymph-
adenopathy should be treated like erythema multiforme.
6. Anaphylactic shock in which many features of the above occur
together with hypotension should be treated with 0-5—1 mg adrenaline i.m.
(the dose can be doubled if the patient is unconscious), hydrocortisone
100mg i.v., oxygen and intravenous Hartmann’s solution to maintain the
blood pressure.

PREVENTION OF ORAL AND DENTAL: DISEASE

A positive approach to the prevention of the two major dental diseases is an
integral part of normal patient management in dental practice. Of course
patient education in preventive measures by the dentist should also
embrace other oral diseases where there are known controllable aetiological
factors.
Patients, and in the case of a child, the patient’s family, faced by the
problems created by debilitating or disabling conditions tend to conserve
their emotional and physical energies by neglecting some of the less
important aspects of daily life. They have got to be convinced of the need for
a conscientious attitude to dental and oral preventive measures or they may
consider these of low priority.
The prevention of dental disease in the normal person will avoid
unnecessary and sometimes hazardous complications. For many patients
365
 ORAL SURGERY, PART 1

with chronic disease not only are the consequences of progressive dental
disease more serious, but both the oral disease and its treatment can be
potentially life-threatening.

SUGGESTED READING
Bailey B.M.W. and Fordyce A. M. (1983) Complications of dental extractions in
patients receiving warfarin anticoagulant therapy. Br. Dent. J. 155, 308-310.
British Medical Association and the Pharmaceutical Society of Great Britain
(published annually) The British National Formulary.
Goodman A. and Gilman L.S. (1985) The Pharmaceutical Basis of Therapeutics,
7th ed. New York: Macmillan.
Laurence D. R. and Bennett P. N. (1980) Clinical Pharmacology, 5th ed.
Edinburgh, London and New York: Churchill Livingstone.
Seymour R. A. and Walton J. G. (1982) Analgesic efficacy in dental pain. Br. Dent.
J. 153, 291-298.

366
 INDEX

Abscess(es) Alveolar abscess (cont.)

buccinator muscle and 143 differential diagnosis 180, 182
bursting 170 Alveolar bone
causes 123 atrophy 114
with collateral oedema 172-3 file 93
drainage of 167-70 fractures 93
encapsulated chronic 163 loss 110
management of patients with 172-3 Alveolar
opening 149-50, 154, 169 cysts, median 272
osteomyelitis following 180, 200-1 osteitis 318
sinus formation 170, (Fig. 6.22) 171-2 acute 174-8
see also under specific sites process mucosa, soft-tissue swellings of
Abseal 274 297
Acetylsalicylic acid 344 Alveolar ridge
Acoustic neurinoma 338 fibrous enlargement, surgical treatment
Actinomycosis 71, 187, 197, (Fig. 7.8) 97-8
198-9, 219 orthognathic surgery for 119
chronic 172 remodelling 110-11
Actinomycotic infections 216 Alveolar wounds 30
Acyclovir 217, 337 Alveolectomy 94
Adenoid cystic carcinoma 331 Alveolitis sicca dolorosa 174
Adrenal Alveolotomy, inter-septal 94
cortex atrophy 354 Ameloblastoma 59,286, 305
steroid production inhibited 352 aspiration 281
Adrenalectomy 352 cystic 276
Adrenaline injection 113 marsupialized 287
Adrenals, destruction of 352 Aminoglutethimide 352
Agranulocytosis 334 Aminoglycosides 213
AIDS 228-31 Ammonium compounds, quaternary 233
antibodies 230 Amoxycillin 210, 222-3, 224, 244
carriers 229 Amphetamine 360
infections from, prevention 230-1 Amphotericin B 217
transmission 230 Ampicillin 210, 358
Air motors, surgical 20-1 Amyloid infiltration 312
Airway, protection of patient’s 23 Anaemia
Alarm clock headache 340 in infancy 363
Albers—Schonberg’s disease 201 sickle cell 362
Alcohol as disinfectant 232 Anaerobes 123, 218
Alcohol injection 334 Anaesthesia
Alcoholism 178 dolorosa 337
Allergy general 19-20
aspirin 344 diabetic under 350-1
dressings 342 in Ludwig’s angina 141
drugs 209, 342, 364-5 preparation for 20
penicillin 223 local 6-7, 12-13, 190
sulphonamides 216 in apicectomy 257-8
upper respiratory tract 235 of nerves 70
Allografts 116 for wisdom teeth removal 60
Alpha-thalassaemia 364 Analgesia, prolonged opioid 346
Alveolar abscess 218 Analgesics 343
acute 121-5, 174 narcotic 345
chronic 123 non-steroidal anti-inflammatory 343-4

367
 INDEX

Anaphylactic shock 365 Antrum

Aneurysm, internal carotid artery 339 carcinoma 331
Aneurysmal bone cyst 272-3 large, cyst and 279
Angina pectoris 333 maxillary 331-2
Angio-oedema 313, 365 unerupted teeth displaced into 247
Angioneurotic oedema (Fig. 6.16) 157-8 Anxiety 321, 323
Ankylosis Aortic valves, biscupid 222
extra articular 325 Aortic valvular disease, degenerative 222
of impacted canine 82 Apical
Antibiotic therapy 208-9 abscess 123
abscesses 124, 163 chronic (Fig. 6.la) 122
actinomycosis 172, 199 cyst 260
canine fossa infection 161 elevators 45
cavernous sinus thrombophlebitis 166 granuloma 255, 257
inadequate 209 periodontal cyst 270-1, 277
infratemporal fossa infections 166 marsupialization (Fig. 11.3) 286
intermaxillary fixation 224-5 root canal obstruction 257
Ludwig’s angina 141 seal, faulty 260
osteomyelitis 180, 218-19 thrombosis, 254
osteoradionecrosis 218-19 Apicectomy 257-61, 262
parapharyngeal space infection 153 in cyst closure 290
pericoronitis 127 flap incision for 30-1
post-apicectomy 260 infection after 158
pre-radiation prophylaxis 189-90, 192 with retrograde seal 260
prophylactic 220-2 Arsenic trioxide 194
quinsy 154, 332 Arterial graft patients 223
sinusitis 220 Arterial malformation 281
soft tissue infections 166-8 Arteriovenous malformation 281
submasseteric infection 149 Arteritis
tetanus 231-2 giant-cell 340-1
upper lip abscesses 157 temporal 340-1
Antibiotic-resistant microbes 210 Arthritis
Antibiotics 208, 210-16 acute 318
allergy to 364 infective 318
antagonistic 209 juvenile rheumatoid 318
contraindications 209 rheumatoid 319
interacting with contraceptives 358 acute 318
placebo response to 326 traumatic temporomandibular 318-19
Anticoagulants, oral 355-7 Arthrography, temporomandibular joint 325
Anticoagulation, aspirin contraindicated 344 Arthromyalgia, facial 319, 322-6, 326, 331,
Anticonvulsant drugs 306-7, 360 340
Antidepressants 343 Aseptic necrosis of bone 193-4
anxiolytic 319 Aspirin 343-4, 361
tricyclic 9, 319, 324, 340 Assistants, training of 8
Antifibrinolytic agents 177 Asthma 365
Antifungal drugs 217 Atropine 348
Antimalarials 361 Auriculotemporal
Antiseptic bath 20 nerve avulsion 336
Antiseptics 24 syndrome, Frey’s 336
Antitetanus serum allergy 364 Autoclaves 9
Antiviral drugs 217
Antral lining, exposure 248
Antroliths mistaken for roots 251
Antrostomy 73 Bacterial resistance 209
intranasal 244 Bacteroides melaninogenicus 218
368
 INDEX

Barbiturate 358 Bridge, odontalgia with fitting 326

Basal cell naevus syndrome 268 Bruxism 319, 323-4
Bath Buccal
antiseptic 20 advancement flap, oroantral fistula closure
preoperative 20, 24 by 241, (Fig. 9.1) 242-4
Benzylpenicillin 208-10 mucosa, swellings of 298, 308-10
Beta-thalassaemia 363-4 rotation flap, oroantral fistula closure by
Betamethazone 354-5 (Fig. 9.3) 246-7
Bicuspid aortic valves 222 space 143, (Fig. 6.10) 144
Black silk, suturing 18 haematoma in 144
Bleeding, postoperative 73 infection 144, (Fig. 6.11) 145, 148,
Bleeding disorders, aspirin contraindicated (Fig. 16.21) 165
344 Buccinator muscle 142-3
Blood Buccolingually orientated teeth, impacted
infected 225 56
pressure, postoperative fall 354 Bucket handle deformity 115
supply to mandible 178 Buprenorphine 346
transfusions, multiple 226 Burning tongue 330
Bone Burs
aseptic necrosis 193-4 bone-cutting 14, 47-8
cancellous 255 in impacted canine exposure 82
cysts (Fig. 11.1) 264-5, 272-4 irrigation of 16
solitary 295 rose-head 85-6
density 58 tungsten carbide tapering fissure 65
destruction 256 in separation of whole crowns 67
cancellous 279 use for mandibular 3rd molar extraction
cortical 279 63
radiographs of 254-5
file, alveolar 93
formation
and destruction 174 Cachageusia 329
new, subperiosteal 148 Caffey’s disease of bone 204
fractures, alveolar 93 Calcifying ododontic cyst 268-9
graft donor sites, preparation 24 Calculus 300, 302-3, 331
grafting in cyst enucleation and closure deposits 111
293-4 Canal, inferior dental, damage during bone
grafts 21, 115 removal 58-9
hypovascularity 187 Cancerophobia 310, 328
infection, childhood 179-80 Candida albicans 214, 217, 300
inflammation 174 Candidiasis 229
necrosis 194 chronic hyperplastic 310
pain 318 Canine
plates, miniature 115 bone removal around 79
sclerosed 176 displaced, surgical repositioning 83
Bone removal fossa 158, (Fig. 6.17) 159
around impacted canine 79 infection 159, (Fig. 6.18) 160
from fractured root 46-50 impacted lower, removal of 83-4
impacted 3rd maxillary molar 72 impacted maxillary 73-4
impacted lower premolar 85 buccal approach 77-8
inferior dental canal and 58-9 elevation 79-80
supernumeraries 89 examination 74
Bone-cutting instruments 14-16 leaving in place 81
Bony ridge augmentation 114-16, (Fig. 5.9) palatal approach 78-81
117 radiology 74-5
Borrelia vincentii 180 reasons for removing 75-6

369
 INDEX

Canine (cont.) Chemotherapy (cont.)

removal (Fig. 4.8-9) 76-81 oral 222
surgical exposure 81-2 parenteral 222-3
suturing after extraction 78, 80-1 Childhood
lower, over-eruption 83 aspirin not under 12 years 344
maxillary, monitoring development of 74 bone infection in 179-80
see also Unerupted canine emotional disturbances 323
Carbamazepine 333-4, 358 enucleation in 284-5
Carbenicillin 211 mandibular osteomyelitis in 180,
Carbuncle 160 (Fig. 7.1, 4) 181-4
Carcinoma 236, 311 ocular abnormalities in 268
adenoid cystic 331 osteomyelitis in 199-200
antrum 240, 332 periostitis in 202
in cyst linings 287 psychosomatic pain 322
metastatic 205, 318 rheumatoid arthritis 318
nasopharyngeal 337-8 tetracycline therapy in 214
squamous cell 193 Chisels 14-15
tongue 330 in impacted canine exposure 82
Cardiac in impacted mandibular 3rd molar removal
arrest 5
transplant patients 224 in removal of fractured root 48
Caries 59-60 Chloramphenicol 224, 361
cervical 190 Chlorhexidine 220-1, 232-3
comforter (Fig. 6.1a) 122 Chlormethiazole 349
radiation 188-9 Cholesteatoma 338
Carotid artery, aneurysms of internal 339 Choramphenicol 214-15
Carotid sheath 131 Chromic gut 18-19
Catgut 18, 36, 89 Clavulanic acid 211
Causalgia 335 Cleidocranial dysostosis, impaction caused
Cavernous sinus by 52
infection 166 Clindamycin 215
thrombophlebitis 155-6, 160, 166 Clinical management of infection 218-20
Cavity, irrigation 170 Clobezam 334
Cellulitis 124, 128, 169, 173 Clostridium difficile 216
acute facial 179 Clostridium tetani 231-2
due to upper lip infection 156 Clotrimazole 217
orbital 160, 179 Cluster headaches 340
poultice increasing spread of 167 Co-trimoxazole 216
right sublingual space (Fig. 6.7) 139 Coagulation diathermy 20-1
Cephalgia, histamine 340 Cocaine 347
Cephalosporins 212, 218, 220 Codeine 345
Cervical Condylar head
caries 190 adhesions or gross osteophytes 325
fascia, deep 130 surgery 320, 325
sympathectomy 336 Condylar shave, high 320
Cetrimide 233 Congenital epulis 305
Cheek chewing 323 Congenital heart disease 222
Cheilitis Connective tissue, loose, breaking down
grandularis apostomatosa 312 34-5
granulomatosa 312 Constipation, 346
Chemical necrosis 194 Contraceptive, oral 357-8
Chemotherapeutic agents 208 Coronary by-pass history 223
Chemotherapy 208, 343-9 Cortical
cytotoxic 194 bone destruction 279
prophylactic regimes 222-32 hyperostosis 179
370
 INDEX
Cortical (cont.) Cysts (cont.)
infantile 204 follicular 263, 265
osteomyelitis 201 gingival 274
Corticosteroids 352-5 globulomaxillary 271
Coumarins 355-6 impaction against 52
Coupland’s chisel 48 incisive canal 269-70
Cranial incisive papilla 270
base lesions 338 inclusion271—2
fossa lesions, middle 339 infected 123, 318
fossa tumours, posterior 338 investigation 278
Crestal incision 28-30 - jaws 263, (Fig. 11.1) 264-5
Crohn’s disease 311-12 large
Crown, odontalgia with fitting 327 antrum differentiation 279
Crowns enucleation 293
acid etched cementation of orthodontic mandibular fractures after removal
bracket to 82 294
tungsten carbide tapering fissure burs in malignant change 279
separation of 67 mandibular 290
Cryotherapy 334, 336 marsupialization 276, 283-4,
Cumine scaler 45 (Figs. 11.2-3) 285-7
Curettes 17 maxillary 278-9
Cyclosporin A 306 incisor 286
Cystic ameloblastoma 276 median
Cystic carcinoma, adenoid 331 alveolar 272
Cysts 237, 263 dermoid 272
apical 260 palatine 271
apical periodontal 270, 277, (Fig. 11.6) multilocular 280
291 nasolabial 270-1, 280
marsupialization (Fig. 11.3) 286 nasopalatine 269-70, 280, 294-5
aspiration 281 ododontic 263, 265
biopsy 282 calcifying and keratinizing 268-9
bone 272-3 periapical 255—7, 277, 279-80
aneurysmal 273-4 periodontal 263, (Fig. 11.1) 264-7, 278,
solitary 295 281
carcinoma in linings 287 periosteal 293
clinical presentation 277-8 postoperative follow-up 295
closure 287-9, 292 radicular 266-7
with bone grafting 293-4 radiology 278-80
dental 162 ramus 293
dentigerous 87, 263, (Fig. 11.1) 264-8, small 294
277-8, 280-1 treatment 282-3
dermoid 275 upper lip 158
in edentulous jaws 96 Cytomegalovirus infections 149
enlargement 275-6, 278, 280, 284 Cytotoxic chemotherapy 194
osmotic theory 276
enucleation 287, (Figs. 11.4-5) 288-9,
(Fig. 11.6) 291-5
with bone grafting 293-4 Dacryocystitis neonatorum 179
in childhood 284-5 Deciduous molar, buried 87
and decompression 292 Deciduous teeth
instruments for 289-90 apical periodontal cysts from 277
eruption 265-6 upper incisors, trauma to 89
fissural (Fig. 11.1) 264-5, 271-2, 272, Dental disease, prevention of 365-6
295 Dentigerous cysts 87, 263, (Fig. 11.1)
fluid electrophoresis 281 264-6, 267-8, 277-8, 280-1

ST
 INDEX

Denture Diabetes 178

hyperplasia 3 mellitus 341, 349-52
intolerance 328, 329 Diabetic
Denture-bearing area 93 coma 351
decrease in 111 neuropathy 336
irregularities in 96-7 vasculopathy, ischaemic necrosis in 338
alveolar ridge remodelling 110-11 Diabetics :
bony ridge, augmentation 114-16 pre-, intra- and post-operative
floor of mouth, lowering 113, (Fig. 5.8) management 351-2
114 under general anaesthesia 350-1
frenal and fibrous bands 98-9 Diagnosis 1, 3-4
maxillary tuberosities 100-1, differential 3
(Figs. 5.2-3) 102-3 Diamorphine 346
muscle attachments 106, (Fig. 5.6) Diathermy forceps 21
107-8 Diazepam, 347
ridges 96-8 Dichloralphenazone 548
tori 103, (Figs. 5.4-5) 104-6 Diguanides 232-3
sulcus deepening 111-13 Dindevan 355
Denture-induced Diphenylhydantoin 305
granuloma 299, (Fig. 12.2) 300 Disinfectants 228, 232-3
hyperplasia 108-9 Disinfection
removal (Fig. 6.7) 109-10 chemical 9
Dentures hand 10
discrepancies in jaws’ relative position and Disto-angularly impacted teeth 56-7
119 Doxycycline 244
elderly patients’ 118 Drainage
established wearers’ problems 95-6 abscesses 167-70
granuloma due to 203 acute infratemporal fossa infections 165
horseshoe shaped 104 Ludwig’s angina surgery 142
immediate 93 parapharyngeal abscess 153
fully-flanged 95 periapical abscess 257
one-stage replacement 94-5 Dress 10
two-stage replacement 93-4 theatre 21-2
loss of retention 95 Dressings 19
modifying to fit new sulcus 112 Drills 16
pathological lesions under 96 Droperiodol 347
persistent intolerance of 95-6 Drug addicts 178, 226
pressure ulcers from 95 intravenous 229
prosthodontic considerations before Drug-induced gingival hyperplasia 305-6
extractions for 92-3 Drugs 343
removal of unerupted canines before fitting allergy 342, 364-5
Ts failure to respond 343
retained roots under 96 interaction 343-4, 356, 358
short lingual frenum displacing 100 Dysaesthesia, oral 328-9
surgical preparation of mouth for 92 Dysphagia, painful 332
temporary, smoothing inside of 93
unerupted teeth under 96
Depression 321-4
Depressor origins damage in sulcus COURD eS
deepening 112 Eagle’s syndrome 332
Depth of tooth, assessment of 56—7 Ear infection, middle 332
Dermoid cysts 275 Electric laboratory type motors 20
median 272 Elevation
Dexamethasone 70, 354-5 bone removal prior to 58
Dextranomer 178 forceful 70
ST2
 INDEX
Elevation (cont.) Excavators (cont.)
impacted canine 77, 79-80 large 17, 35
lower 83 Exodontia 16
impacted lower 3rd molar 61, 65 Exostoses, developmental 103, 105
impacted teeth 57 Extraction
impacted upper 3rd molar 72 excess trauma during 176
Elevators 16-17 impacted lower canine 83-4
apical 45 with local anaesthetic and vasoconstrictor
application 50-1 aS)
inferior dental nerve at risk from 71 mandibular 3rd molar 61-70
lingual nerve at risk from 70 burs for 63
periosteal 14, 29, 31, 35, 61, 70 examination prior to 54
Embolism, pulmonary 357 maxillary molars, oroantral fistula in
Emergencies 5, 19 236-7
Emotional disturbances, childhood 323 odontalgia with 327
Emotional illness 321 osteomyelitis complicating 176, 200-1
Emphysematous pulmonary disease 192 of partly erupted wisdom teeth 59-60
Endarteritis, obliterative 176, 187 pre-radiation 189-91
Endocarditis 216 in preparation for dentures 92-3
bacterial 221 resorption after 110
infective 222 socket toilet after 68
Endodontic split-bone technique 63, (Figs. 4.2-7)
osseous implants 261-2 64-9
paste, removal of periapical 262 Eyes
therapy, orthograde 256 pain in region of 332
Endorphin 343 protection of patient’s 10, 23
Endosseus implants 118
Endosteal implants 123
Enkephalins 343
Envelope flaps 28-9 Facial
suture 69 arthromyalgia 319, 322-6
Enzyme deficiency 361 deformity 21
Epanutin hyperplasia 307 pain, atypical 326-8
Ephedrine 360 Family history 2
Epileptics, surgery for 360-1 Felypressin 13, 241
Epstein’s pearls 271 Fentanyl 347
Epulides 298-9 Fibrinolytic alveolitis 174
congenital 305 Fibro-epithelial polyps 300, (Fig. 12.6)
fibrous (Fig. 12.1) 298-9, 302 306-9
giant cell 303, (Fig. 12.5) 304-5 Fibroblastoma 305
pregnancy (Fig. 12.4) 302-3, 306 Fibromas 307, 309
Ergotamine tartrate 340 Fibromatosis
Erupt, failure of tooth to 52 gingivae 306-7
Eruption cysts 265 von Recklinghausen’s 309
Erythema Fibromatous enlargement of maxillary
multiforme 365 tuberosities 307
post-irradiation 188 Fissural cysts (Fig. 11.1) 264-5, 271-2,
Erythromycin 212, 218, 220, 222, 224 295
Ethyl alcohol 232 median mandibular 272
Eugenol 177 non-odondontic 269-72
Eusol 233 Flaps
Ewing’s sarcoma 205 raising 28-9
Examination 2 reflection 29, 30-1, 46, (Fig. 3.1) 47
Excavators rhomboidal 258
bi-angled spoon 45 Flucloxacillin 210-11
 INDEX

Foliate papillae, inflamed 310 Giant cell (cont.)

Follicular granuloma 158, 274, 303-4, 310
cysts 76, 263, 265 Gingival
formation 72 cysts 274
Food impaction 121, 300 diffuse enlargements 305-7
Food withheld before general anaesthetic fibromatosis, hereditary 306-7
20 granulomas, pyogenic 305
Forceps hyperplasia 311
angled 17 drug-induced 305-6
artery 17, 21, 108 Gingival margin
contouring 16 avoided in outlining flap 29
diathermy 21 examination before removal of 3rd molar
dissecting 18 534
toothed 17 incision 28
extraction 16-17 protection in impacted canine exposure
upper roots pattern 84 82
Foreign bodies 71, 123, 239 suturing 93
Formaldehyde 232 Gingival mucoperiosteum, thick, retaining
Fractured root for denture support 93
elevation of 48, (Fig. 3.2) 49-50 Gingival swellings 297-307
elevation application (Fig. 3.2) 49, 50-1 Gingivectomy 306-7
infected 43 Gingivitis
leaving 43 pregnancy 303
localization 45-6 ulcerative 176
removal Vincent’s 125
by forceps 43-4 Gingivostomatitis, herpetic 127
non-surgical 44—5 Glands, swollen salivary 330
in preparation for dentures 92 Glaucoma, acute 332
surgical 45, 46-50 Globulomaxillary cyst 271
Fractures 21, 123, 318 Glossitis, median rhomboid 309-10
after large cyst removal 294 Glossodynia 328, 330
apex 257 Glossopharyngeal neuralgia 332, 334
cranial base 338 Glossopyrosis 329, 331
jaw 21 Gloves 10
styloid process 332 against infection 230-1
tuberosity 73 Gloving (Figs. 1.3-4) 22-3
maxillary 252-3 Glucocorticoids 353-4
with unerupted teeth removal 71 Glucose-6-phosphate dehydrogenase 361
Frenectomy 98-9, 100 Glutaraldehyde 232
Frey’s auriculotemporal syndrome 336 Gorling and Goltz syndrome 268
Fucidin 215 Gouges 15, 48
Gout 318-19
Gradenigo’s syndrome 338
Grafting
Gangrene 128 bone 115
Garre’s osteomyelitis 148 sandwich 115
General practitioner, notification of skin 21, 24, 114
operation to 26 Grafts, bone, in cyst enucleation and closure
Genial 293-4
muscle mass, displacement downwards Gram-negative bacteria 232-3
108 Granular-cell myoblastoma 305, 311
tubercles, removal of 107-8 Granulation tissue, infected 111
Giant cell Granuloma 109-10
arteritis 340-1 apical 255, 257
epulis 303, (Fig. 12.5) 304-5 denture-induced 299, (Fig. 12.2) 300-1

374
 INDEX
Granuloma (cont.) Heroin 346
giant cell 158, 274, 303-4, 311 Herpes simplex, ulcerating 229
localized destructive 312 Herpes zoster 194, 337
malignant 312 Herpetic gingivostomatitis 127
periapical 237, 244 Hexachlorophane 233
pregnancy (Fig. 12.4) 302-3, 306 Hibitane 221
pulse 203 Histamine cephalgia 340
pyogenic (Fig. 12.3) 301-3, 309 Homosexuals 226, 229
of tongue 309 Hooks, skin 18
Gray’s syndrome 214 Hopkins ridge augmentation 116, (Fig. 5.9)
Gum polyp 299 117
Gut 18-19 Horizontally impacted teeth 56
Horten’s syndrome 340
Hospital, discharge from 26—7
Hospitalization in soft tissue infection cases
Haemangioma 148, 310 169
capillary 305 Human skeletal growth factor (HSFG)
intramedullary cavernous 281 174
Haematoma 35-6, 148 Hydrocortisone sodium succinate 353-4
after suturing 77-8, 80 Hydrogen peroxide injections 194
postoperative 73 Hydroxylapatite
prevention 110, 244 blocks in bony ridge 116
Haemoglobinopathies 361-2 cones in sockets 111
Haemolysis 361 granules in subperiosteal pockets 116
Haemophilus influenzae 212, 214 subperiosteal injection of particulate 97
Haemorrhage 5 Hygiene, oral 10
postoperative 359 Hygienist, dental 26
Haemostasis in lingual frenum excision Hyoid bone (Fig. 6.2e) 133
100 Hyoscine 348
Halitosis, obsessional fear of 328-9 Hyperaemia, reactionary 260
Halogens 233 Hypercementosed molar roots 252
Hamartoma, dental 305 Hypercementosis 176
Hands Hyperostosis, infantile cortical 204
preparation 10 Hyperparathyroidism, giant cell epulides in
scratched or cut 231 304
Head support for operation 23 Hyperplasia 307
Headache denture-induced 108-9, (Fig. 5.7)
alarm clock 340 109-10
Cluster 340 drug-induced gingival 305-6
see also Migraine epanutin 306
Heart disease fibro-epithelial, of tongue 309
congenital 222 gingival 311
ischaemic 332 pseudoepitheliomatous 311
Heart valve Hyperplastic
disease 221 candidiasis, chronic 310
prosthetic 222 papilla 298
Heparin injections 355-8 Hypertension 358-9
Hepatitis, viral 225 Hypertrichosis 306
accidents 227 Hypochlorites 233
carriers 224—5 Hypochondria 321
immunity to 228 Hypochondriacal neurosis, mono-
infection from 224, 226-7 symptomatique 329
instruments’ sterilization or disinfection Hypogammaglobulinaemia 129
228 Hypoglycaemia 349-52
operative procedures 226-7 Hypophysectomy 352

378
 INDEX

Hypotensive agents 358-9 Infratemporal fossa 163, (Fig. 6.20) 164

Hypothyroidism, impaction caused by 52 Inhalations 244
Hypovascularity 187 Instruments (Fig. 1.1) 11-12, 11, 34-5
Hysteria 321 bone-cutting 14-16
for major surgery 20-1
preparation 8
sterilization 9
Ibuprofen 345 suturing 17-18
Idoxuridine 217 Insulin injection 349
Impacted teeth 52 Interdental papillae, division of 28
canines, see Canines, impacted septa
dentigerous cysts on 266 removal 94
molars smoothing for dentures 93
lst and 2nd 87 Intermaxillary fixation 224-5
see also Molars, impacted mandibular Interosseous wires at fracture site 115
and maxillary; Premolars Intracranial
Impacted wisdom teeth, pain and 315 infection 166
Impaction of teeth lesions 338
degree of 57 neoplasms 333
disto-angular 56-7 Intratemporal fossa infection 164,
horizontal 56 (Fig. 6.21) 165-6
palatal 74 Iodine 233
vertical 56-7 Todophors 233
Implant Irradiation
endodontic osseous 26 1—2 morbidity after 187-91
procedures 118-19 therapy 176
Impressions 94-5 Irrigation 16
with oroantral fistula 240 cavity 170
Incisions 28-31 Ischaemia 187
closing 35, 40 Ischaemic
Incisive canal cysts 269-70 heart disease 333
Incisive papilla cysts 270 necrosis in diabetic vasculopathy 338
Incisors Isoprenaline 360
dilacerated 89-90 Isopropyl 232
imbrication, 3rd molar eruption and 59
lateral, abscesses arising from 161,
(Fig. 6.19) 162
malpositioned 88
maxillary 88 Jacobsen’s nerve, intracranial section of
retained pulpless deciduous 52 336
upper deciduous, trauma to 89 Jaw fractures 21
Inclusion cysts 271-2 Jawbone, resistance to infection 174
Indomethacin 178 Jaws, painful movement of 319
Infantile cortical hyperostosis 204 Joint
Infants primary organic disease 318-20
non-accidental injury 205 replacement, patients 224
osteomyelitis 179 temporomandibular functional disorders
Inferior dental 320N322=6
canal, damage during bone removal Juvenile rheumatoid arthritis 318
58-9
nerve, risk to during extraction 71
Inflammation, persistent 172
Inflammatory agents 174 Kaposi sarcoma 231-2
Infraorbital lining, safeguarding in exposing Keratin pearls 271, 274
antral lining 248 Keratocyst formation 72
376
 INDEX

Keratocysts 263, 267-8, 271, 275-6, 278, Mandible

280-1, 284, 287, 292-3, 295 arthritis following blow to 318
Ketosis 350 blood supply 178
Knots cysts of 278, 290, 293
infections from 41 median fissural 272
tying surgical 38, (Fig. 2.1) 39, 41 potentially infected spaces related to 132,
(Figs. 6.2-7) 133-9
severe pain in left 332-3
surgical access to 32
Labial flap, pyramidal 89 see also Molar, impacted mandibular,
Labial frenum, excision of 98-9 removal
Langhan’s giant cell granuloma 158 Mandibular
Lateral pharyngeal abscess 144
abscess, differential diagnosis 154, edentulous ridge, incision along 28
(Table 6.1) 155 molar, see Molar, impacted mandibular
space (Fig. 6.13c) 150, 152-3 3rd
Leucoplakia of oral mucosa 230 nerve fibres, division of 334
Light, operating 8 retrognathism 320
Lignocaine 13, 334 space infections 132-48, 149-55
Lincomycin 215 differential diagnosis 148—9
Lingual Marsupialization of cysts 276, 283,
flap retretors 70 (Figs. 11.2-3) 283-4, 285-7
frenum, excision of 100, (Fig. 5.1) 101 Masseter muscle 146-7
lymphoid tissue 310 Mastication stresses, pain due to 319
nerve Masticatory mucosa
risk to during extraction 70 breach in 99
safeguarding in incision 33 stable 112
pain 330 Maxilla
thyroids 210 gumma 195, (Fig. 7.7) 196
Lip, upper, infection (Figs. 6.14-16) potentially infected spaces
155- (Figs. 7.14-21) 155-66
Lip chewing 323 surgical access to 33
Lipoma 148, 309 Maxillary
Lips, lubrication in major surgery 25 alveolar process, exposure of 28
Lithium 360 antrum 331-2
Loose teeth, anaesthesia and 53 cysts 278-9
Ludwig’s angina 128, 139 (Figs. 6.8-9) large 286, 290
140-2 median alveolar 272
drainage 168 impacted 3rd molar, see Molar, impacted
Lymph node enlargement 311 maxillary
_Lymphadenopathy (PGL) syndrome 229 incisors, malpositioned 88
Lymphangiomas 310 nerve fibres, division of 334
Lymphokine osteoclast activating factor pain 331
(OAF) 174 Maxillary sinus 236, 240
Lymphoma 29, 203, 205 irrigation 240
periapical abscesses in relation to 163
spontaneous expulsion of root from 250
tooth or root displacement into 247-8
Malignant removal of 248, (Fig. 9.4) 249-51
granuloma 312 Maxillary sinusitis, acute 160
otitis externa 338 Maxillary supernumeraries 88-9
tumours 318 Maxillary tuberosities
ulcers 330 enlarged 100
Mallet 15 bony 100-2
Malocclusion 323-4 fibromatous 307

SPT
 INDEX
Maxillary tuberosities (cont.) Molars (cont.)
fibrous 102, (Figs. 5.2-3) 102-3 removal 52, 59-60
fractured 252-3 anaesthesia 60
Mefanamic acid 345 bone density and 58
Melkersson—Rosenthal syndrome 312 complications 70
Meningitis, post-traumatic 224 envelope flap incision 61, (Fig. 4.1)
Meniscectomy 3220 62
Meniscus, anterior dislocation 325 flap suture after 69
Mental analgesia 318 investigation prior to 60
Mental nerve lubrication of retractors and elevators
damage in sulcus deepening 112 61
injury by incision 32 prophylactic 60
preservation during buccinator detachment radiological assessment 55-8
ils socket toilet after 68
syndromes, neuralgia from 334-5 split-bone technique 63, (Figs. 4.2-7)
Mental retardation, fibromatosis gingivae 64-9
associated with 306 surgical technique 61-70
Mentally handicapped children 226 root relationship to inferior dental canal
Mepivacaine 13 58-9
Merkerson-Rosenthal syndrome 158 root shape 57-8
Mesial caries A.A. (Fig. 6.1b) 122 Molars
Mesio-angular teeth, impacted 56-7 impacted maxillary 3rd, removal 71-3
Mesiodens 87, 89 mandibular 3rd
Metastatic carcinoma 318 bleeding from 144
Methyl morphine 345 displacement causing parapharyngeal
Metoclopramide 349 infection 152
Metronidazole 168, 175, 177, pericoronitis associated with 125-6
180, 211-13, 215, mandibular 4th 88
218, 220, 224-5 maxillary 3rd, infections of 165
Miconazole 217 abscesses involving 160-1
Microbiology 169-70 extractions 236-7
Microcysts 271 tuberosities, fibromatous enlargement
Midazolam 347-8 of 308
Migraine 315, 339-40 periapical infection 143
dental 328 removing palatal root of upper 44
Migrainous neuralgia, facial 340 root
Mitchell’s trimmer 17 amputation and sealing 260-1
Mitral valve prolapse 222 blind elevation of lower 3rd 45
Molars hypercementosed 252
2nd deciduous, premature extraction 52 second, distal periodontal pocketing 71
ankylosed 87 supernumerary teeth in region of 88-9
buried deciduous 87 unerupted maxillary 3rd removal,
impacted Ist and 2nd 87 tuberosity fractured in 252
Molars, impacted mandibular 3rd Monoamine oxidase inhibitors 324,
bone removal 62-3, 65 359-60
diseased 59 Monocyte cell factors (MCF) 174
disto-angular, removal 65, (Fig. 4.3) 66 Mononucleosis 125
elevation of 57-8, 61, 70 Morphine 346, 349, 360
examination 53-5 methyl 345
horizontal, removal 67, (Figs. 4.6-7) Mouth
68-9 lowering floor of 113, (Fig. 5.8) 114
mesio-angular, removal 65, (Figs. 4.4-5) props 20
66-7 substantial swelling of floor of 169
orientation 55-6 Mucoperiosteal flaps 30, 78-9
patient assessment 52-3 Mucoperiosteum, raising 33

378
 INDEX
Mucosa radiopacity 235-6 Neurinoma (cont.)
Multiple sclerosis 339 acoustic 338
Mumps 149, 330 Neuroblastoma 205
Myelomatosis 311 Neurofibroma 309
Mylohyoid Neurofibromatosis, plexiform 309
muscle (Fig. 6.2d) 133, (Fig. 6.3) 134, Neurofibrosarcoma 309
ridge resection 106, (Fig. 5.6) 107, 113, Neuroleptanalgesia 347
(Fig. 5.8) 114 Neuropathy, diabetic 336
Myoblastoma, granular cell 305, 311 Neuropraxia 70
Myofascial pain dysfunction syndrome Neurosis 321
322-6 Neurosis, mono-symptomatique
hypochondriacal 329
Neurovascular bundle
avulsion of inferior dental 336
Narcotic analgesics 345 damage during bone removal 59
Nasal furuncle 156 division of 78
Nasolabial cysts 270-1, 280 preservation 33-4
Nasopalatine cyst 269-70, 280, 294-5 retarding cyst enlargement 278
Nasopharyngeal Nibblers, bone 15
carcinoma 337-8 Nitrazepam 348
tumour 332 Noradrenaline 359
Needle holders 17, 36-7 Nurses, postoperative care by 26
Needles Nutrient vessels, thrombosis of 178
contaminated 151 Nystatin 217
curved 36-7
disposable 13
half-circle cutting 80-1
radium 191 Occlusal trauma, repeated 121
suturing 18, 36 Occlusion, examination prior to 3rd molar
Neomycin 213 removal 54
Neoplasm Ocular abnormalities 268
intracranial 333 Odontalgia, atypical 317, 326-8
malignant, 172 Ododontgenic cyst 263, 265
upper lip 158 calcifying and keratinizing 268-9
Neoplastic disease 205 Odontomes 123
Nerve avulsion 336 impaction against 52
Neural morbidity in bony ridge augmentation Oedema 124, 126
116 angioneurotic (Fig. 6.16) 157-8
Neuralgia in cavernous sinus thrombophlebitis 166
atypical facial 326-8, 333, 336, 340 forehead 160
glossopharyngeal 334 gangrene due to 128
mental nerve 335 glottis 141
migrainous facial 340 Ludwig’s angina 142
paroxysmal 319, 333, 343 periodontal membrane 254
trigeminal 333 periorbital 73
in youth 339 postoperative 40
post-herpetic 337 quinsy 154
primary 333-4 radiopacity 235
psychogenic atypical facial 332 upper lip 158-9
secondary 334-5 Oestrogens 357-8
splenopalatine 340 Omnopon 346
trigeminal 315 Operation site preparation 10-11
vidian nerve 340 Operative procedures
Neurilemmomas 309 diabetics 351-2
Neurinoma 309 where corticosteroids given 353

399
 INDEX
Ophthalmia neonatorum 179 Osteotome (cont.)
Ophthalmoplegia 166 tooth splitting with 71
Opioids 360 Osteotomy
endogenous 343 Hopkins sandwich 116, (Fig. 5.9) 117
Oral disease, prevention of 365-6 horizontal sandwich 116
Oral mucosa, soft-tissue swellings of 297 Le Fort I level, incision in 31
Orientation of teeth 55-6 Obwegeser—Dalpont sagittal split 193
Oroantral fistula 73, 163, 236-9 visor 115
chronic 239-40 Otitis externa 332
closure of 241, (Figs. 9.1-3) 242-7 malignant 338
Orthognathic surgery 119 Over-eruption of lower canine 83
Osmotic theory of cyst enlargement 276 Overdentures 110
Osseous Oxygen concentration 192
implants, endodontic 261-2
integrated implants 118
tumour 202
Osteitis Pacemakers 223
acute alveolar 174-8 Packing material 19
alveolar 318 Paget’s disease 176, 199, 338
localized 174 osteomyelitis in 200
petrous temporal 338 Pain
Osteoarthritis, temporomandibular joint atypical facial 326-8
319-20, 333 bone 318
Osteomycosis, chronic hypertrophic 199 control 343
Osteomyelitis, 71, 176, 178-80, 318 placebo response 343
actinomycotic 197, (Fig. 7.8) 198-9, postoperative 26
219 episodic 317
acute 218 eye region 332
pyogenic, of mandible 180, investigation 315
(Figs. 7.1-5) 1814 maxillary 331
childhood 180 orofacial 315
chronic 185-7, 218 patient’s history of 315-17, 321
cortical 201 psychogenic 315-16, 321-2, 326-7, 343
following submasseteric abscess 147-8 relief 319-20
Garre’s 200 sharp 316-17
infants’ 179 starting point 315
intramedullary 201 treatment, empirical 315-16
involucrum of 174 trigeminal 338
localized (Fig. 7.5) 184, 188, 197 vascular 339-41
neoplastic simulations 205 Palatal
non-pyogenic 194-9 access 33-4
non-suppurating sclerosing 200 impaction 74
in osteopetrosis 201 mucoperiosteal flap 89
in Paget’s disease200 mucoperiosteum 161
sclerosing 196 mucosa
squestrectomy in 185 graft 112
subperiosteal 201 plate protection 113
syphilitic 194-5, 195 swellings of 298, 307-9
tuberculous 196-7 rotation flap, oroantral fistula closure by
typhoid 197 (Fig. 9.3) 246-7
Osteopetrosis 201 subperiosteal abscess 161, (Fig. 6.19)
Osteoporosis 195 162
Osteoradionecrosis 187-9, (Fig. 7.6) 191-3, transposition flap, oroantral fistula closure
216, 219 by 244, (Fig. 9.2) 245-6
Osteotome 15 Palatine artery, division of 33
380
 INDEX
Palatine cyst, median 271 Periapical (cont.)
Palsy, facial 312, 337 osteomyelitis following 180, 200-1
Papaveretum 346 pus spreading from 146
Papilla, hyperplastic 299 related to maxillary sinus 163
Papilloma (Fig. 12.7) 308 cyst 255-7, 277, 279-80
Paracetamol 339, 344-5 endodontic paste removal 262
Parapharyngeal granuloma 237, 244
abscess, differential diagnosis 154, infection
(Table 6.1) 155 molar 143
space infection 152-3 soft-tisue infections due to 128
Paratyphoid fever 197 lamina dura, loss of 254—5
Parotid radiolucency 255
fascia 130 Pericoronal abscess 123
painful 331 Pericoronitis 59-60, 72, 125-8, 151, 218,
swellings 149 265
Paroxysmal neuralgia 319, 343 of 3rd molar 144
in youth 339 acute, quinsy complicating 153
Patient submasseteric abscess due to 146
age of, teeth extraction and 52-3 ulcerative 127-8
with arterial grafts 223 Periodontal
assessment for surgery 52-3 abscess
with cardiac transplants 224 acute 121, 123
with chronic liver disease 226 primary acute 317
with coronary by-pass 223 cyst 263, (Fig. 11.1) 264-7, 275-6, 278,
discharge from hospital 26-7 281
discussion of difficult surgery with 261 apical 270-1, 277
dying 347 marsupialization (Fig. 11.3) 286
elderly 116-18 developmental lateral 274-5
extra-European 226 disease, maxillary sinusitis due to 163
family history 321 membrane, oedema of 254
follow-up arrangements 27 pocketing 60, 71
general health 1 Periodontalgia, idiopathic 327-8
high-risk, prophylactic regime 223 Periodontitis 317-18, 327
history 1-2, 342 Perioral tissues, incision in 34
of pain 314-16 Periosteal
with joint replacement 224 cyst 293
management of, in abscess cases 172-3 damage during sulcus deepening 112
multiple blood transfusions history 226 elevators 13-14, 21, 29, 31, 35
oral hygiene instruction 10 incision 32, 33-4
past medication 342 Periostitis 196, 201-3
postoperative care 25-6 actinomycotic 219
preparation 7 chronic 203
for major surgery 20, 23-5 ossificans 200
preventive education 365-6 Peritonsillar
smoker 357-8 abscess 153-4, 332
social history 322 differential diagnosis 154 (Table 6.1)
tattooed 226 155
Penicillin 210-11, 218 space (Fig. 6.1b) 150
allergy 212, 223, 364 Perpenazine 349
Pentazocine 345-6 Pethidine 345, 349
Peptic ulceration, aspirin contraindicated Petrous temporal osteitis 338
344 Phantom bite syndrome 328-9
Periapical Pharyngeal
abscess 257 space
acute 121-5, 255 abscess in lateral 131

381
 INDEX

Pharyngeal (cont.) Premolars (cont.)

lateral (Fig. 6.13c) 150 examination 84
sucker 19 leaving in situ 86
Pharynx, substantial swelling of side of radiography 84
169 removal 84-6
Phenacetin 361 impacted maxillary 86-7
Phenindione 355 with inclined apices 86
Phenol injections 194 Preoperative procedure 7—12
Phenolics 233 Pretracheal fascia 131
Phenoperidine 347 Prevertebral fascia 130
Phenothiazine 324, 329 Prilocaine 13
Phenoxymethylpenicillin 210 Promethazine hydrochloride 348
Phenylephrine 360 Propionic acid derivatives 345
Piperacillin 211 Proplast sponge in subperiosteal pockets
Pituitary tumours 339 116
Pizotifen 340 Prostaglandins 174
Plaque 300 Prosthetic heart valve 222
Platybasia 338 prophylactic regime 223
Pneumatosis cystoides intestinales 263 Proteus vulgaris 211
Pneumocystis carinii Pneumonia (PCP) Pseudomonas aeruginosa 211, 213
229 Psoriasis 318
Polymers, synthetic 36 Psychogenic
Polymyalgia rheumatica 341 atypical facial neuralgia 332
Polyp oral dysaethesia 95
fibro-epithelial 300, (Fig. 12.6) 306-9 pain 315-16, 321-2, 326-7, 343
gum 299 dysfunctional 322
pedunculated fibro-epithelial 300 Psychosis, hypochondriacal 329
prolapsed 240 Psychosomatic pain 322
pulp 299 Pterygomandibular space (Fig. 6.13) 150-1,
tongue 309 (Fig. 6.20) 164
vascular antral 302 abscess 151-2
Porphyria 361 differential diagnosis 154, (Table 6.1)
Post-herpetic neuralgia 337 155
Posterior cranial fossa tumours 338 infection 151, (Fig. 6.21) 165
Postoperative Pulmonary disease, emphysematous 192
bleeding 5 Pulmonary embolism 357
care 25-6 Pulp
feeding 221 infection, treatment 256-7
infection 158, 218 infective necrosis of 121
medication 348 inflammation 254, 327
oedema 40 necrosis 354-7
Poultices 167 pain 316-17
Pregnancy polyp 299
ergotamine tartrate contraindicated in Pulpitis, acute 163
340 Pus, sites of accumulation 131-2
gingivitis 303 Pyriform aperture wires 115
granuloma 306
tumour (epulis or granuloma) (Fig. 12.4)
302-3
warfarin contraindicated 357 Quinsy 153-4, 332
Premedication 347
Premolar region, supernumerary teeth in
88-9
Premolars Radiation caries 188-9
impacted lower Radicular cysts 266-7
382
 INDEX
Radiofrequency thermocoagulation 334 Root
Radiographs antrolith mistaken for 251
cysts 278-80 displacement into antrum 248, 250-1
calcifying ododontic 269 filling
dry socket 177 faulty 256-6
enlarged tuberosities 101-2 preoperative 282, (Fig. 11.6) 291
impacted mandibular 3rd molar removal fractured, removal in preparation for
55-6 dentures 92
occlusal 54, 74-5, 202 hypercementosed 73
oroantral fistula 238-9 residual, see Fractured root
osteomyelitis (Figs. 7.1-5) 181-4, resorption 75-6
186-7 retained, dentures and 96
osteoradionecrosis (Fig. 7.6) 191 retention
periapical 54-5, 74-5 accidental 111
periostitis 202 deliberate 110-11
prior to extractions 92 giant cell epulis related to (Fig. 12.5)
pulp infection 254 304
sinusitis, 235-6 pain and 315
of supernumeraries 88-9 sections, intracranial 336
toothache 318 shape 57
unerupted premolar 84 spontaneous expulsion from maxillary
see also Tomography sinus 250
Radiotherapy Root-canal therapy 173
impaction caused by 52 Roots, separation of 48, (Fig. 3.2d)
malignant granuloma 311 49
morbidity after 187-91 Rotation of teeth, supernumeraries causing
prophylaxis 189-91
Radium needles 191 Rubella immunization, arthritis reaction to
Ramsay Hunt syndrome 337 318
Ramus Rugines 35
cysts 293
enlargement 149
frame implant 119
infection following submasseteric abscess Salivary
147-8 fistula 172
Record of major operation 25 glands
Red cell abnormalities, hereditary 361 swollen 330
Resorption tumours 331
burrowing 96 sand 329
irregular 96-7 Salmonella 197, 214
Respiratory Sandwich grafting 115
failure 5 Sarcoid 311-12
tract infection 126 Sarcoma 148
Restorations, loose or lost 316 Ewing’s 205
Retractors 13 Kaposi 231
double-ended 21 Scalpel 13-14, 21
lingual flap 70 Schwannoma 309, 338
tongue 20-1 Scissors 18
Retrognathism, mandibular 320 dissecting 21
Reye’s syndrome, aspirin in causation 344 suturing 17-18
Rheumatic valvular disease 222 Sclerosants 194
Rhinitis, allergic 235 Sclerosis, disseminated 333, 339
Rhinitis, non-allergic vasomotor 326 Scrub technique 21-2
Ribbon gauze 19 Sedation 347-8
Rongeurs, bone-cutting 15 night 348-9

383
 INDEX

Self-inflicted lesions 329 Staphylococcus aureus 178-9, 180,

Serum sickness 365 211—12, 215, 232=3
Sialoadenitis 218, 331 penicillin resistant 209
Sickle cell Staple implants 118-19
anaemia 361 Sterilization 8-9
crisis 318 dry heat 9
disease 194, 362-3 following viral hepatitis surgery 228
trait, 362-3 Steroids 353-5
Sinus intra-articular 320
excision 172 Still’s disease 318
formation 170 (Fig. 6.22) 171-2 Streptococcus viridans 123, 216, 221-2
see also Maxillary sinus Streptomycin sulphate 213
Sinusitis 163, 220, 235-6 Stress 321, 324, 329
acute 331 Students 5
chronic 326, 331 errors 22-3
maxillary 235 Styloid process, elongated 332
acute 160 Sublingual space (Fig. 6.6) 137
SjOgren’s disease 149, 329 infections 138, (Figs. 6.7-8) 139-40
Skin graft 21 Submandibular space (Fig. 6.3) 134
periosteal 114 infections 134-5, (Figs. 6.4-5) 136-7
sites Submasseteric
Skin hooks 18 abscess 146, (Fig. 6.12) 147
Skin incisions 21 infections
Skin rashes 365 differential diagnosis 148-9
Skull fractures 224 treatment 149-50
Sluder’s syndrome 340 space 145
Smoking 357, 358 swellings 148
Social history 2 Submental
Socket sinus (Fig. 6.22) 171
dressing 177-8 space infections 132, (Fig. 6.2)
dry 174-6, 318 133
infection 71, 176 Submucosal dissections 112
rocking to expand 92 Subperiosteal
suppurative infection of 71 implants 118, 123
suturing gingival margins 93 new bone formation 148
toilet 68 osteomyelitis 201
Soft tissue Suction 8
abscesses, use of heat in 167 tips 19
infection tubes 19
hospitalization with 168 Sulcoplasty 115-16
management 218 Sulcus
spreading 128-31 deepening 111-13, 115
swellings of 311-12 mucosa folds 99
see also Swellings Sulcus tissue
Splenopalatine neuralgia 340 incisions in 30
Splinting, fractured tuberosity 253 unerupted canine in 82
Splints 21, 115, 190 Sulphadiazine 216, 224
Split bone technique 57 Sulphonamides 177, 208, 216, 361
for impacted mandibular 3rd molar allergy 364
removal 63, (Figs. 4.2-7) 64-9 Supernumerary teeth 87-9
Split skin graft in sulcus deepening anterior maxillary 89
112-13 extraction 88-9
Split tooth 316 inverted palatally placed 88
latent 327 Suppurative infection 128
Staphylococci 128 Surgeon, preparation of 8
384
 INDEX

Surgery 4-7 Temporal arthritis 340-1

contraindications 53 Temporomandibular joint
difficult 261 arthritis, traumatic 318-19
elderly patients and 117-18 arthrography 325
major 19-27 dysfunction syndrome 322-6
record 25 functional disorders 320
oral contraceptive before 357-8 osteoarthritic 319-20, 333
orthognathic 119 surgery 336
preparation 20, 23, 220 Tetanus 231-2
under local anaesthetic 7 Tetracycline 177, 209, 213-14, 218
Surgical repositioning of displaced tooth Thalassaemia 363-4
83 Thermocoagulation, radiofrequency 334
Surgicel 356 Thrombo-embolism 357
Suture scars 40 Thrombophlebitis 129, 148
Suture-cutting scissors 18 cavernous sinus 166
Sutures due to upper lip infection 156
absorbable 37, 41 injection site 347-8
atraumatic 36 in soft tissue infection 153, 160
braided 37 Thrombosis
buccal advancement flap 243 apical 254
continuous 40-1 deep vein 355, 356-7
horizontal mattress 31 nutrient vessels 178
envelope flap 69 vasa nervorum 318
interrupted 40 Thyroid, lingual 210
materials for 18-19, 36-7 Tic douloureux 333, 335, 339
mattress 41 Ticarcillin 211
polyglactin 36, 113 Tinnitus 322, 344
removal 41-2, 69 Tissue
resorbable 113 dividing 35
under tension 30-1 space abscess 173
Suturing 35, 37-8, (Fig. 2.1) 39-42 Tissue-dissection scissors 18
instruments 17-18 Titanium screw-type implants 118
sulcus tissue adhesion due to 71 Tomography
while bleeding continues 77, 80 rotational 55, 75, 84, 92
Swabs 19, 25 unerupted upper 3rd molars 72
Swellings Tongue
buccal mucosa 298, 307-9 burning 328
floor of mouth or side of pharynx 169 carcinoma of 330
gingival 297-307 pain 330
oral mucosa 297-8 retractors 20
palatal mucosa 298, 307-9 swellings of 298, 309-11
tongue 298, 309-11 Tongue-tie 100
Sydenham’s chorea 222 in edentulous patient 100, (Fig. 5.1)
Sympathectomy, cervical 336 101
Syphilis 187 Tonsils, painful 332
acquired 195, (Fig. 7.7) 196 Tooth, lack of vitality 256
neonatal 195 Toothache 317
Syphilitic osteomyelitis 194-5 Torus 103-5
Syringes 16 lingual 105
local anaesthetic 12-13 mandibularis 105, (Fig. 5.5) 106
palatinus, removal 103, (Fig. 5.4)
104-5
Towels, in major surgery preparation 25
Taste abnormallities 328 Tracheostomy 221
Temgesic 346 in Ludwig’s angina 142
385
 INDEX

Traumatic temporomandibular arthritis Unerupted teeth (cont.)

318-19 supernumeraries causing 88
Treatment, selection of 6 transplantation 82
Treponema pallidum 194-5 Uveitis 310
Tricyclic antidepressants 359-60
Trigeminal
nerve compression 334
Vancomycin 215-16, 223
neuralgia 315
Vascular disease, ergotamine tartrate
pain 338
contraindicated in 340
paroxysmal neuralgia 333
Vascular pain 339-41
Trolley, surgical 12
Vasoconstriction
Trotter’s syndrome 337
in apicectomy 258, 260
Tubercles, genial, removal of 107-8
excessive 175
Tuberculosis 187
Vasoconstrictors, felypressin 241
Tuberculous osteomyelitis 196-7
Vasomotor rhinitis, non-allergic 326
Tuberosity
Vertically orientated teeth, impacted 56-7
fibromatous enlargement of 307
Vicryl 18-19
fractured maxillary 252-3
Vidian nerve neuralgia 340
fragments 73
Vincent’s organisms, ulcerative pericoronitis
Tumour
due to 127-8
in edentulous jaws 96
Vincent’s ulcerative gingivitis 125
osseus 202
Von Recklinghausen’s neuro-fibromatosis
Typhoid fever 197
309

Ulcer Warfarin 355-7

malignant 330 contraindicated drugs 356
pressure 95 Washing 10
Ulceration of patients 24
factitious 329 Wegener’s granulomatosis 312
peptic, aspirin contraindicated 344 Wire cutters, theatre 21
Ulcerative gingivitis, acute 176 Wiring kit 21
Ultrasound, reducing postoperative Wisdom teeth
morbidity 70 impacted
Unerupted 3rd molar, extraction, tuberosity covered by denture 60
fractured in 252 mandibular 3rd molar and 53
Unerupted canine removal of partly erupted 60
extraction 76-81 Wisdom tooth, displacement into antrum
leaving in situ 81 73
radiological examination 74-5 Wounds
reasons for removing 75-6 alveolar 30
surgical exposure 81—2 infection of moist unhealed 221
transplantation 82-3
Unerupted mandibular premolars 84, 86
Unerupted teeth 52
cyst enucleation and 295 Yaws 187, 196
dentigerous cysts on 266
dentures and 96
displacement into antrum 247 Z-plasty 99-100
removal of permanent 90 Zovirax cream 217

386
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DENTAL PRACTITIONER HANDBOOKS
General Editor DONALD D DERRICK pps Lbs rcs

ISBN 0 7236 0735