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CHAPTER12 The lower jaw andface
oedema and cellulitis spread backwards in the space between the hypo glossus and genioglossus to the epiglottis and lar ynx, resulting eventually
in respiratory obstruction.
Clinical features
• Systemicupset.
• Massive rm swelling bilaterally in theneck.
• Swelling in the oor of the mouth, forcing of the tongue up onto the
palate.
• A‘hot- potato’ voice. This term is used to describe the characteristic
pattern of speech, which has been likened to a person speaking
with a hot potato in the mouth. It has several causes in addition to
Ludwig’s angina.
• Diculty in swallowing and drooling.
• Inability to protrude the tongue.
• Eventually this leads to diculty breathing.
Management
The rst consider ation is the airway which can rapidly obstruct. Diculty
in breathing, swallowing, or talking, and gross swelling are all indications to
call for senior help (often anaesthetic) urgently. Refer to maxillofacial team
urgently. Further management includes IV uids (patients often present after a few days, having not been able to dr ink), IV antibiotics (e.g.
penicillin and metronidazole), together with surgical drainage of the submandibular and sublingual spaces and removal of the underlying cause.
If there is respirator y diculty, give oxygen. These cases are commonly
associated with self- neglect (including alcohol and smoking) and immunosuppression (e.g. diabetes)
Never underestimate these fascial space infections. They are often referred
to as ‘dental abscesses’ but this terminology will put you, the anaesthetist,
and theatre sta, in the wrong state of mind and a lower gear of alertness.
Do not underestimate the rapidity with which these infections can come to
threaten the airway. If you suspect the airway may potentially be threatened,
do not ‘wait and see’ by treating with antibiotics. Get senior help and consider
electively securing the airway with endotracheal intubation before draining
the abscess.
Antibiotics alone will not treat these infections. They require incision and
drainage.
cAcute bacterial submandibular sialadenitis
The majority of these infections are secondary to a calculus (stone) in the
duct . Other causes include surgical scarring or strictures secondary to
radiation or other causes of chronic brosis. The whole gland swells up
and there is malaise, pyrexia, and pain. Submandibular calculi are opaque
in 80% of cases, so a radiogr aph may aid in the diagnosis. Antibiotics are
required. If the stone is easily felt in the mouth it can be removed intraorally. If the infection leads to a collection, then incision and dr ainage of
the submandibular space must be carried out, and the gland removed on
an elective basis later. Mumps virus infection involving the submandibular
gland is rare but has been repor ted.
INFECTIVE SWELLINGS AROUND THE LOWE R JAW ANDFACE
bChronic submandibular sialadenitis
(Kuttner’s tumour)
This results from repeated episodes of acute sialadenitis. The structure,
parenchyma, and funct ion of the gland are gradually destroyed. The gland
ends up feeling ver y hard to palpation. Treatment is by sur gical excision.
cParotid sialadenitis
Mumps is the commonest cause of parotid swelling, even unilaterally. It has
a peak incidence in childhood but can occur in adult s. In teenagers, coxsackieviruses and echoviruses can also cause acute sialadenitis. Clinically
there is pyrexia and malaise. Pain is the most striking symptom. There is
diuse swelling of the gland over the ramus, which raises the lobe of the
ear, and often tr ismus. Treatment is suppor tive
‘Ascending’ infection, i.e. bacteria in saliva passing back along the ducts
into the glands, can involve the parotid (and submandibular) glands. In
such cases, predisposing conditions are often associated, e.g. dehydration, diabetes, or immunosuppression. Fibrosis following radiotherapy
or pre- existing obstruction from a calculus or stricture may also predispose to infection.
Clinical features
• Fever
• Pain
• Erythema
• Tender swelling
• Dischar ge of pus from theduct.
If the infection is not treated early, this may develop into a chronic or
recur rent infection. Progressive destruc tion of the gland ag gravates the
situation, resulting in a non- functionalgland.
Management
In the absence of an obvious abscess, management initially consists of IV
antibiotics, rehydration, analgesia, and correction of any systemic conditions, e.g. diabetes. If an obstr uction is found, e.g. stone, this needs to
be removed to enable drainage. Gland massage, especially after meals,
and ‘lemon drops’ to stimulate salivary ow, help to maintain a ushing
eect and prevent stagnation of saliva. Abscesses need to be incised and
drained on an urgent basis. If infection persists or continues to recur,
excision of the gland may be necessar y. This is best done when there is
no active infection.
cCellulitis
Spreading infection within the skin (cellulitis) is characterized by swelling,
warmth, er ythema, and pain. The patient may present with minimal signs
initially, or they may be unwell with malaise, fatigue, chills, or a fever.
Regional lymphadenopathy may also be present. Cellulitis around the
lower jaw and face may be a presenting sign of an underlying deeper
infection. These include:
• Dental infection (tooth orcyst)
• Skin cyst (e.g. sebaceous) infection
• Infected laceration with or without a retained foreignbody
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CHAPTER12 The lower jaw andface
• Infected lymph node (usually cellulitis is in theneck)
• Submandibular infection
• Untreated fracture.
In the absence of these, inammation is conned initially to the deeper
dermis and subcut aneous tissue resulting in an ill- dened red rash.
Untreated this can progress to sepsis, abscess formation, or necrotizing fasciitis. The most common infecting organisms in cellulitis are group
AStreptococcus followed by Staphylococcus aureus. These gain access to
the dermis through a break in the skin (e.g. during shaving).
Management
Flucloxacillin has become a mainstay of treatment due to its bactericidal
eect on both commonly occurring organisms. Benzylpenicillin is particularly aective against streptococci and is also commonly prescribed.
In immunocompromised individuals and children, a wider var iety of bacteria may be implicated and a broader spectrum of antibiotic cover may
be necessar y. Oral antibiotics are sucient for mild disease; more severe
cases need admission for IV antibiotics.
Treat cellulitis in the head and neck carefully. This can rapidly deteriorate
resulting in abscess formation and necrotizing fasciitis. Always consider an
underlying cause (often dental infections) and the possibility of immunocompromise (diabetes and alcohol abuse especially).
cInfected mandibular fracture
Severe infection of a mandibular fracture resulting in osteomyelitis is
rare. However, localized infection still happens relatively frequently,
particularly when patients have poor oral hygiene, smoke, and present late. Debilitated patients, diabetics, and patients on steroids or
chemother apy are more likely to develop infected fractures because of
lowered general resistance. Commonly, these occur at the angle of the
mandible, where the patient has retained third molars (wisdom teeth).
Comminuted fractures of the mandible may be complicated by the formation of bone sequestra which become a potential source of infection.
In some cases the sequestra may extrude spontaneously into the mouth
with quite minimal symptoms, but sometimes a localized abscess forms
and surgical removal of the dead bone becomes necessary. Infected fractures need urgent referral. Management involves antibiotics and stabilization of the fracture.
cOsteomyelitis
Osteomyelitis of the jaws is uncommon and most commonly associated
with odontogenic infection (infections of the teeth). It can occur following extractions, trauma, or irradiation to the mandible. It can also occur
in patients taking bisphosphonates (BRONJ). Infection is more common
in the lower jaw, as the upper jaw has a relatively better blood supply.
Before the antibiotic er a, however, it was frequently fatal. Acute osteo myelitis is less common than chronic osteomyelitis, with patients rarely
presenting with obvious suppuration. A small amount of pus exuding
from around a tooth is more likely to be a periodont al abscess, but if
multiple adjacent teeth are involved, mobile, and the overlying soft tissue are
inamed, there is probably acute osteomyelitis (see Figure12.7).
INFECTIVE SWELLINGS AROUND THE LOWE R JAW ANDFACE
Figure12.7 Osteomyelitis of the mandible.
Clinical features
These depend upon the type and extent of infection and may include:
• Pain— in acute osteomyelitis, this can be severe, throbbing, and deep
seated. Chronic infection has a less intense but still deep- seated and
unremitting character.
• Swelling, erythema, and tenderness. Initially soft, the swelling is
secondary to inammation and oedema. This may later progress to a
rm subperiosteal abscess.
• Tris m u s .
• Dysphagia.
• Cervical lymphadenopathy.
• Numbness of the lower lip andjaw.
• Halitosis.
• Pyrexia, anorexia, and malaise.
• Friable granulation tissue, exposed necrotic bone, and sequestrum
formation are all common in chronic infection. It is important to make
sure these features are not those of a malignancy.
Usually there is an obvious cause such as a decayed tooth. This may be
tender and mobile. Most patients are either malnourished or immune
decient to some extent. This condition is therefore commonly seen in
smokers, diabetics, and alcoholics as well as other well- k nown at- risk
groups.
The infection is usually a polymicrobial in nature. It is caused by a mix-
ture of streptococci and anaerobic bacteria, which pass into the bones
from the infected tooth. Haematogenous spread is r are. Osteomyelitis
may also arise in an infected frac ture. This tends to be chronic. Smokers
are at particularly high risk of this. Actinomycosis is an unusual but specic
infection, also known to occur. This result s in recurrent and chronic jaw
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CHAPTER12 The lower jaw andface
abscesses. These can discharge large amounts of pus, frequently through
multiple skin sinuses, which often contains characteristically appearing
bright yellow granules (referred to as ‘sulphur granules’). Consider actino-
mycosis in any patient with chronic bone abscesses and discharging sinuses.
Management
Acute osteomyelitis needs urgent referral for admission, IV antibiotics,
and drainage of pus. Chronic osteomyelitis may be managed as an outpatient with appropriate long- term antibiotics. If so, close follow- up is
required. Any associated contributing factors should also be identied
and treated if possible. Surgical debridement may be required.
cInfected branchialcyst
(See E Chapter 5.) Most branchial c ysts present in the neck and are
painless, but they may become infected and involve the upper part of the
lateral neck/ parotid region. These are dicult to treat and recurrence is
common. If infected, refer urgently.
cInfected bonecysts
These can present in a number ofways:
• Chronic jaw pain, with or without swelling
• Chronic swelling, with or withoutpain
• Acute fascial space infection
• Cellulitis
• Halitosis
• Pathological fracture.
In most cases, the presence of the c yst is not apparent until plain lms have
been t aken, alth ough some cysts may pour pu s into the oral cavity on ex amination, sug gesting the presence of a large cavit y. Management may be the
same as for fascial space infections, de pending on the severity of symptoms.
Refer urgently if systemic symptoms are present or the cyst islarge.
bNon- infective swellings aroundthe
lower jaw andface
bOsteoradionecrosis
The lower jaw is particularly susceptible to ORN due to its low vascularity and greater bone density. The clinical spectr um of presentation is
wide. Patients usually have a non- resolving painful mucosal ulcer with
evidence of exposed bone or sequestrum. This is usually in the posterior mandibular region. There may be trismus and this usually appears
3– 6months following radiotherapy. See Figure12.8.
At the other end of the spectrum, patients may present with an orocutaneous stula, pathological fracture, and paraesthesia of the infer ior
alveolar nerve. Typically radiological appearances will include a moth
eaten appearance of the bone. Management principles are based on
controlling any acute superimposed infection, strict oral hygiene, analgesia, and nutritional support as well as minimal surgical debridement . In
severe cases resec tion of the bone and reconstruction with a free tissue
transfer may be required.
NON-INFECTIVE SWELLINGS
Figure12.8 ORN of the mandib le.
bBisphosphonate- related osteonecrosis
ofthe jaw (BRONJ)
Bisphosphonates inhibit osteoclastic action and reduce bone loss in
patients with multiple myeloma, bony metastasis in breast cancer, Paget’s
disease of bone, and postmenopausal osteoporosis. However, osteonecrosis can occur as a serious side eect in both jaws. Patients present with
pain and swelling aecting the mucosa of the jaw, which may be confused
with chronic osteomyelitis, ORN or even malignancy. See Figure12.9.
CT usually shows regions of mottled bone and sequestrum forma-
tion. Treatment usually involves meticulous oral hygiene, antibiotics and
gentle debr idement. Cessation of the drug, if not contraindicated may
help some recovery.
bPaget’s disease
Paget’s disease is a localized disorder of bone remodelling that typically
begins with excessive bone resorption followed by an increase in bone
formation. Usually the bone is mechanically weaker, larger, less compact,
more vascular, and more susceptible to fracture than normal adult lamellar bone. Although rare for the maxilla to be involved, when it is, patients
can present with bone pain associated with marked deformity. Clinical
examination may reveal excessive warmth, due to hypervascularit y and
paraesthesia of the infraor bital ner ve due to bony compression. These
symptoms may be confused with chronic infection or a tumour.
bFibrous dysplasia
This is a disorder of bone grow th where normal bone is replaced with
immature brous bone. It can occur in any part of the skeleton but the
skull and face are commonly involved. Patients present with a smooth
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Figure12.9 BRONJ.
hard swelling and deformity usually in childhood or early adulthood.
During rapid growth this may become painful. Two types of Fibrous dysplasia are described.
• Monostotic— involving a single bone, or adjacent bones, such as the
upper and lowerjaw
• Polyostotic— involving manybones.
The most severe form of polyostotic brous dysplasia is known as
McCune– Albright syndrome, which includes endocrine diseases (precocious puberty) and skin pigmentation. Fibrous dysplasia may also be
associated with neurobromatosis. The condition is said to burn itself
out during puber ty but exceptions are well known. Management include
bisphosphonates and surgical contouring of and cosmetic deformity.
bOdontogenicmyxoma
Odontogenic myxomas are uncommon benign odontogenic tumours
arising from embryonic connective tissue associated with tooth formation. It usually occurs in younger patients (10– 35years old). The lower
jaw is most commonly involved. Patients generally notice a painless, slow
growth in the jaw, sometimes with tooth loosening or displacement. As
the tumour expands, it frequently inltrates adjacent structures and posterior lesions are associated with inltration of ther amus.
bMandibulartori
These will rarely present as an emer gency. Tori are painless, bilateral bony
growths present on the inner aspect of the mandible, usually in the premolar region. In some patients they can grow to the size of a walnut. They have
normal overlying mucosa. They are usually an incidental nding in patients
with parafunctional habits, but are sometime referred as a ‘lump in the jaw’
particularly in edentulous patients where they are more noticeable.
bHaemangiomas
Central haemangioma s within the mandible are extremely rare. They
arise from a proliferation of vessels within the medullary cavity. They
usually present as a painless, rm swelling that can be associated with a
subjective sensation of pulsation. They can be locally destructive because
of pressure eects and can cause mobility of surroundingteeth.
TEMPOROMANDIBULAR JOINT DYSFUNCTION SYNDROME
bCystic lesions/ tumours
(See E Chapter 11.) The dierential diagnosis for any large ‘cyst’ or cavity
in the bone must include AVM. Although rare, these can lead to torrential
haemorrhage if breached (i.e. during a dental extraction). Contrast imaging
may be required.
bTemporomandibular joint
dysfunction syndrome
This is a controversial topic. TMJDS is a collective term used to describe a
number of related conditions aecting the joints, muscles of mastication,
and associated str uctures. These all result in common symptoms such as
pain and limited mouth opening. No single condition has been found to
cause i t. Although up to 70% of the ge neral population may have at leas t one
clinical feature of this disorder, only about 5% will actually seek treatment.
Females outnumber males by at least four to one. Patients most commonly
present in early adulthood. Temporomandibular dysfunction is not always
progressive or destructive. It is a complex disorder involving many interacting factors including stress, anxiety, and depression. Non- surgical treatments, such a s counselling, pharmacotherapy, and occlusal splint therapy,
continue to be the most eective way of managing >80% of patients.
Three common temporomandibular disorders are myofascial pain and
dysfunction, internal derangement, and osteoarthrosis:
• Myofascial pain and dysfunction are by far the commonest. This is
primarily a muscular problem resulting from ‘parafunctional’ habits,
such as clenching or bruxism (gr inding teeth). Stress, anxiety, and
depression are commonly associated.
• Internal derangement describes a disorder in which the articular disc
is in an abnormal position, resulting in mechanical interference and
restriction of movement. Disc problems can result in both limitation
of mouth opening and clicking/ crepitus.
• Osteoarthrosis is a localized degenerative disorder that aects
mainly the articular cartilage of the joint. Usually in older age groups.
Applied anatomy
The TMJ is a synovial ‘ball and socket’ type joint . A brous sleeve
encapsulates the joint . Bet ween the condyle and fossa there is a brocartilaginous disc, or ‘meniscus’. The muscles of mastication act directly
across the TMJ to eect mandibular movements. Of note, the inser tion
of the lateral pter ygoid is into both the condylar neck and the anterior
aspect of the disc. Joint movement is complex. On opening the mouth
from the closed position, there is initially a hinge- type movement for the
rst 1cm. After that a for ward translation is added in which the condyle
moves forwards and downwards along the slope of the eminence. Very
little movement occurs side toside.
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CHAPTER12 The lower jaw andface
Aetiology
Various aetiological factors have been suggested, but in reality it is likely
that the condition is multifactorial:
• Parafunction, such as tooth clenching and grinding (often
subconsciously or during sleep), or abnormal movements of the jaw
(e.g. a swing from left to right, reversed on closing— ‘chewing the
cud’). Such movements often exert unbalanced loads on the joints,
resulting in painful musclespa sm.
• Occlusal anomalies are a common feature and there may be a
higher frequency of TMJ problems in patients with heavily restored
dentitions. However, there are also plent y of patients who have
abnormal bites yet do not have any TMJ symptoms.
• Poorly t ting dentures can contribute to TMJ dysfunction. Over
closure of the jaws when the back teeth/ dentures are severely worn
down (loss of posterior support) can put a strain on the joint s.
• Trauma either directly from a blow, or indirectly from stretching
(e.g. for dental treatment) may cause tears or adhesions around the
disc, or a synovitis resulting in pain and altered function.
• Stressful life event s and impaired coping mechanisms are more
frequent in patients with TMJ dysfunction, compared to non-
aected control patient s. Anxiety neuroses and aective disorders
(par ticularly depression) are more common. These psychogenic
factors are often considered as exacerbating factors, r ather than the
primary cause of temporomandibular disorders.
Management
This is dicult and controversial. Most patients do not need to be
referred and can be treated by their own doctor or dentist. Treatment
options include:
• Physiotherapy and jaw exercises.
• Psychosocial and behavioural interventions (such as biofeedback
techniques, cognitive behavioural therapy, hypnosis, and relaxation
techniques). Reassurance plays an impor tant role in management.
• Occlusal splints (bite plates, bite raising, or intraoral appliances) are
made of acrylic and can be hard or sof t. They are designed to t over
the upper or the lower teeth. Normally splints are worn duringsleep.
• Medications include analgesics, benzodiazepines, and muscle relaxants.
• Botulinum toxin solution (Botox®).
• Occlusal adjustment.
• In selected ca ses where the joint is damaged, surgery may be
indicated (arthrocentesis, arthroscopy, menisectomy, disc
repositioning, condylotomy or joint replacement).
bClickingjoints
The commonest cause of a clicking joint is internal derangement. This
is managed initially as for TMJDS. Osteochondral loose bodies are
uncommon, but should be considered if symptoms are severe or persist. Common clinical features are pain, swelling, joint noise, and sudden onset of impaired joint movements (‘locking’). Exclude any history
of trauma. In the absence of fractures these patients require outpatient
follow- up for imaging (CT/ MRI) to conr m the presence of a loose body.
This will need to be removed.
LIMITATION OF MOUTH OPENING
bLimitation ofmouth opening
Inability to fully open the mouth has many causes, some of which are serious. This may present acutely and is often misdiagnosed as a ‘ dislocated
jaw’. However, in a dislocation the problem is one of closing— the mouth
is typically wide open. ‘Trismus’ is a specic term. It refer s to reduced
opening of the jaws caused by spasm of the muscles of mastication. This
implies specic pathologies, the commonest being trauma, infection or
a tumour.
Normal mouth opening ranges from 35 to45mm.
Causes oflimitation ofmouth opening
These include:
• Trismus (notably tr auma, infection, or tumour)
• ‘Inter nal derangement’ of the TMJ (meniscus displacement or
‘locking’)
• Trauma (including an untreated depressed z ygomatic arch fracture)
• Infection within and around the joint (notably parotid)
• Osteoarthritis and other types of arthritis (e.g. rheumatoid)
• Ankylosis and osteophyte formation
• Myofascial pain/ TMJDS
• Radiation brosis
• Submucous brosis
• Systemic sclerosis
• Myositis ossicans
• Coronoid hyperplasia
• Psychiatric causes.
Assessment
The histor y may give some indication of the cause. Dierentiate between
painless and painful restriction. Plain lms, CT, or MRI may be required
depending on the suspectedcause.
The important thing is not to miss an occult tumour— examine the orophar-
ynx carefully (especially the ‘con corner’— the deep recess between the side
of the tongue and wisdom teeth).
bClosedlock
The TMJ contains an articular disc which overlies the condylar head
and prevents direct contact between it and the glenoid fossa. The disc
can sometimes displace anterior to the condyle and become trapped
between it and articular eminence. If this occurs it can prevent free
movement of the condyle dur ing mouth opening. This is usually an acute
event but patients may give a histor y of preceding joint symptoms. This
condition may require outpatient referral to ma xillofacial if patient s have
signicantpain.
bTMJ ankylosis
True joint ankylosis is unlikely to present acutely. This progressive
destructive arthropathy results in loss of joint space and fusion of the
condylar ar ticular surface to the glenoid fossa. It usually occurs following untreated fractures of the condyle, or middle ear infections in childhood and is therefore uncommon in the developed world. Imaging of the
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