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–
Orbital floor line for fracture.
–
Opacity in the antrum due to blood.
¾
CT scan is done to see orbital depression and herniation
of orbital fat.
Treatment
¾
Every patient with zygoma fracture need not require
A
surgical correction.
¾
Need for surgery is decided based on clinical features.
INDICATIONS FOR SURGERY ARE:
B
x Infraorbital anaesthesia, trismus
x Diplopia, enophthalmos
SRB's Manual of Surgery
x Flattening of the cheek
x Undisplaced fracture with infraorbital anaesthesia
Surgical Approaches
1. Closed reduction of the zygomatic arch through Gillies
temporal approach:
Fig. 2.20: Technique showing method of temporal reduction using
disimpaction forceps.
An oblique skin incision of 2 cm length temporal is made
between the two branches of the superficial temporal artery.
Care is taken to avoid injury to artery. Whitish glistening temporal
fascia is identified and incised. Zygoma elevator is introduced
beneath the zygoma and fracture fragments are manipulated and
elevated into proper position. An audible snap is heard when
fracture gets reduced into position. Reduced, disimpacted fracture is always stable. Additional corrections in other parts can
be done by different leverage actions of the elevator. Orbital rim
and zygomatic arch are palpated for completion of correction.
Skin wound is closed with sutures.
Elevators used are Bristow’s periosteal elevator, Rowe’s
zygomatic elevator.
2. Internal fixation by open reduction and fixation is needed
¾
When fracture is unstable or
¾
Comminuted or
¾
Zygoma fracture with middle third fractures.
By proper incisions, infraorbital and zygomaticofrontal frac-
ture sites are exposed; after open reduction, they are fixed
using wires/plates and screws.
B
Figs. 2.21A and B: Disimpaction of maxilla using Rowe’s
disimpaction forceps by downward leverage action.
Fig. 2.22: Fracture zygoma showing open reduction and fixation using
wires directly. Two types of incisions are shown depending on the site
of the fracture.
3. Exploration of the orbital floor is necessary whenever there is
¾
Comminuted fracture in orbital floor.
¾
Orbital fat herniation.
¾
Diplopia with entrapment of the inferior rectus muscle.
FRACTURE OF THE MANDIBLE
Types
I. At the neck of the condyle (35%), as it is the weakest point.
The condyle is displaced in front and medially often with
dislocation. Painful jaw movement is the clinical features.
It may be unilateral or bilateral.
II. At the angle of the mandible: If fracture is upwards and
inwards, it is impacted and undisplaced. So it is a favourable fracture. If fracture is downwards and outwards, it gets
displaced and so it is an unfavourable fracture. It needs open
reduction using wires.
Fig. 2.23: Types of mandibular fractures.
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III. Fracture near the mental foramen through the canine fossa.
This fracture causes displacement. Such bilateral fractures
can cause pull on digastric and geniohyoid muscles precipitating fall of tongue backwards which will block the airway.
Other Classications
Classification of the fracture mandible
T
Depending on the type Depending on the anatomical site
• Simple • Dentoalveolar fracture
• Compound • Condylar fracture
• Comminuted • Coronoid fracture
• Pathological • Fracture ramus of the mandible
• Green stick fracture in
children
• Fracture angle of the mandible
• Fracture in the body of the
mandible
• Symphyseal region fracture
347
CHAPTER 2 Faciomaxillary Diseases
Fig. 2.24: Muscle actions in mandible fracture causing
different displacements.
Guardsman fracture is direct fracture of symphysis and indirect
fractures of both the condyles of the mandible. In olden days
guards of the queen who are in attention position used to faint
and fall forward to get these fractures.
Dentoalveolar fracture
T
Features Management
• Horizontal fracture below the
alveolar margin
• Dentoalveolar segment will be
freely mobile
• Tooth may get split vertically/
horizontally
• Derangement in occlusion
and alignment
• Gingival laceration • Liquid diet for 3–4 weeks
• Bleeding
• Infection and late osteo-
myelitis of mandible
• Look for other injuries in face
• X-ray face to see injuries
• Dentoalveolar segment
reduction and placing jaws in
central occlusion position
• Stabilisation using interdental wires or arch bars
The rst two letters of goals are go.....
Fig. 2.25: Unreduced and reduced fracture mandible.
Fig. 2.26: Different sites of fracture mandible.
Clinical Features
Pain and tenderness in the lower jaw with bruising over the
surface.
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SRB's Manual of Surgery
Fig. 2.27: Arch bar wiring. Figure shows both simple and Erich arch bar wiring with cleats to pass wire.
Haematoma in the floor of the mouth is called as Coleman‘s
sign.
Difficulty in opening the mouth, speech and swallowing.
Anaesthesia of the lower lip due to compression of inferior
dental nerve.
Deranged dental occlusion.
Step deformity.
Investigations: X-ray of the mandible; Orthopantomogram
(OPG), CT head and face.
Treatment
¾
Antibiotics to prevent formation of osteomyelitis of the
mandible.
¾
Open fixation of the fracture segments using silver wires
for 4–6 weeks.
¾
Fixation by: Interdental wiring; Using arch bars; Silver
alloy or plastic caps.
Only fluid diet for 6 weeks.
Irrigation wash to the oral cavity to maintain the hygiene.
Complications of fracture mandible: Obstruction of the
airway; Osteomyelitis of the mandible; Trismus; Speech
disturbances
DISLOCATION OF THE MANDIBLE
It occurs at temporomandibular joint.
Unilateral dislocation after trauma is common.
Fig. 2.28: Circummandibular wiring used in gunning splints.
Fig. 2.29: Interdental wiring. It is commonly used and
accepted method of wiring.
Bilateral dislocation occurs during yawning and it is recurrent.
Clinical features are difficulty in opening the mouth with
pain and tenderness over the joint.
Treatment: Reduction of dislocation under general
anaesthe sia; If there is associated fracture mandible, it
should be dealt with accordingly.
Fig. 2.30: Upper and lower border wiring. It is used to fix the mandibular fractures and is often done together
with other fracture fixations in the face.
Fig. 2.31: Compression plating of a mandibular fracture. Note the different methods.
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349
CHAPTER 2 Faciomaxillary Diseases
TREACHER-COLLINS SYNDROME
B
x Mandibulofacial dysostosis
x Hypoplasia of the zygomatic bone and mandible
x Antimangoloid slant to the palpebral fissure
x Coloboma of lower eyelid
x Low ear lobule with deficient middle ears
x Familial—3rd arch syndrome (Mandibulofacial dysostosis)
Fig. 2.32: Microtia which is corrected later
(Courtesy: Dr Sathish Bhat, Plastic Surgeon, Mangaluru).
JAW TUMOURS
The term ‘Jaw tumours’ is a gross terminology which denotes
any tumour which arises from jaw either benign or malignant;
from upper or lower jaw; from any tissues (layers) of the jaw
from mucosa to soft tissues.
Swelling arising from the gums (Epulis): Congenital epulis,
Fibrous epulis, Pregnancy epulis, Giant cell epulis, Myelomatous epulis, Sarcomatous epulis, Carcinomatous epulis.
Swelling arising from the dental epithelium and ectomes-
enchyme (Odontomes): Ameloblastoma, Compound odon-
tome, Enameloma, Cementoma, Dentinoma, Odontogenic
fibroma and myxoma, Radicular odontome, Composite
odontome. Cysts arising in relation to dental epithelium:
Dental cyst, Dentigerous cyst.
Swelling arising from the mandible or maxilla: Osteoma
and osteoblastoma, Torus palatinus and mandibularis,
Fibrous dysplasia, Osteoclastoma (Common in mandible),
Osteosarcoma; Secondaries; Giant cell reparative granuloma.
Surface tumours: Tumours from the surface which extend
into the jaw—Ossifying fibroma, Osteofibrosis of maxilla,
Ivory osteoma of jaw, Leontiasis ossea (diffuse osteitis),
Carcinoma extending into the jaw.
It can be odontogenic or non-odontogenic.
Odontogenic tumour can arise from (A) odontogenic epithelium
like—(1) Ameloblastoma; (2) Pindborg’s tumour; (3) Clear cell;
(4) Squamous cell type. (B) from odontogenic epithelium and
ectomesenchyme like—(1) Ameloblastic fibroma; (2) Adenomatoid odontogenic tumour; (3) Compound odontome; (4) Complex
odontome. (C) From odontogenic ectomesenchyme like—(1)
Odontogenic fibroma; (2) Myxoma; (3) Benign cementoblastoma.
Nonodontogenic tumours are classified as—(A) Ossifying
neoplasm like cemento-ossifying fibroma. (B) Nonneoplastic
bone lesions like fibrous dysplasia, cemento-ossifying dysplasia.
(C) Cemento-osseous dysplasias like cherubism, central giant
cell granuloma. (D) osteoma, osteoblastoma, osteoclastoma,
osteosarcoma.
Other lesions like haemangioma, neurofibroma also can
occur in jaw.
Pindborg’s tumour is calcifying epithelial odontogenic tumour
(CEOT). It arises from epithelial remnant of enamel; it is common
Many receive advice, only wise prot from it.
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A
B
SRB's Manual of Surgery
C
Figs. 2.33A to C: Lower jaw tumour with images.
A
Figs. 2.34A and B: Lower (B) and upper (A) jaw tumours
in two different patients.
B
in mandibular molar. 50% or more arises from unerupted tooth.
It presents as painless slow growing jaw tumour. Image shows
scattered flaks of calcification with driven snow appearance. It
can be uni or multilocular lesion. Treatment is wide excision;
shows 15% recurrence.
Investigations: Open incision biopsy is preferred. CT of the part;
MRI to evaluate soft tissues. CT chest and abdomen are done in
malignant cases to assess metastases.
Treatment: Wide excision with part of the bone with 2 cm clearance. Reconstruction is needed with bone graft and reconstruction prosthesis and flaps. Maxillectomy, mandibulectomy are
often needed depending on location, size and extent.
EPULIS (GREEK—MEANS UPON GUM)
Swelling arising from the mucoperiosteum of gums (gingiva). It
is gross terminology but still term is used in many conditions.
Fig. 2.35: Epulis.
Types
Congenital Epulis: It is a benign condition seen in a newborn
arising from gum pads (Neumann’s tumour). It is a variant of
granular cell myoblastoma originating from gums. It is more
common in girls. It is more common in upper jaw, common
in canine or premolar area. It is not a malignant condition.
Clinical features are—Well localised swelling from the gum
which is firm and bleeds on touch. Treatment: Excision.
Fibrous Epulis: It is a benign condition, can occur in any
individual. It is red, firm/hard, sessile/pedunculated. It is
the commonest type. It is fibroma arising from periodontal
membrane. Clinical features are—Painless, well localised,
hard, non-tender, grey pink swelling in the gum which bleeds
on touch. Differential diagnosis: Squamous cell carcinoma
from the gum. Investigations—X-ray jaw, Orthopantomo-
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gram, Biopsy from the lesion. Treatment: Excision with
extraction of the adjacent tooth. Recurrence can occur if root
is not removed properly.
Pregnancy Epulis: It occurs in pregnant women due to
inflammatory gingivitis. Usually, it occurs during 3rd
month of pregnancy. Clinically, it resembles fibrous epulis
or pyogenic granuloma. It usually resolves after delivery.
Otherwise, it should be excised.
Epulis fissuratum: It is a benign hyperplasia of fibrous
tissue developing as a reactive lesion to chronic irritation to
ill-fitting dentures.
Myelomatous Epulis: It is seen in leukaemic patients. It is
investigated for leukaemia by peripheral smear, bone marrow
biopsy. Treatment is for leukaemia.
Granulomatous Epulis: It is a mass of granulation tissue in
the gum around a caries tooth. It forms a localised soft/firm/
fleshy mass in the gum which bleeds on touch.
Giant Cell Epulis: Osteoclastoma causing ulceration and
haemorrhage of gum.
Carcinomatous Epulis: Squamous cell carcinoma of the
alveolus and gum presenting as localised, hard, indurated
swelling with ulceration.
Fibrosarcomatous Epulis: Fibrosarcoma arising from fibrous
tissue of the gum.
351
CHAPTER 2 Faciomaxillary Diseases
Fig. 2.36: Large jaw tumour—could be adamantinoma/
osteoclastoma.
EPULIS
B
x Congenital x Carcinomatous
x Fibrous—commonest x Myelomatous
x Granulomatous x Fibrosarcomatous
x Pregnancy
ODONTOGENIC TUMOURS
B
Epithelial tumours
x Ameloblastoma
x Calcifying odontogenic tumour
x Odontogenic adenomatoid tumour
x Composite odontoma, which may be either complex or
compound. It is odontogenic hamartoma contains all 4 layers,
dentin, enamel, cementum and pulp
Mesodermal tumours
x Odontogenic fibroma, myxoma
x Cementoma, dentinoma
Malignant odontogenic tumours
x Malignant ameloblastoma
x Fibrosarcoma
AMELOBLASTOMA (Adamantinoma, Eve’s
Disease, Multilocular Cystic Disease of the Jaw)
It arises from the dental epithelium probably from the enamel/
dental lamina.
It occurs commonly in mandible (5:1) or maxilla.
Occasionally, it is seen in the base of the skull in relation to
Rathke’s pouch or in tibia.
It is a locally malignant tumour. Histologically, it is
a variant of basal cell carcinoma. It neither spreads
Fig. 2.37: Orthopantomogram (OPG) X-ray showing unilocular
odontogenic tumour in lower jaw.
A
B
Figs. 2.38A and B: X-ray (two different X-rays) showing typical
honeycomb/multiloculated features of adamantinoma (Courtesy:
Dr Veena Jagadish, MDS).
Rudeness is a weak imitation of strength.
352
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through lymph node nor through blood. Hence it is
curable.
It is usually unilateral. It can occur in a pre-existing denti-
gerous cyst.
It is usually multilocular cystic spaces but can be unilocular
also.
Histologically cords of odontogenic epithelium, connective
tissue, stellate reticulum like cells with columnar ameloblast
like cells.
Features
A B
Figs. 2.39A and B: (A) Dentigerous cyst; (B) Orthopantomogram
showing dentigerous cyst.
SRB's Manual of Surgery
Swelling in the jaw usually in the mandible near the angle
which attains a large size, extending to vertical ramus—
Eggshell crackling.
It is a gradually progressive, painless swelling which is smooth
and hard with intact inner table (enlarges externally).
Lymph nodes are not enlarged.
Outer table expansion.
It is common in males, common in 4th to 5th decades.
Differential diagnosis
¾
Osteoclastoma of the mandible: Here inner table is not
intact.
¾
Dentigerous cyst; Dental abscess.
¾
Giant cell reparative granuloma (Jaffe’s tumour): It is a
swelling which occurs due to haemorrhage within the
bone marrow. It contains vascular stroma, collagen
and connective tissue cells. It is common in women. It
causes painless enlargement of jaw. It can be treated by
calcitonin (100 units/0.5 mg subcutaneously daily for 12
Complication: It can turn into adamantinoma.
Investigation: Orthopantomogram. Tooth within the cyst, which
is well-defined.
Treatment
¾
If it is small, excision of the cyst is done.
¾
If it is large, initial marsupialisation and later excision is
done.
¾
Unerupted tooth should be extracted.
DENTAL CYST (Radicular Cyst, Periapical Cyst)
It occurs under the root of the chronically infected dead
erupted tooth.
It is lined by squamous epithelium derived from epithelial
debris of Mallassez.
Clinical feature: As a smooth, tender swelling in the jaw in
relation to caries tooth which causes expansion of the jaw
bone.
months) or surgical curettage.
Investigations:
¾
Orthopantomogram (OPG) shows multiloculated lesion—
Honeycomb appearance. CT scan of the region in ideal.
¾
Biopsy from the swelling.
Treatment: Segmental resection of the mandible. OR Hemi-
mandibulectomy with reconstruction of the mandible.
Note:
• Curettage and bone grafting should not be done. It is a curable
condition.
• Recurrent adamantinoma can spread through blood into lungs.
DENTIGEROUS CYST (Follicular Odontome)
It is a unilocular cystic swelling arising in relation to the dental
epithelium from an unerupted tooth.
Common in lower jaw, but can also occur in upper jaw.
It occurs over the crown of unerupted tooth. Commonly seen
in relation to premolars or molars.
It causes expansion of outer table of the mandible.
Clinical feature: Painless swelling in the jaw which is smooth
and hard.
Differential diagnosis: Adamantinoma; Dental cyst; Osteo-
clastoma
Fig. 2.40: Dental cyst with orthopantomogram x-ray.
Complicati on: It can cause osteomyelitis of the jaw.
Differential diagnosis: Dentigerous cyst.
Investigation: Orthopantomogram.
Treatment:
Antibiotics; Drainage or excision of the cyst with
extraction of the infected tooth is done.
CURABLE MALIGNANCIES
B
x Adamantinoma x Papillary carcinoma thyroid
x Basal cell carcinoma x Marjolin‘s ulcer
x Verrucous carcinoma x Carcinoma colon
Differences between dental cyst and denti gerous cyst
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T
Dental cyst Dentigerous cyst
Site of
a.
occurrence
b. Infection Common Not common
c. Complication Osteomyelitis Adamantinoma
d. Treatment Excision and
Erupted tooth under
the root
extraction of tooth
Over the crown of an
unerupted tooth
Marsupialisation,
excision and then
extraction of tooth
OSTEOMYELITIS OF JAW
It is an inflammatory process in jaw; acute or chronic. It can
be in the maxilla or mandible.
Causes:
¾
Alveolar abscess leading into osteomyelitis.
¾
Recurrent dental infection; Trauma.
¾
After dental extraction; surgeries of the jaw.
¾
Postradiotherapy osteomyelitis (osteoradionecrosis).
Types
Acute is common in children; maxilla or mandible may get
involved; swelling, redness, fullness are the features; pus
may trickle through nostril if it is in maxilla.
Subacute type is the commonest type; common in adult;
apical sepsis, endarteritis, bone necrosis is the pathology;
common in mandible; rare in maxilla due to existing network
vasculature which prevents endarteritis. Compression over
inferior dental nerve causes numbness in chin in area of
distribution of mental nerve. Pain, swelling, tenderness,
irregularity, bone thickening are typical.
Chronic type is also common in mandible; apical abscess,
alveolar abscess, trauma, radiation, chemicals like phosphorus,
tuberculosis, syphilis, actinomycosis are the causes. Pain, bone
thickening, irregularity, discharging sinus, sequestrum in the
discharge, discomfort are the features. Infection from lower
incisor causes median mental sinus. X-ray shows features of
osteomyelitis with new bone formation and sequestrum.
Management
¾
X-ray jaw; CT scan of jaw; discharge study; ESR are essential investigations. Biopsy from the sinus is needed often.
¾
It is often difficult to treat. In acute phase, antibiotic
coverage, treatment of cause is done. In chronic type,
sequestrectomy, mandibulectomy is needed.
Actinomycosis of Jaw (Refer Chapter 1D)
Faciocervical is the commonest type; lower jaw is commonly
involved; infection begins at carious tooth; indurated gums →
nodules → abscess → multiple sinuses → discharging sulphur
granules with normal X-ray (Ray fungus). Actinomycosis israelii
is the causative agent. It is treated by penicillins.
ALVEOLAR ABSCESS (Dental Abscess)
It is due to spread of infection from root of the tooth into the
periapical tissue. Initially, it forms periapical abscess which later
spreads through the cortical part of the bone into the soft tissues
around forming an alveolar abscess.
Fig. 2.42: Tooth infection causing large dental abscess. It needs
antibiotics, proper drainage and tooth extraction. Patient may develop
trismus/retropharyngeal infection/chronic osteomyelitis of the mandible.
Disease begins in the pulp of tooth → pulpitis → spread to
root → localized osteitis → abscess formation → spread into
soft tissues outside in cheek → initially diffused later localised
swelling in the jaw with redness and oedema of gum. Initial dull
continuous pain later becomes severe excruciating pain.
Bacteria: Staphylococci, streptococci, anaerobic-bac
gram-negative organisms.
teria and
353
CHAPTER 2 Faciomaxillary Diseases
Fig. 2.41: Osteomyelitis of the mandible. Discharging sinus is obvious.
Features
Deep, throbbing pain in the jaw and adjacent oral cavity with
diffuse swelling over the cheek.
Tender soft tissue swelling in the jaw which eventually bursts
spontaneously leading to sinus formation.
Open confession is good for the soul.
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Oedema, pain and tenderness in the floor of the mouth.
Trismus and dysphagia. Fever and features of toxaemia.
Tender palpable lymph nodes in the neck.
Investigations: X-ray of the mandible or maxilla; Discharging
pus for culture study; CT mandible.
COMPLICATIONS
B
x Septicaemia.
x Spread of infection into other spaces like para pharyn geal spaces;
sublingual and submandibular spaces causing Ludwig’s angina;
oedema of epiglottis and respiratory distress; spread to pterygoid space and along pterygoid muscles through emissary vein
SRB's Manual of Surgery
→ cavernous sinus thrombosis; upper canine tooth abscess
→ medial corner of eye → angular vein thrombophlebitis →
cavernous sinus thrombosis; submasseteric abscess.
x Lower incisor abscess can cause abscess in the chin and later
median mental sinus; chronic osteomyelitis of the jaw with
discharging sinuses. Osteomyelitis is common in mandible
– horizontal process near the mentum, presenting with pain,
swelling, discharging sinuses, bone thickening, loose tooth,
and trismus. Sequestrum is commonly seen. It is treated by
antibiotics, sequestrectomy, mandibulectomy.
x Treatment: Antibiotics, sequestrectomy, mandibulec tomy.
Treatment: Antibiotics; Drainage of the abscess under general
anaesthesia; Extraction of the tooth at a later period; Excision
of the sinus whenever required.
FIBROUS DYSPLASIA OF BONE/JAW
It is benign self-limiting non-capsulated lesion of bone
wherein normal bony architecture is replaced by collagen,
fibroblasts, osteoid and calcified tissue. It is often classified
as benign tumour with localized developmental arrest, with
bone being not differentiated into a mature bone tissue.
It is seen in childhood and adolescents.
Types
It may be polyostotic or monostotic. Condition can occur in
long bones, ribs and jaw bones, either mandible or maxilla.
Disease is either metaphyseal or in the shaft, never in epiphysis.
1. Monostotic (70%)
It is equal in both sexes. It occurs in children and adolescents;
stops once growth plate is closed.
Femur is the commonest bone involved; tibia, ribs, jaw bones,
skull and humerus can get involved.
It can present as asymptomatic diffuse hard bony swelling
or can be painful due to fracture. Discrepancies of the part
with asymmetry are common.
Monostotic will not turn into polyostotic type.
Monostotic will not turn into sarcoma.
2. Polyostotic Fibrous Dysplasia (27%) without
Endocrine Dysfunction
It begins in earlier age group than monostotic.
It is common in femur, skull, tibia, humerus, ribs, fibula,
radius, ulna, mandible and vertebrae. Craniofacial bones are
involved in more than 50% of patients.
It may continue to grow in adulthood (progressive).
There is no evidence of hyperparathyroidism. It should be
differentiated from primary hyperparathyroidism of bone.
Involvement of shoulder and pelvis causes severe deformity.
Severe involvement of femur causes ‘shepherd crook’
deformity.
Recurrent spontaneous fractures are common.
Polyostotic occasionally turns into sarcoma.
3. Polyostotic Fibrous Dysplasia with
Endocrinopathies (3%)
Polyostotic fibrous dysplasia with skin pigmentation (Café
au lait, on same side of the disease in neck, chest, back,
shoulder, pelvis, larger) with sexual precocity in females
(McCune Albright’s syndrome); often with hyperthyroidism,
growth hormone secreting pituitary adenoma and primary
adrenal hyperplasia is 3% common.
It is due to mutation of guanyl nucleotide binding protein
gene (GNAS gene).
x Fibrous dysplasia is most common in femur—Shepherd Crook
deformity; metaphyseal
x In the jaw, mandible is the common site, vertical ramus, outer
table expansion
x Monostotic is more common
x Polyostotic is more problematic—discrepancies, pathological
fracture, sarcoma changes
x Monostotic ceases with cessation of growth
x Surgery should never be done during growing period
Fibrous Dysplasia of Jaw
In the jaw, it can occur in maxilla or mandible; but mandible
is more common site.
It presents with diffuse swelling of vertical ramus of the
mandible or maxilla. Gritty white, hard cartilages with cysts
are the pathology. Diffuse hard, painless swelling which
causes asymmetry is the usual presentation. It progresses
with the growth of the bone.
It is commonly monostotic but can be polyostotic. Monos-
totic ceases once bone develops completely. Polyostotic may
continue to grow.
Teeth are normal.
Expansion is towards outer cortex of the mandible.
Polyostotic occasionally turns into sarcoma (but not monos-
totic).
Complications of fibrous dysplasia: Deformity and cosmetic
problems; Pathological fractures; Sarcomatous transforma-
tion in polyostotic type only.
Differential diagnosis: Osteoclastoma, adamantinoma;
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Osteitis fibrosa cystica of primary hyperparathyroidism.
Investigations
¾
X-ray is diagnostic showing ground glass/smoke screen
appearance.
¾
Serum alkaline phosphatase may be slightly elevated.
A
Fibrous dysplasia mandible
¾
Biopsy may be needed to confirm the condition and to
rule out other conditions.
¾
Parathormone assay, serum calcium estimation in
suspected parathyroid pathology.
Treatment: It should not be operated during growing period
as if intervened there may be chances that it may turn into
osteosarcoma. As it is a self-limiting disease it can be left
alone once the growth stops or can be corrected by restora-
tive excision to maintain facial contour. Thorough curettage
with grafting of cancellous bone may be done. Bisphospho-
nates are often used to relieve pain.
CHERUBISM (Cherub—Angelic Being)
It is an autosomal dominant condition that occurs in first year
of life.
Giant cell granuloma with fibrous tissues in the jaw.
It is commonly bilateral. Commonly seen in the angles of the
mandible and also in maxilla.
It is familial fibrous dysplasia of jaw commonly involving
both halves of the mandible with bulging outwards near
the angle of the jaw causing ‘winged face’ appearance of
angelic babies.
Diffuse enlargement of maxilla and both sides of the
mandible.
Bulging of the cheek causes pull of the lower eyelid. Hence,
child appears like, as if looking upwards.
Interference with the development and eruption of the teeth.
Treatment: It is a self-limiting disease. Often requires dental
care and treatment for proper dentition.
355
CHAPTER 2 Faciomaxillary Diseases
B
Fibrous dysplasia maxilla
Figs. 2.43A and B: Fibrous dysplasia of mandible and maxilla in two
different patients. Mandible is common site in jaw. Overall femur is
the commonest site.
PIERRE-ROBIN SYNDROME
B
x Congenital condition
x Cleft palate alone
x Mandibular hypoplasia
x Cyanotic episodes
x Deficiency in transforming growth factor
x Defective sucking and tongue falling back wards in infants
x Cryptorchidism
Attitudes are more important than facts.
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