Maxillofacial infections – abscesses

Maxillofacial Surgery

Most of maxillofacial infections have an odontogenic aetiology and they are usually caused by the extension of dental-socket abscesses or by peristefanitis. During the initial states a odontogenic infection is relatively easily manageable.

The treatment of every abscess is based on lifting the cause (endodontic treatment – root canal treatment) or on extracting the responsible tooth, fission-drainage and administration of the appropriate antibiotic treatment.

A dental abscess, if left untreated or if the responsible microbes have an increased infective strength, may extend to the throat and possibly become dangerous for life. When an abscess expands to the face or throat, an oral and maxillofacial surgeon’s contribution is necessary. The role of visceral cranium-throat CT during the diagnosis is determinant. Due to the complicated anatomical structure of the throat, the CT indicates all of the spaces where the abscess extends.

The side-pharynx abscess requires direct treatment. It is described usually by fever, pain, inability to open the mouth. The swelling can be limited. Some extensions of a side-pharynx abscess that may lead to dangerous, for the patient’s life, complications are the extensions to rear-pharynx space and to the mesothorax. For example mesothorax condition (mesothoracitis) has a death rate of 50%.

Bruxism Night Guard

Implants, Dentistry

A large percentage of people suffers from bruxism and they often do not realize it. Bruxism is the unintentional tooth grinding or tightening which is associated with dynamic lateral movements of the jaws.

The most common cause is anger, tension, stress or frustration, sleep disturbances, missing teeth or teeth that are wrong, an accident. It is usually detected during the night. Do not make your teeth a “receiver” of your anxiety!

Wearing a bruxism night guard helps you with:

  1. stopping the tooth abrasion
  2. improving your breath
  3. relieve from pain in the neck and shoulders
  4. reduction of headaches
  5. reduction of sleep discomfort
  6. reduction of stress in jaw joints
  7.  protection of natural teeth and dental work from damage caused by teeth grinding
  8. reduction of abrasions, fractures, but also excessive tooth decay
  9. any reduction in snoring

 

Common Symptoms:

  1. Pain, tension or intense tightening on the jaws, after breakfast wake up
  2. Headache or ear pain, especially after morning wake
  3. Teeth sensitivity to hot, cold, pressure, sweets
  4. Your partner complains that you are making noise during sleep
  5. When you open your mouth, sounds a strong click
  6. Tooth decay, broken teeth, teeth with cracks are noted in your oral cavity
  7. People who tighten or rub their teeth during the night usually like to bite pencil with their teeth, chew the inside of their cheek or eat their nails

 

Treatment:

1st visit:

  • Receive patient history
  • Clinical oral examination
  • Obtaining fingerprints on an individual diskette with imprints

 

2nd visit:

  • Final application (the patient needs to wear the bruxism night guard daily during sleep)

Periodontology

Implants, Dentistry

Periodontitis is an inflammatory disease of the tissues surrounding and supporting the teeth.

Inflammation extends deeply into the tissues and gradually removes the gum from the teeth and damages the bone that supports the teeth roots. If not treated directly, teeth initially show intense mobility and are eventually lost.

Periodontitis is considered the most common cause of tooth loss in adults, and its frequency of appearance is very high in age over 45 years. Periodontal disease can be diagnosed by the periodontist expert or by the dentist at an early stage.

The patient usually realizes the disease at a very advanced stage. Periodontitis, depending on the loss of adhesion, is distinguished in early, intermediate or advanced and depending on its extent in localized or generalized.

 

The symptoms commonly associated with periodontal disease are:

  • Bleeding of the gums in brushing or on their own
  • Red, swollen or sensitive gums
  • Gums that have subsided (gum recession)
  • Tooth mobility (sometimes small and sometimes large)
  • Gums detached from the tooth
  • Immigration (moving) of teeth
  • Persistent stench
  • Puss between tooth and gums

 

Agents predisposing periodontitis:

  • Insufficient removal of the dental plaque from the teeth
  • Smoking
  • Uncontrolled diabetes
  • Inheritance
  • Anxiety
  • Systematic diseases
  • Diseases that affect the immune system (eg aids)
  • Hormonal disorders
  • Traumatic occlusion
  • Poor oral hygiene
  • Drug intake

 

Treatment:

1. Conservative treatment:

With special tools, plaque, microbes and toxins are removed from the root, painlessly with local anesthesia. The patient does not feel pain either during the procedure or after going home. The disadvantage is that this treatment has finite abilities to fully resolve the periodontal problem, with the result that the destruction continues at a slower pace. Usually 4-6 visits are required.

Oral hygiene instructions are given to the patient (correct tooth brushing, interdental brushes and sometimes oral solution and / or gel). The ideal time to evaluate the effects of conservative periodontal treatment is 3 months.

2. Surgical treatment:

In some cases, where periodontal disease has gone far enough, it is necessary, after the conservative treatment, to take a surgical arrangement at selected points of the mouth. Surgical treatment, when required, always follows the conservative one.

A cut is made (the gums are opened locally with microsurgical methods) the tissues are settled and then they are stitched. The advantages are the regeneration of lost periodontal tissues, sometimes the reduction of periodontal sockets, easier access to the root surface of the tooth with tartar deposition, more accurate prognosis.

The patient feels pain after surgery. The drawback is that teeth cold and hot sensitivities are present after surgery and until healing.

 

3. Conservative laser therapy:

Additional use of laser in conservative treatment greatly reduces the likelihood of requiring periodontal surgeries. In conjunction with conservative treatment, periodontal laser therapy (LPT) is effective allowing the patient to stay healthy and live comfortably, controlling the disease.

Periodontal laser therapy (LPT) is a safe and absolutely painless treatment. At the same time, there is no sensitivity to the teeth and it is particularly indicated for patients with health problems such as diabetes, heart diseases, patients with allergies to antibiotics, haemophilia, HIV, periodontitis with socket depth etc.

The laser energy is transferred to the periodontal pouch to remove the infected gum tissue and disinfect the micro-environment of the pouch by killing the bacteria and by inactivating the toxins on the surface of the tooth root and the gum tissue, leading to the activation of the healing process.

Sialendoscopy

Oral Surgery

Patients who present sialadenitis incidents from obstruction caused by stone (formed by saliva’s salts) or from narrowing of the glands’ pores, are treated using a technique that consists of inserting a very small endoscope (optical fiber) into the pore that drains saliva, which is connected to a camera.

The procedure is simple and is executed using local anesthesia; it can solve the problem either during the acute phase or after such frequent infections, and can determine the diagnosis.

The classic methods of displaying obstructive phenomena of salivary glands are: Sielography, ultrasound, x-ray, axial and magnetic tomography. Sielography has remained until now a method of choice for diagnosing obstructive phenomena of major salivary glands.

Ultrasound remains a reliable diagnostic tool for displaying stones within the salivary glands with the limitation that stones less than 3mm cannot be displayed.

Another examination presupposing the use of magnetic resonance is magnetic sielography that gives images of the salivary glands without the use of radiation.

Sialendoscopy system is a new revolutionary technique for endoscopic removal of stones from major salivary glands. (Parotid – submaxillar). Using local anesthesia, we enter the glandular pore and examine its lumen with a 1.3 mm diameter endoscope.

The patient leaves after approximately 40 minutes, having the obstructive phenomenon that has plagued him removed and without needing further hospitalization.

In conclusion, it is possible to remove or decompose the obstructive phenomenon that plagues the patient without requiring surgery or some other surgical operation, and the patient, using only local anesthesia, is relieved of the obstructive phenomenon with the least possible damage to the adjacent tissues and soon recovers immediately.

This operation can be performed by an otorhinolaryngologist, a Maxillofacial surgeon and by a specialized dentist with the help of the previous specialties.

 

Salivary Glands Diseases

Oral Surgery

Salivary glands are organs that are distributed around the oral cavity and produce saliva.

They are distinguished in major and minor. The parotid, submaxillar and sublingual salivary glands are considered to be the major ones. Minor salivary glands are around 400-500. Saliva is a liquid essential for digestion, speech, swallowing and for the maintenance of oral health.

The quantity of saliva produced daily is normally about 1-1.5 liters. In the salivary glands, the most common pathological conditions are infections, sialolithiasis, tumors (benign and malignant) and autoimmune diseases.

 

Salivary Gland Diseases:

 

Salivary gland inflammations

They are called sialadenitis and may be due to viruses or microbes. The appearance of mumps in childhood caused by the mumps virus is typical. Microbial sialadenitis often occurs in submaxillar glands or parotids, and may be due to obstruction of pores that drain saliva from stenoses, inflammations or stones.

 

Sialolithiasis

Saliva contains salts that can, in some cases, form stones just like in the kidneys. Then the emissary of the gland is blocked, the drainage of the saliva stops, the gland swells and this is followed by inflammation with pain.

Sometimes sialolithiasis self-heals and sometimes requires the removal of the stone by a cut through the mouth. Endoscopy (sialendoscopy) is a useful diagnostic and therapeutic tool in the sialolithiasis of major salivary glands. In some cases it is necessary to remove the gland itself by surgery under general anesthesia.

 

Salivary Gland Tumors

These may be malignant or benign. Benign tumors are more common especially in the parotid area. The most common are the manifold gland and the Warthin tumor. Tumors usually grow slowly. But if not treated over the years, a benign tumor can be transformed into malignant.

Therefore, these tumors should always be treated with surgical abscission.

The most common surgical procedures performed for this reason are:

The appropriate surgery considering the parotid is partial or superficial parotidectomy. The surgery includes removal of part of the gland together with the tumor (en block).

It is done with an outer cut around the ear that extends towards the neck. It has the particularity of the presence of the facial nerve within the gland. Damage to the facial nerve leads to a disorder in the movement of the facial muscles.

The gland with the tumor is detached from the nerve branches and gets removed en block. In these procedures, we use a neuro-monitoring system, a system that checks the integrity of the nerve during surgery and warns us when, using our tools, we handle very close to the branches of the personal nerve.

The operation is executed with general anesthesia and usually requires hospitalization for two days. The aesthetic result is very satisfactory. In the submaxillar glands, an operation of choice is the abscission of the gland. This is done with a sub-maxillar cut and the aesthetic result is excellent.

 

Autoimmune Diseases

Sjogren’s syndrome is an autoimmune disease that causes dry mouth and dry eye due to salivary and lacrimal glands filtration. Sjogren’s syndrome is divided into the primary one when it appears on its own and in the secondary one when it is accompanied by other conditions.

Such diseases are rheumatoid arthritis, lupus erythematosus and scleroderma. Patients with secondary Sjogren syndrome need long-term follow-up due to the risk of developing a non-Hodgkin lymphoma that is 5-10%.

Osteonecrosis caused by bisphosphonates

Oral Surgery

As a side effect, jaw’s osteonecrosis was recorded for the first time in 2003 bibliography.

Bisphosphonates are a group of medicines that, due to their osteolytic effect, are considered the first choice of medicines for patients who suffer from osteoporosis and osteopenia because they reduce the danger of an osteoporotic fracture by 50%.

They are also administered to patients with multiple myeloma, cancer at breast, prostate, kidney, lung and when there are bone metastases.

Also, they are administered for the Paget bone disease treatment and the imperfect osteogenesis. Bisphosphonates, nowadays, are frequently prescribed medicines by doctors of various specialties like rheumatologists, orthopedists, endocrinologists, oncologists, pathologists.

Most commonly administered bisphosphonates include:

  • Zoledronate (Zometa)
  • Ibandronate (Bonviva)
  • Risedronate (Actonel)
  • Pamidronate (Aredia)
  • Alendronate (Fosamax)

 

Bisphosphonates are administered either intravenously or from the mouth. The probability for them to cause jaw osteomyelitis or osteonecrosis is increased if they are received from the mouth for more than 3 years or if they are received intravenously for more than 6 months. Generally, the danger of jaw osteonecrosis is much higher when the patient receives the bisphosphonate intravenously.

Osteonecrosis caused by bisphosphonates is more frequent at the lower jaw and usually a dental operation like a tooth extraction has been preceded. During osteonecrosis, there is a decomposition of the mucous membrane and revelation of the necrotic bone which may be asymptomatic or painful. Every patient who receives bisphosphonates in any way must maintain a very high level of oral hygiene.

It is good to avoid executing any intraoral operations (like extractions) to these patients, but if it is necessary, it is considered deliberate to stop receiving the medicine 3 months before and 3 months after the operation. The treatment for osteomyelitis by bisphosphonates is extremely difficult.

Frenectomy

Oral Surgery

The frenulum is a part of soft tissue that starts from the inner part of the lips or the tongue and ends at the gums. In some cases, frenulums can cause receding or divergence between central sectors of the upper jaw.

Apart from dental and periodontological reasons, frenulums are removed from children when they cause difficulties to speech. A short frenulum at the tongue needs to be released as soon as possible before it causes speech problems to the child.

The operation is extremely simple and takes place in the infirmary’s space, using local anesthesia and is usually concluded in 10 minutes. A more conservative technique concerning frenectomy is conducted using a laser.

Oroantral communication

Maxillofacial Surgery

Oroantral communication is a pathological state during which there is a communication between the maxillary sinus and the oral cavity. It occurs usually after extractions of rear teeth of the upper jaw. The upper jaw’s rear teeth’s roots, are many times directly related with the sinus’ mucous membrane. In these cases, due to anatomical variation, even a non-traumatic extraction of a tooth may have an occurrence of communication between the oral cavity and the sinus as a result, via the tooth’s socket.

If not dealt with, a chronic oroantral fistula will occur and cause a chronic odontogenic sinusitis. This is a major complication that requires direct convergence from an Oral and Maxillofacial Surgeon expert.

The most common convergence of communication technique is the production of a propulsive tissue from the mucous membrane. Palatinate tissue can also be used.

Osteoplastic – grafts

Maxillofacial Surgery

Volume maintenance of the post-extraction socket.

Right after the extraction of a tooth, the healing process starts with the formation of a blood clot.

After some time, this clot transforms into a bone through the natural process of healing. In order to avoid the absorption and the atrophy of the bone socket in the extraction area, it is ideal that the grafts are placed during the time of extraction.

Process:

  1. The tooth gets extracted.
  2. A careful surgical cleaning is conducted locally.
  3. A suitable graft is placed inside the socket to occupy the empty space.
  4. The graft maintains its volume to help the prevention of shrinkage and atrophy of the post-extraction socket.
  5. The graft acts like a scaffold that is used from the body’s cells, so they can be reborn into a bone in a predictable and effective way.
  6. After 3-4 months of healing approximately, the area can be ready for dental implants placement. The volume maintenance grafts of the post-extraction socket are recommended for every patient’s tooth extraction and we design the bone restructuring and dental implants placement.

TRANSPLANT USING BONE CHIPS
If a tooth is missing in an area, the jaw, eventually, starts getting absorbed leaving a deficit that can’t be rebuild. Bone chips is a method that is used for the restoration of the bone areas that have been absorbed using graft material in the form of granule.

Procedure:
The area is prepared for the material to be placed inside. Graft materials can be received either from the trade (foreign grafts) or from the patient himself. Nevertheless, prefabricated materials are those that are used more often. A sufficient piece of graft is placed in the area and then the graft is covered from soft tissues and gets sewed.
A healing period follows before restoration with dental implants is conducted, that lasts 4-6 months approximately.

Bone block transplant
Bone block transplant is another method for bone restoration of an area where teeth are already lost. Typically, this method is used in cases of greater deficits comparing with those where the placement of bone chips is adequate. In those cases, a larger part of bone is received from the patient and gets placed in the area where there is a bone deficit.
After a period of 3-4 months, the graft is integrated in the jaw bone for the improvement of the bone’s quantity and quality, with the purpose of implant placement. The places that are usually used as a source for this type of graft include the jaw or the third molar area of the lower jaw.

Bone chips vs bone block transplant
A common question brought forward concerning oral surgery is if bone chips should be used instead of bone blocks. Each case is unique and must be examined separately. Therefore, there isn’t an explicit answer. However, for smaller deficits, the grafts in the form of granule are often used in order to avoid the creation of a second surgical field for the graft removal. Larger deficits are predictably dealt by using bone blocks. The creation of a second surgical field to remove the block results in a more intense post-surgical discomfort and swelling. Most of the time the healing percentages are essentially equivalent, as well as the quality and quantity of the resulting bone.

Major bone transplant (Large bone quantity)

In cases of important trauma or pathological situations (cysts, tumors), larger quantities of bone grafts are required to rebuild the jaw bone so that the placement of implants or other restoration procedures are possible. In these cases, the granules (chips) and small bone blocks are considered inadequate techniques for the bone quantity required for the final restoration. In these cases, grafts can be received from the ilium, the parietal bone, the patient’s shinbone etc.

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