CLINICAL REVIEW

of ORAL
and MAXILLOFACIAL
SURGERY

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t.me/Dr_Mouayyad_AlbtousH
 CLINICAL REVIEW
of ORAL and
MAXILLOFACIAL
SURGERY
THIRD EDITION
Shahrokh C. Bagheri, BS, DMD, MD, FACS, FICD
Private Practice, Georgia Oral and Facial Reconstructive Surgery,
All On Smile, and Eastern Surgical Associates and Consultants
Director of Fellowship in advanced Oral and Maxillofacial Surgery
Attending Oral and Maxillofacial Surgeon and immediate past Chief of Division,
Northside Hospital, Atlanta, Georgia, USA

Special Consulting Editior

Behnam Bohluli, DMD, FRCD(C)
Private Practice
Toronto, Ontario, Canada

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Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043

CLINICAL REVIEW OF ORAL AND MAXILLOFACIAL SURGERY, ISBN: 978-0-443-11030-6

THIRD EDITION
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Notices

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t.me/Dr_Mouayyad_AlbtousH
 Dedication
This book is dedicated to my loving family Jana, Shaheen, Bijan, Lilianna, Parviz, Ladan,
Homayoun, and all the students of oral and maxillofacial surgery across the world.
Shahrokh C. Bagheri

Acknowledgments
This book would not have been possible without the support and hard work of the many
contributors who gave their time and expertise without hesitation. It is them who make
this book possible. The section editors were instrumental in this project, with no reward other
than contributing to the profession and care of patients; I am forever grateful to their com-
mitment. Special thanks go to Dr. Behnam Bohluli, Dr. Deepak Kademani, Dr. Marty Steed,
and Dr. Husain Ali Khan. We must further acknowledge the interest and curiosity of the
students and younger generation of oral and maxillofacial surgeons who are ultimately the
driving force and behind this project.
Academic surgery has seen further separation from private practice oral and maxillofacial
surgery. It is essential that all practitioners, young and old, recognize the dedication of
academic surgeons to our profession. On a personal note, I would like to thank the several
surgeons who have impacted my personal growth surgically and academically. It is through
the coalescence of our mentors teachings and that we formulate our own personal style and
point of reference. I would like to thank Dr. Eric J. Dierks (who has also authored the forward
in this text), Dr. Roger A. Meyer, Dr. Bryce E. Potter, Dr. Robert A. Bays, Dr. Leon Assael,
Dr R. Bryan Bell, and Dr. Sam E. Farish for their selfless dedication of my surgical career.
I was also inspired, perhaps unknown to them, by my children Shaheen Bagheri (who assisted
on several illustrations and logistics of this project), Bijan Bagheri (who has help me at work
on many occasions) and my daughter Lilianna Bagheri who was miraculously born in 2024.
The production of this book would not have been possible without the efficient and enthu-
siastic team at Elsevier. Special thanks to Ms. Lauren Boyle, Ms. Akanksha Marwah,
Ms. Priyadarshini Pandey, and Mr. Sheik Mohideen, Ms. Nadhiya Sekar, Ms. Kelly Skelton
and Ms. Kristin Wilhelm.

Shahrokh C. Bagheri, BS, DMD, MD, FACS, FICD

Private Practice, Georgia Oral and Facial Reconstructive Surgery,
All On Smile, and Eastern Surgical Associates and Consultants
Director of Fellowship in advanced Oral and Maxillofacial Surgery
Attending Oral and Maxillofacial Surgeon and immediate past Chief of Division,
Northside Hospital, Atlanta, Georgia, USA

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Contributors

Alex Afshar, DDS, MD Shahid R. Aziz, DMD, MD, FACS, FRCS(Ed)

Oral and Maxillofacial Surgery Fellow Division Director
Department of Oral and Maxillofacial Surgery Department of Oral & Maxillofacial Surgery
University of Alabama at Birmingham Hackensack University Medical Center
Birmingham, Alabama, United States Hackensack, New Jersey, United States;
Clinical Professor
David Y. Ahn, DMD Department of Oral and Maxillofacial Surgery
Program Director Rutgers School of Dental Medicine
Department of Oral & Maxillofacial Surgery Newark, New Jersey, United States;
David Grant US Air Force Medical Center Professor
Fairfield, California, United States Department of Otolaryngology
Hackensack Meridian School of Medicine
Lior Aljadeff, MD, DDS Maj, USAF, DC Nutley, New Jersey, United States;
Staff Surgeon Visiting Professor
Department of Oral & Maxillofacial Surgery Department of Oral and Maxillofacial Surgery
Brooke Army Medical Center Update Dental College
Wilford Hall Ambulatory Surgical Center Dhaka, Bangladesh
Joint Base San Antonio–Lackland Air Force Base
Lackland Texas, United States Shaheen F. Bagheri
Medical Illustrator, Atlanta, GA
Galit Almosnino, MD Student Georgia Institute of Technology
Resident Researcher, Health Sciences, Emory University
Department of Surgery Surgical Assistant
Section of Otolaryngology Head and Neck Surgery Georgia Oral and Facial Reconstructive Surgery
Dartmouth Hitchcock Atlanta, Georgia, United States
Lebanon, New Hampshire, United States
Shahrokh C. Bagheri, BS, DMD, MD, FACS, FICD
Bruce W. Anderson, DDS Private Practice, Georgia Oral and Facial Reconstructive Surgery,
Private Practice All On Smile, and Eastern Surgical Associates and Consultants
Peachtree City, Georgia, United States Director of Fellowship in advanced Oral and Maxillofacial Surgery
Attending Oral and Maxillofacial Surgeon and immediate past
Vincent M. Aquino, DDS, MD Chief of Division, Northside Hospital, Atlanta, Georgia, USA
Fellow
Department of Pediatric Cleft & Craniofacial Surgery Suzanne Barnes, DMD
El Paso Children’s Hospital Assistant Professor
El Paso, Texas Department of Oral and Maxillofacial Surgery
University of Louisville
Mariah Aron, MD, DDS Louisville, Kentucky, United States
Resident
Department of Oral and Maxillofacial Surgery Michael Lawrence Beckley, DDS
Oregon Health and Sciences University Clinical Assistant Professor
Portland, Oregon, United States Department of Oral and Maxillofacial Surgery
University of the Pacific School of Dentistry
Robert S. Attia, DMD Livermore, California, United States
Adjunct Assistant Professor of Surgery
Division of Oral and Maxillofacial Surgery R Bryan Bell, MD, DDS, FACS, FRCS(Ed)
Emory School of Medicine; Physician Executive
Partner Head and Neck Surgeon and Cancer Researcher
Sandy Springs Oral Surgery Providence and the Earle A. Chiles Research Institute
Atlanta, Georgia, United States Portland, Oregon, United States

vi
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 Contributors vii

Christopher Bernard, DDS, MSc Allen Cheng, DDS, MD, FACS

Resident Medical Director
Department of Oral and Maxillofacial Surgery Department of Head and Neck Oncology
University of Toronto Legacy Good Samaritan Cancer Center;
Toronto, Ontario, Canada Medical Director
Head and Neck Surgical Associates;
Jo-Lawrence Martinez Bigcas, MD Assistant Professor
Assistant Professor Department of Oral and Maxillofacial Surgery
Program Director Oregon Health Sciences University
Department of Otolaryngology Head and Neck Surgery Portland, Oregon, United States
Kirk Kerkorian School of Medicine at the University of Nevada,
Las Vegas Sung Cho, DDS, MD
Las Vegas, Nevada, United States Oral Maxillofacial Surgeon
Department of Head and Neck Surgeon
Audra Alexandra Boehm, DDS, MD Riverside Oral Surgery
Resident PGY5 Westwood, New Jersey, United States
Bernard & Gloria Pepper Katz Department of Oral & Maxillo-
facial Surgery Scott T. Claiborne, DDS, MD
Director of Research Attending Surgeon
University of Texas School of Dentistry at Houston Department of Dentistry–Oral Maxillofacial Surgery
Houston, Texas, United States North Memorial Medical Center
Robbinsdale, Minnesota, United States;
Behnam Bohluli, DMD, FRCD(C) Co-director
Private Practice Minnesota Head and Neck Fellowship
Toronto, Ontario, Canada Minnesota Head and Neck Surgery
Sartell, Minnesota, United States
Shae Bryant, DDS
Department of Oral & Maxillofacial Surgery Gisela Contasti-Bocco, DDS, Certificate in Orthodontics
David Grant Medical Center Orthodontist
Travis Air Force Base Department of Orthodontics
Fairfield, California, United States Nova Southeastern University
Fort Lauderdale, Florida, United States
Tuan Bui, MD, DMD
Oral Surgeon Marcus A. Couey, DDS, MD
Department of Oral and Maxillofacial Surgery Assistant Professor
South Calgary Oral Surgery Department of Oral and Maxillofacial Surgery
Calgary, Alberta, Canada Boston University, Boston
Massachusetts, United States
Evan Busby, DMD
Department of Oral and Maxillofacial Surgery Robert Cronyn
University of Florida Health Clinical Associate Professor
College of Medicine Program Director
Jacksonville, Florida, United States Department of Oral & Maxillofacial Surgery
Oral & Maxillofacial Surgery Residency
Nicholas Callahan, MPH, DMD, MD, FACS University at Buffalo School of Dental Medicine
Associate Professor Buffalo, New York, United States
Department of Oral and Maxillofacial Surgery
University of Illinois at Chicago Karl Cuddy, DDS, MD, MSc, FRCD(C)
Chicago, Illinois, United States Assistant Professor
Director of Education and Maxillofacial Trauma
Dan Caruso, DDS, MD Department of Oral and Maxillofacial Surgery
Fellow University of Toronto
Department of Oral and Maxillofacial Surgery Toronto, Ontario, Canada
University of Florida College of Medicine–Jacksonville
Jacksonville, Florida, United States Danielle Cunningham, DDS
Private Practice
Jeffrey William Chadwick, BHSc, DDS, MSc, PhD, FRCDC Syracuse Oral & Maxillofacial Surgery
Fellow Fayetteville, New York, United States
Department of Maxillofacial Oncology and Microvascular Re-
construction
Department of Oral and Maxillofacial Surgery
The University of Texas Health Science Center at Houston
Houston, Texas, United States

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viii Contributors

James Daniell, MBBS, BDS, PGDipSurgAnat, MTrauma Rui P. Fernandes, MD, DMD, FACS, FRCS(Ed)
Registrar Professor
Department of Oral & Maxillofacial Surgery Oral and Maxillofacial Surgery
The Royal Melbourne Hospital Departments of Neurosurgery, Orthopedics, and Surgery
Melbourne, Victoria, Australia; University of Florida
Registrar College of Medicine
Department of Oral & Maxillofacial Surgery Jacksonville, Florida, United States
Barwon Health
Geelong, Victoria, Australia Elie M. Ferneini, DMD, MD, MHS, MBA, FACS
Medical Director
Jennifer M. Dolan, MD, DDS, MPH, MHSA Beau Visage Med Spa
Chief Resident Private Practice, Greater Waterbury OMS
Department of Oral and Maxillofacial Surgery Cheshire, Connecticut, United States;
University of Florida Health Associate Clinical Professor
Jacksonville, Florida, United States Division of Oral and Maxillofacial Surgery
University of Connecticut
David Drake, DDS Farmington, Connecticut, United States;
Oral and Maxillofacial Surgeon Associate Clinical Professor
Department of Oral and Maxillofacial Surgery Department of Surgery
Malcolm Grow Medical Clinics and Surgery Center Frank H Netter MD School of Medicine Quinnipiac University
Joint Base Andrews Hamden, Connecticut, United States
Maryland, United States
Vladimir Frias, DDS, MS, FACP
Elise L. Ehland, DDS, FAACS, FACS Director of Maxillofacial Prosthetics
Facial Cosmetic Surgeon Department of Oral Oncology
Department of Oral and Maxillofacial Surgery Roswell Park Comprehensive Cancer Center
Trillium Oral Surgery and Implantology Buffalo, New York, United States
Ann Arbor, Michigan, United States
Marianela Gonzalez Carranza, DDS, MS, MD
Marawan El Naboulsy, MD, DDS Oral and Maxillofacial Surgery
Chief Resident Department of Oral Surgery
Oral and Maxillofacial Surgery Texas A&M University;
Case Western Reserve University. Department of Oral and Maxillofacial Surgery
Cleveland, Ohio, United States Baylor University Medical Center;
Department of Oral and Maxillofacial Surgery
Zakir Hussein Esufali, BSc, MD, FRCPC Department of Dentistry
Anaesthesiologist Department Texas Scottish Rite Hospital
of Anaesthesia Scarborough Dallas, Texas, United States
Health Network Toronto,
Ontario, Canada Shannon Green, DDS
Resident
Fariba Farhidvash, MD, MPH Department of Oral and Maxillofacial Surgery
Neurologist University at Buffalo
Department of Neurology Buffalo, New York, United States
The Neuron Clinic
San Diego, California, United States Jonathan D. Griffin, DMD, MD
Resident
Farangis Farsio, DDS, BS Department of Oral and Maxillofacial Surgery
Resident University of Louisville
Department of Oral and Maxillofacial Surgery Louisville, Kentucky, United States
University at Buffalo
Buffalo, New York, United States

Tirbod Fattahi, DDS, MD, FACS

Professor and Chair
Department of Oral and Maxillofacial Surgery
University of Florida
College of Medicine
Jacksonville, Florida, United States

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 Contributors ix

Cesar A. Guerrero, DDS Alireza Jahangirnia

Private Practice Oral and Maxillofacial Surgeon
Department of Oral and Maxillofacial Surgery Master of Implant Dentistry
Hermann Memorial Hospital Fellowship in Laser Dentistry
Houston, Texas, United States; Head of Department
Ex Professor Oral and Maxillofacial surgery
Department of Oral and Maxillofacial Surgery Erfan Niayesh Hospital
Central University of Venezuela Tehran, Islamic Republic of Iran
Caracas, Venezuela;
Ex Director Chris Jo, DMD
Oral and Maxillofacial Surgery Private Practice
Santa Rosa Maxillofacial Center Atlanta
Caracas, Venezuela; Georgia, United States
Ex Assistant Professor
Department of Oral and Maxillofacial Surgery Jae Jun, MD, DDS FACS
University of Texas Medical Branch Maxillofacial Surgeon
Galveston, Texas, United States Department of Maxillofacial Surgery
TPMG Kaiser South Sacramento
Helia Sadat Haeri Boroojeni, DMD Sacramento, California, United States
Research Assistant
Department of Oral and Maxillofacial Surgery Deepak Kademani, DMD MD FACS
Shahid Beheshti University of Medical Sciences, School of Minnesota Oral and Facial Surgery
Dentistry Head and Neck Surgery Medical Director
Tehran, Iran Oral and Maxillofacial Surgery Fellowship Director
Dentist Department of Oral/Head and Neck Oncologic and Recon-
Toronto, Ontario, Canada structive Surgery
Minneapolis, Minnesota, United States
Heidi Jes Hansen, DMD, DABOM
Director of Oral Oncology Bryan Kendricks, DMD, MD
Oral Oncology and Oral Medicine Department of Oral and Maxillofacial Surgery
Oral Head and Neck Cancer Program Alabama Center for Oral Surgery and Dental Implants
Providence Cancer Institute Dothan, Alabama, United States
Portland, Oregon, United States
Seied Omid Keyhan, DDS, OMFS
Sina Hashemi, DMD, MD,CM FRCD(C) OMFS, DABOMS Co-investigator
Assistant Professor Department of Oral and Maxillofacial Surgery
Department of Oral and Maxillofacial Surgery College of Medicine
McGill University Health Centre Jacksonville, Florida, United States;
Montreal, Quebec, Canada Adjunct Honorary Professor
Department of Oral and Maxillofacial Surgery
Ali Hassani, DMD College of Dentistry
Professor of Oral & Maxillofacial Surgery Gangneung-Wonju National University
Implant Research Center Gangneung, Republic of Korea;
Tehran, Iran Founder and Director
Head Maxillofacial Surgery & Implantology & Biomaterial Research
Implant Research Center Tehran Foundation
IAU Dental School Tehran, Maxillogram
Islamic Republic of Iran Isfahan, Islamic Republic of Iran;
Founder & Director
Eric P. Holmgren, DMD, MD, FACS iFACE Academy
Department of Oral and Maxillofacial Surgeon Istanbul, Turkey
Otolaryngology and Maxillofacial Department
Dartmouth Health Husain Ali Khan, MD, DMD, FACS, FAACS, MCh
Lebanon, New Hampshire, United States Private Practice
Georgia Oral and Facial Reconstructive Surgery
Branko Huisa, MD Attending Surgeon
Medical Director Northside Hospital
Department of Neurology Atlanta, Georgia, United States;
The Neuron Clinic Lecturer
San Diego, California, United States Anglia Ruskin University
Chelmsford, United Kingdom

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x Contributors

Baber N. Khatib, MD, DDS, FACS, FRCD(C) Patrick J. Louis, DDS, MD

Oral and Maxillofacial Surgeon/Head and Neck Microvascular Professor
Reconstructive Surgeon Department of Oral & Maxillofacial Surgery
OMFS/Microvascular Reconstructive Surgery University of Alabama at Birmingham;
Head and Neck Surgical Associates Chairman
Providence Franz Cancer Center; Department of Oral & Maxillofacial Surgery
Director University of Alabama at Birmingham
Portland 3D Printing Lab Birmingham, Alabama, United States
Portland, Oregon, United States
Kelly R. Magliocca, DDS, MPH
Arash Khojasteh, DDS, MS, PhD Associate Professor
Professor Department of Pathology
Department of Oral and Maxillofacial Surgery Emory University
Shahid Beheshti University of Medical Sciences Atlanta, Georgia, United States
Tehran, Islamic Republic of Iran
Kolina Mah-Ginn, DMD
Jason Rae Kim, DDS Resident
Resident Department of Oral and Maxillofacial Surgery
Department of Oral & Maxillofacial Surgery Loma Linda University
David Grant Medical Center Loma Linda, California, United States
Fairfield, California, United States
Michael R. Markiewicz, DDS, MD, MPH, FAAP, FACS,
Deepak Gopala Krishnan, DDS, FACS FRCD(c)
Associate Professor of Surgery Professor and Chair
Residency Program Director Department of Oral and Maxillofacial Surgery
Division of Oral Maxillofacial Surgery University at Buffalo;
University of Cincinnati Clinical Professor
Cincinnati, Ohio, United States Department of Neurosurgery and Department of Surgery
Jacobs School of Medicine and Biomedical Sciences
Nashwin Laungani, DMD, MD University at Buffalo;
Resident Co-director
Department of Oral & Maxillofacial Surgery Craniofacial Team of Western New York
University of Louisville School of Dentistry John R. Oishei Children’s Hospital;
Louisville, Kentucky, United States Attending Surgeon
Head & Neck and Plastic & Reconstructive Surgery
Joyce T. Lee, DDS, MD, FACS Roswell Park Comprehensive Cancer Center
Clinical Adjunct Professor Buffalo, New York, United States
School of Medicine
Division of Oral & Maxillofacial Surgery Robert E. Marx, DDS, FACS
Emory University; Chief Science Officer
Oral & Maxillofacial Surgeon Research
Private Practice Lenbar, LLC
Atlanta, Georgia, United States Naples, Florida, United States;
Chief
Kevin C. Lee, DDS, MD Oral Maxillofacial Surgery (Retired)
Fellow Department of Surgery
Department of Head and Neck Surgery University of Miami Miller School of Medicine
Roswell Park Comprehensive Cancer Center Miami, Florida, United States
Buffalo, New York, United States
Victoria Andrea Mañón, DDS, MBA, MD
Ryan Everett Little, MD Resident
Assistant Professor Benard and Gloria Katz Department of Oral and Maxillofacial
Department of Surgery Surgery
Division of Otolaryngology University of Texas Health Science Center at Houston
Dartmouth Hitchcock Medical Center Houston, Texas, United States
Lebanon, New Hampshire, United States
Caitlyn McGue, DDS, MD
Andrew Lombardi, DDS Resident Physician
Resident Department of Oral and Maxillofacial Surgery
Division of Oral and Maxillofacial Surgery Loma Linda University
University of Toronto Loma Linda, California, United States
Toronto, Ontario, Canada

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 Contributors xi

William Stuart McKenzie, DMD, MD Michael Miloro, DMD, MD, FACS

Private Practice Professor and Head
Owner Department of Oral and Maxillofacial Surgery
Mid-State Oral Surgery and Implant Center University of Illinois;
Nashville, Tennessee, United States Division Chief
Department of Oral and Maxillofacial Surgery
Landon McLain, MD,DMD, FACS UIHealth Hospital
Private Practice Chicago, Illinois, United States
McLain Surgical Arts
Huntsville, Alabama, United States Justine Moe, MD, DDS, FACS, FRCD(C)
Associate Professor
Daniel J. Meara, MS, MD, DMD, MHCDS, FACS Department of Oral and Maxillofacial Surgery
Chair University of Michigan
Oral and Maxillofacial Surgery & Hospital Dentistry Ann Arbor, Michigan, United States
Christiana Care Health System
Wilmington, Delaware, United States; Sadra Mohaghegh, DDS
Director of Research Research Assistant
Department of Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery
Christiana Care Health System Shahid Beheshti University of Medical Sciences
Wilmington, Delaware, United States; Tehran, Islamic Republic of Iran;
Affiliate Faculty Graduate Student Oral
Physical Therapy Health Sciences
University of Delaware University of Washington
Newark, Delaware, United States Seattle, Washington, United States

Jai Kumar Mediratta, DDS Sarah Loren Moles, DMD

Resident Physician Assistant Professor
Department of Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery
Mayo Clinic University of Illinois Chicago
Rochester, Minnesota, United States Chicago, Illinois, United States

Mehran Mehrabi, DMD, MD Stephen Daniel Moreno, DDS

Department of Oral and Maxillofacial Surgery Fellow, Head and Neck Oncologic Surgery and Microvascular
Advanced Dental Specialists Reconstruction
Watertown, Wisconsin, United States Department of Oral & Maxillofacial Surgery
University of Florida
James C. Melville, DDS Jacksonville, Florida, United States
Associate Professor
Bernard & Gloria Pepper Katz Department of Oral & Maxillo- Anthony Morlandt, DDS, MD, FACS
facial Surgery Professor
Department of Oral & Head and Neck Oncology and Micro- Vice Chairman
vascular Reconstructive Surgery Head and Neck Oncology Fellowship Program Director
University of Texas School of Dentistry Houston Department of Oral and Maxillofacial Surgery
Houston, Texas, United States University of Alabama at Birmingham;
Professor
Roger A. Meyer, DDS, MS, MD, FACS Department of Otolaryngology
Director University of Alabama at Birmingham
Maxillofacial Consultations, Ltd Birmingham, Alabama, United States
Greensboro, Georgia, United States;
Clinical Associate Professor Seyed Ali Mosaddad, DDS
Department of Oral & Maxillofacial Surgery Researcher
Georgia Health Sciences University Student Research Committee
Augusta, Georgia, United States; School of Dentistry, Shiraz University of Medical Sciences
Private Practice Shiraz, Fars, Islamic Republic of Iran;
Georgia Oral & Facial Surgery Postgraduate Student
Marietta, Georgia, United States Department of Conservative Dentistry and Bucofacial Prosthesis
Faculty of Odontology
Claire Mills, DDS Complutense University of Madrid
Graduate Student Madrid, Spain
Oral Health Science
University of Washington
Seattle, Washington, United States

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xii Contributors

Maggie M. Mouzourakis, MD Mayoor Patel, DDS, MS

Department of Surgery Healthcare Provider
Dartmouth-Hitchcock Private Practice
Lebanon, New Hampshire, United States Craniofacial Pain Center of Georgia
Atlanta, Georgia, United States
James Murphy, DDS, MD, FACS
Attending Piyushkumar Patel, DDS
Department of Oral and Maxillofacial Surgery Oral & Maxillofacial Surgeon
Cook County Health; Private Practice
Assistant Professor Plastic Surgery Perimeter OMS
Department of Plastic Surgery Dunwoody, GA, United States
Rush University Medical Center;
Attending Sandeep Pathak, MD, DMD, FACS
Department of Oral and Maxillofacial Surgery Oral & Maxillofacial Surgeon
Advocate Illinois Masonic Department of Oral & Maxillofacial Surgery
Chicago, Illinois, United States Oral & Facial Surgery Associates;
Oral & Maxillofacial Surgeon
Sara Nada, BDS, MSc, PhD Department of Oral & Maxillofacial Surgery
Clinical Director Northside Hospital Gwinnett Medical Center
Dental Department Lawrenceville, Georgia, United States
iTXPros
Tampa, Florida, United States Stanford R. Plavin, MD, Diplomate of American Board
Anesthesiology
Marshall F. Newman, DMD President
Interim Program Director Department of Anesthesiology
Department of Oral & Maxillofacial Surgery Oral Surgery Anesthesia Associates
The Dental College of Georgia at Augusta University Atlanta, Georgia, United States
Augusta, Georgia, United States
David J. Psutka, DDS, FRCD(C)
Nam H. Nguyen, DDS, MD Assistant Professor
Resident Department of Oral and Maxillofacial Surgery
Department of Oral and Maxillofacial Surgery University of Toronto
Emory University School of Medicine Mississauga, Ontario, Canada;
Atlanta, Georgia, United States Co-chair
Fellowship Program in Advanced TMJ and Orthognathic
Sanil B. Nigalye, DDS, MD Surgery
Clinical Assistant Professor University of Toronto
Department of Oral & Maxillofacial Surgery Toronto, Ontario, Canada;
University at Buffalo Senior Surgeon
Buffalo, New York, United States Mount Sinai Hospital Center for Excellence in TMJ
Reconstructive Surgery
Ashish Patel, DDS, MD, FACS Mount Sinai Hospital
Fellowship Director Toronto, Ontario, Canada;
Department of Head and Neck Oncologic and Microvascular Private Practice
Surgery Fountain View Oral, Facial and Implant Surgery
Providence Cancer Institute; Mississauga, Ontario, Canada
Medical Director
Department of CranioMaxillofacial and Neck Trauma Mohammed Qaisi, DMD, MD, FACS
Legacy Emanuel Medical Center; Professor and Section Chair
Attending Surgeon and Director of Reconstructive Microsurgery Department of Oral & Maxillofacial Surgery
Head and Neck Surgical Associates Advocate Illinois Masonic Medical Center
Portland, Oregon, United States Chicago, Illinois, United States

Ketan Patel, DDS, PhD Faisal A. Quereshy, MD, DDS, FACS

Chief Professor
Department of Oral and Maxillofacial Surgery Program Director
North Memorial Health Department of Oral & Maxillofacial Surgery
Minneapolis, Minnesota, United States Case Western Reserve University
Cleveland, Ohio, United States;
Kumar Patel, BDS, LDSRCS, DMD, MS Medical Director
Prosthodontist Facial Cosmetic Surgery
Private Practice Visage Surgical Institute and V-Spa
Marietta, Georgia, United States Medina, Ohio, United States

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 Contributors xiii

Anastasiya Quimby, MD, DDS Bedrettin Cem Sener, DDS, PhD

President Instructor and Lecturer
Department of Surgery Department of Oral and Maxillofacial Surgery
AQ Surgery University of Toronto, Faculty of Dentistry
Head and Neck Microvascular Surgery Institute; Toronto, Ontario, Canada;
Director Retired Professor
Head and Neck Multidisciplinary Tumor Board Department of Oral and Maxillofacial Surgery
Department of Surgery Marmara University Faculty of Dentistry
Good Samaritan Hospital Istanbul, Turkey
West Palm Beach, Florida, United States
Rahul Manhar Shah, BDS, MDS Oral and Maxillofacial
Frederic Rahbari-Oskoui, MD, MS Director
Professor of Medicine Department of Department of Oral and Maxillofacial Surgery
Medicine–Renal Emory University Sahyog Maxillofacial Centre
School of Medicine Atlanta, Georgia, Thane, Maharashtra, India
United States
Maziar Shahzad Dowlatshahi, DDS, MS
Ali R. Rahimi, MD, MPH, FACC Private Practice Smile
Director of Cardiovascular Quality Kaiser Permanente Georgia Studio Dental Toronto,
The Southeast Permanent Medical Group Ontario, Canada
Atlanta, Georgia, United States
Kaushik H. Sharma, BDS, DMD, MPA
Kevin L. Rieck, DDS, MD, FACS Adjunct Clinical Assistant Professor
Nebraska Oral and Facial Surgery Department of Oral & Maxillofacial Pathology, Medicine and
Lincoln, Nebraska, United States Surgery
Temple University Kornberg School of Dentistry
Sepideh Sabooree, MD, DMD Philadelphia, Pennsylvania, United States;
Facial Cosmetic and Reconstructive Surgeon Oral/Head & Neck Oncologic and Microvascular Reconstruc-
Department of Oral and Maxillofacial Surgery tive Surgeon
First Coast Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery
Jacksonville, Florida, United States St. Luke’s University Hospital
Bethlehem, Pennsylvania, United States
Pooyan Sadr-Eshkevari, DDS, MD
Resident Jonathan Shum, DDS, MD
Department of Oral and Maxillofacial Surgery Associate Professor
University of Louisville Department of Oral and Maxillofacial Surgery
Louisville, Kentucky, United States University of Texas Health Science Center of Houston
Houston, Texas, United States
Omid Reza Fazli Salehi, DDS
Oral and Maxillofacial Surgeon Felix Sim, MBBS, BDS, FRACDS(OMS)
Department of Oral and Maxillofacial Surgery Oral and Maxillofacial Surgeon
Islamic Azad University Department of Oral and Maxillofacial Surgery
Tehran, Islamic Republic of Iran Melbourne Health
Melbourne, Victoria, Australia;
Salar Chaychi Salmasi, DDS Head and Neck Reconstructive Surgeon
Head of Research Committee Department of Oral and Maxillofacial Surgery
REDDEN Barwon Health
School of Dentistry Geelong, Victoria, Australia
Tehran University of Medical Sciences
Tehran, Islamic Republic of Iran; Somsak Sittitavornwong, DDS, DMD, MS
Peer Reviewer Professor
BMC Trials Department of Oral and Maxillofacial Surgery
BioMed Central University of Alabama at Birmingham
Springer-Nature Birmingham, Alabama, United States
London, England, United Kingdom
A. Michael Sodeifi, DMD, MD, MPH
Edward R. Schlissel, DDS, MS Private Practice
Emeritus Professor San Francisco, California, United States;
General Dentistry Adjust Professor of Oral and Maxillofacial Surgery
School of Dental Medicine Stockton University of Pacific
Stony Brook University California, United States
Stony Brook, New York, United States

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xiv Contributors

Keith Sonneveld, DDS Amber Watters, DDS, MPH, MS

Oral and Maxillofacial Surgeon Dentist
Department of Surgery Department of Oral Oncology
FACES Fort Worth Providence Cancer Institute
Fort Worth, Texas, United States Portland, Oregon, United States

Martin Steed, DDS, FACS Austin Way, DMD, MD

Professor and James B. Edward’s Chair Resident
Department of Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery
Medical University of South Carolina University of Louisville
Charleston, South Carolina, United States Louisville, Kentucky, United States

Scott Steward-Tharp, DDS, PhD Joyce Yueshuo Xu, DMD, MD, MS

Clinical Assistant Professor Resident in Training
Department of Pathology and Laboratory Medicine Emory Oral & Maxillofacial Surgery
Emory University School of Medicine Emory University School of Medicine
Atlanta, Georgia, United States Atlanta, Georgia, United States

Lance Thompson, DDS, MD Jina Yavarifar, DMD

Oral and Maxillofacial Surgeon Dentist
Department of Surgery Whittier Street Health Center
Head and Neck Surgical Associates Boston, Massachusetts, United States
Oregon Health and Science University
Portland, Oregon, United States Simon Young, DDS, MD, PhD
Associate Professor
Chi T. Viet, DDS, MD, PhD, FACS Bernard & Gloria Pepper Katz Department of Oral &
Associate Professor Maxillofacial Surgery
Department of Oral and Maxillofacial Surgery University of Texas Health Science Center at Houston
Loma Linda University Houston, Texas, United States
Loma Linda, United States

Chad Wagner, DDS

Resident
Oral and Maxillofacial Surgeon
Department of Oral and Maxillofacial Surgery
David Grant Medical Center
Fairfield, California, United States

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Preface

It is remarkable how the specialty of oral and maxillofacial surgery but essential services. Such challenges are best addressed by a uni-
has changed since the first edition of Clinical Review of Oral and fied front from our professional bodies. It is also enhanced by
Maxillofacial Surgery in 2007. Several changes and challenges have inspiring younger surgeons about the professional fulfillment in-
emerged in our specialty, all of which bear on our future. These tegral to providing comprehensive care for all our patients’ needs
ongoing concepts will shape the profession beyond the profes- in the oral and maxillofacial region. Oral and maxillofacial sur-
sional lifespan of individual surgeons. And for this reason, their gery, after all, is first and foremost a “calling” and a duty to serve
impact may go unnoticed until it has perhaps positively or ad- the public, not a business.
versely influenced the landscape. This kind of evolution warrants Despite the effects of any challenges, it remains very clear that
thought and concern beyond one’s own individual perspective. the services of oral and maxillofacial surgeons remain in heavy
Since 2007, we have seen changes in our scope of practice, chal- demand. As reflected in the highly diverse array of diseases, inju-
lenges in the academic sector such as faculty shortage, innovation ries and other conditions, and procedures that are sampled as
of new procedures, emerging diseases, the COVID-19 pandemic, educational case presentations in this text, our profession will
the impact of politics and new laws, anesthesia guidelines and need to be ready and available to serve all the needs of our
enhanced monitoring, private equity acquisitions, and stagnant patients. As the world’s population continues to age and with
insurance reimbursements. All of these further emphasize the medical treatments and surgical procedures that prolong a useful
importance of organized local and global oral and maxillofacial life span even further, there will be a sustained and consistent in-
surgery groups and associations, which can help navigate this crease in the need for the services of modern oral and maxillofacial
broad horizon. As one reflects on these changes, it is clearer than surgeons.
ever that we are all in the “same boat.” Regardless of where we After completing my formal surgical training in 2004, the
practice or what is the scope of our practice, we are all united by need for a text to help prepare students and younger surgeons for
the commonality of our roots in oral and maxillofacial surgery. training, examinations, and surgical care based on real patient
We are unique and proud that we are the only known specialty scenarios was clear. The purposes of this third edition of Clinical
that has to constantly adapt and maintain the earned position and Review on Oral and Maxillofacial Surgery are to inspire, unite,
respect of our specialty in three sectors, dentistry, medicine, and and educate the younger generation of surgeons. This oral and
surgery. Among many factors, this is enhanced via the continued maxillofacial surgery textbook provides its readers with a system-
output of peer-reviewed literature and texts; a strong presence in atic approach to the surgical management of patients with the
private and academic hospital centers; and most important, by most common presentations of congenital, development, trau-
delivery of quality surgical care. In the United States, the recent matic, and pathological conditions seen in this specialty. Similar
acceptance of qualified oral and maxillofacial surgeons into fel- to the prior editions and contrary to traditional textbooks of
lowship in the American College of Surgeons has strengthened surgery, we emphasize a case-based approach to learning that is
our bonds with our surgical colleagues in other specialties and suitable for readers of oral and maxillofacial surgery at all levels of
gains well-deserved recognition and respect for our specialty training or practice. We have elected some of the most common
among our medical colleagues. 1 This establishment of inter- as well as complex cases to illustrate the presentation, physical
professional collegiality bodes well for the future of oral and examination findings, and laboratory and imaging studies, along
maxillofacial surgery. with an analysis of treatment options, complications, and discus-
A notable change and perhaps the elephant in the room is the sion of other relevant information. Each chapter is more than a
weight of economic forces that has landed upon our profession. patient scenario but rather a carefully written teaching case that
Stagnant and even decreasing insurance reimbursement, increas- outlines essential and fundamental information pertinent to his-
ing cost of education, and the ever-increasing difficulties and tory and physical examination, laboratory and imaging studies,
challenges of working with insurance companies and governmen- differential diagnosis, surgical management, and postoperative
tal bureaucracies have changed the decision process, particularly care of the condition as the present in the practice of oral and
of younger surgeons, toward their career choice.2 Economic fac- maxillofacial surgery.
tors rather than professional patient care–driven decisions have It has been my experience that learning can be enhanced by
started to play a larger role than ever before. This dichotomy has incorporating teaching around real patient scenarios. In this man-
and will further adversely affect the decades-old achievements of ner, readers are actively engaged into the cases with the intent of
the increased scope of practice in trauma, orthognathics, tem- raising the interest and therefore maximizing the retention of in-
poromandibular joint, cosmetics, oncologic surgery, and pediatric formation presented. Traditional textbooks of surgery present the
craniofacial care.3 If unrealistically low compensation is continued material in a fashion not directly related to a patient but rather list
by “managed care” governmental and private insurance plans, the all the findings, pathophysiology, and treatment modalities. Al-
ambitions of wide-scope surgery of our future generation may though the intent of this book is not to replace a full-scope text-
dwindle toward these more challenging and technically difficult book of oral and maxillofacial surgery, it can serve as a powerful

15
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xvi Preface

learning tool for those interested in the field. It provides a rapid, volunteered their time to put together this material. It is with
concise, and easily comprehensible approach to disorders that great excitement that we launch this edition and hope that it
readers can access as they encounter patients. Predoctoral students continues to inspire surgeons and improve the care of patients
will benefit from the basic presentation of the disorders and treat- worldwide.
ment options. More advanced readers, such as residents in train-
ing and board candidates, will benefit from the more detailed Shahrokh C. Bagheri
material and will get accustomed to the style of patient presenta- Atlanta, GA, United States
tion that is reflected in the clinical teaching of students, residents,
and fellows in training, which is currently emphasized across the
world in many certifying examinations. References
We have continued to grow scientifically and have improved in 1. Dodson TB: A surge of surgeons [editorial], J Oral Maxillofac Surg
many aspects that are reflected in this book. With better care, 74:2333, 2016.
advancing technology, cooperation, and “finger touch” availability 2. Bagheri SC, Meyer RA: Do you want to be a donkey? J Oral Maxillofac
of information, we are better and stronger. It is my great honor to Surg 80:975, 2022.
have been involved in this third edition with the help and contri- 3. Meyer RA: Making trauma care worthwhile [letter], J Oral Maxillofac
bution of extremely talented and dedicated surgeons who have Surg 75:1093, 2017.

t.me/Dr_Mouayyad_AlbtousH
Foreword
3rd edition, Clinical Review of Oral and Maxillofacial Surgery

“Live as if you were to die tomorrow. Learn as if you were to live that he is today, both nationally and internationally. His teachings
forever.” and writings reflect a clear sense of what is existentially important.
— MAHATMA GANDHI It has been my privilege to accompany Shahrokh Bagheri on
several international teaching events, and perhaps his polyglot
As the fellowship candidate from Georgia sat down for his inter- upbringing is responsible for his knack of being equally relevant in
view, long before the COVID pandemic would forever remove Dubai as he would be in Dallas.
the direct, in-person interview from our toolboxes, I could tell First published in 2007, Clinical Review of Oral and Maxillofa-
from his body language and demeanor that Shahrokh Bagheri cial Surgery is now in its third edition, and the reader-learners
was very comfortable within his own skin. Intracutaneous con- benefit from Shahrokh’s assemblage of talent among his authors
tentment is a laudable attribute regardless of the field of one’s and section editors. Since its inception, the format of this text has
professional endeavor. It bespeaks a level of satisfaction without emphasized the clinical pertinence of the subject matter. He and
complacency with one’s current skill set and fund of knowledge his authors link their discussions of diseases, tumors, injuries, and
such that the individual is comfortable moving ahead to the other conditions to the real people that the authors describe. For
next step in his or her professional evolution. This proved to be many learners, this connection of didactic material to a human
but one of Shahrokh’s many attributes. Upon completion of being who is experiencing the effects of this condition is a critical
his fellowship, it was apparent that Shahrokh Bagheri had con- step in the consolidation of knowledge. As you read this book,
siderably expanded his body of knowledge and depth of surgical consider the authors’ patients to be your patients and their disor-
experience. One would expect this of any successful fellow, but ders to be your challenges to accurately diagnose and skillfully
beyond this, Shahrokh had already begun an internal taxonomy treat. The third edition has expanded with 14 new chapters,
of learning to guide his further acquisition of even more knowl- including timely new material on the effects of marijuana and
edge. He told me later that the concept of this textbook actually vaping as well as the opioid epidemic. Bob Marx has contributed
came to him during his fellowship while he was engaged in two new chapters on drug-induced osteonecrosis.
conversation with Deepak Kademani in the Legacy Emanuel It is a distinct pleasure to write this Foreword for the latest
Hospital library. textbook of my former fellow, now colleague and friend,
2023 marks the 20th anniversary of the commencement of Shahrokh Bagheri. I am confident that this third edition will be
Shahrokh Bagheri’s fellowship in craniomaxillofacial trauma and welcomed by the worldwide community of oral and maxillofacial
cosmetic surgery under Bryce Potter, Bryan Bell, and me. Deepak surgeons and by learners in related disciplines.
was Shahrokh’s running mate during the 2003 to 2004 academic
year in our parallel fellowship in head and neck oncologic and re- Eric J. Dierks, MD, DMD, FACS, FACD, FRCS(Ed)
constructive surgery. The cross pollination that occurred between Emeritus Consultant, The Head and Neck Institute
these two during their shared fellowship year was as extensive as it Emeritus Professor of Oral and Maxillofacial Surgery
was fruitful, and both are now the authors of major textbooks. Oregon Health and Science University
Following his fellowship in Portland, Shahrokh returned to At- Portland, Oregon
lanta, where he has blossomed into the widely recognized figure [email protected]

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Contents

Contributors, vi 13 Subcutaneous Drug–Induced Osteonecrosis of

Preface, xv the Jaws in Patients With Osteoporosis, 60
Foreword, xvii Robert E. Marx
14 Subcutaneous Drug–Induced Osteonecrosis
Section I: Oral and Maxillofacial of the Jaws in Patients With Cancer, 63
Robert E. Marx
Radiology, 1
Shahrokh C. Bagheri︎ and Sara A. Ami︎n Section III: Anesthesia, 67
1 Multilocular Radiolucent Lesion in the Shahrokh C. Bagheri︎
Pericoronal Region (Odontogenic
Keratocyst), 4 15 Laryngospasm, 68
Clai︎re Mi︎lls and Pi︎yushkumar P. Patel Mi︎chael L. Beckley and Shahrokh C. Bagheri︎
2 Unilocular Radiolucent Lesion of the 16 Perioperative Considerations in Pregnant
Mandible, 9 Patients, 70
Sepi︎deh Sabooree, Mi︎chael R. Marki︎ewi︎cz, James C. Melvi︎lle, Suzanne Barnes and Bryan Kendri︎cks
and Kevi︎n C. Lee 17 Effects of Marijuana and Vaping, 73
3 Multilocular Radiolucent Lesion in the Eli︎se L. Ehland and Davi︎d S. Drake
Periapical Region (Ameloblastoma), 14 18 ERAS (Early Recovery After Surgery)
Eri︎c P. Holmgren and Shahrokh C. Bagheri︎ Protocol, 77
4 Unilocular Radiolucent Lesion in a Periapical Eli︎se L. Ehland
Region (Periapical Cyst), 18 19 Respiratory Depression Secondary to
Kelly R. Magli︎occa and Shahrokh C. Bagheri︎ Oversedation, 81
5 Mixed Radiolucent-Radiopaque Lesion Pi︎yushkumar P. Patel, Stanford Plavi︎n, Clai︎re Mi︎lls, and
(Cemento-Ossifying Fibroma), 21 Shahrokh C. Bagheri︎
Sara Nada and Dani︎elle Cunni︎ngham 20 Trigeminal Neuralgia, 87
6 Cone-Beam Computed Tomography, 25 Mayoor Patel, Fari︎ba Farhi︎dvash, and Pi︎yushkumar P. Patel
Clai︎re Mi︎lls, Pi︎yushkumar Patel, and Mayoor Patel 21 Malignant Hyperthermia, 92
Zaki︎r Hussei︎n Esufali︎
22 Emergent Surgical Airway Management, 98
Section II: Pharmacology, 30 Maggi︎e M. Mouzouraki︎s and Eri︎c P. Holmgren
Shahrokh C. Bagheri︎
Section IV: Oral and Maxillofacial
7 Penicillin Allergy and Anaphylaxis, 31
Clai︎re Mi︎lls, Pi︎yushkumar P. Patel, and Shahrokh C. Bagheri︎
Infections, 104
8 Antibiotic-Associated Colitis, 37 Behnam Bohluli︎, Husai︎n Ali︎ Khan, and Shahrokh C. Bagheri︎
Clai︎re Mi︎lls, Pi︎yushkumar P. Patel, and Shahrokh C. Bagheri︎
9 Opioid Side Effects, 41 23 Ludwig’s Angina, 106
Clai︎re Mi︎lls, Pi︎yushkumar P. Patel, and Shahrokh C. Bagheri︎ Ni︎cholas Callahan, Shannon Green, Loren Moles, Karl Cuddy,
10 The Opioid Epidemic, 46 Robert Cronyn, and Mi︎chael Marki︎ewi︎cz
Eli︎se L. Ehland, Shae Bryant, and Chad Lowell Wagner 24 Buccal and Vestibular Space Abscess, 110
11 Oral Drug–Induced Osteonecrosis of the Kei︎th A. Sonneveld
Jaws, 50 25 Lateral Pharyngeal and Masticator Space
Robert E. Marx Infection, 114
12 Intravenous Drug–Induced Osteonecrosis Clai︎re Mi︎lls, Pi︎yushkumar P. Patel, and Shahrokh C. Bagheri︎
of the Jaws, 55 26 Osteomyelitis, 120
Robert E. Marx Lance Thompson

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 Contents xix

Section V: Dentoalveolar Surgery, 125 42 Aphthous Ulcers, 208

Kelly Magli︎occa, Scott Steward-Tharp, and Deepak Kademani︎
Shahrokh C. Bagheri︎ 43 Sialolithiasis, 211
Jeffrey W. Chadwi︎ck, Mi︎chael R. Marki︎ewi︎cz, James C. Melvi︎lle,
27 Third Molar Odontectomy, 126 Jonathan W. Shum, and Karl K. Cuddy
Shahrokh C. Bagheri︎ and Sandeep V. Pathak
44 Acute Suppurative Parotitis, 215
28 Surgical Exposure of an Impacted Maxillary Dani︎el P. Caruso, Vi︎ncent M. Aqui︎no, Tuan G. Bui︎,
Canine, 132 Rui︎ P. Fernandes, Dani︎el J. Meara, and Mi︎chael R. Marki︎ewi︎cz
Bruce W. Anderson, Shahrokh C. Bagheri︎, Jenni︎fer M. Dolan, and
45 Differential Diagnosis of a Neck Mass, 220
Evan M. Busby
Jai︎ K. Medi︎ratta and Kevi︎n L. Ri︎eck
29 Lingual Nerve Injury, 136 46 Oral Leukoplakia, 224
Shahrokh C. Bagheri︎, Roger A. Meyer, Evan M. Busby, and
Li︎or Aljadeff, Anthony B.P. Morlandt, and Deepak Kademani︎
Jenni︎fer M. Dolan
47 Osteoradionecrosis, 227
30 Endodontic-Related Inferior Alveolar Nerve Amber L. Watters, Ashi︎sh A. Patel, and Hei︎di︎ J. Hansen
Injuries, 140
Kei︎th A. Sonneveld and Shahrokh C. Bagheri︎
31 Displaced Root Fragments During Dentoalveolar Section VIII: Craniomaxillofacial Trauma
Surgery, 144 Surgery, 233
Dani︎elle M. Cunni︎ngham and Shahrokh C. Bagheri︎
Shahrokh C. Bagheri︎ and Marti︎n B. Steed

Section VI: Dental Implant Surgery, 148 48 Dentoalveolar Trauma, 235

Patri︎ck J. Loui︎s, Anthony B.P. Morlandt,
Behnam Bohluli︎ and Shahrokh Bagheri︎
and Somsak Si︎tti︎tavornwong
32 Posterior Mandibular Implants, 149 49 Subcondylar Mandibular Fracture, 242
Sani︎l B. Ni︎galye, Dani︎el P. Caruso, Farangi︎s Farsi︎o, Vladi︎mi︎r Fri︎as, and Evan Busby, Deepak Gopala Kri︎shnan, and Stephen Moreno
Mi︎chael R. Marki︎ewi︎cz 50 Combined Mandibular Parasymphysis and Angle
33 Maxillary Implants, 153 Fractures, 248
Ali︎ Hassani︎, Omi︎dreza Fazli︎ Salehi︎, and Salar Chaychi︎ Salmasi︎ Evan Busby, Deepak Gopala Kri︎shnan, and Stephen Moreno
34 Sinus Lift for Implants, 157 51 Zygomaticomaxillary Complex Factures, 252
Ali︎reza Jahangi︎rni︎a and Seyed Ali︎ Mosaddad Chri︎stopher Bernard and Karl K. Cuddy
35 Zygoma Implants, 168 52 Zygomatic Arch Fracture, 257
Cesar A. Guerrero, Mari︎anela Gonzalez Carranza, and Baber Andrew Lombardi︎ and Karl K. Cuddy
Khati︎b 53 Nasal Fracture, 260
36 Contemporary Treatment Options for Gali︎t Almosni︎no, Eri︎c P. Holmgren, and Ryan E. Li︎ttle
Edentulism, 175 54 Frontal Sinus Fracture, 265
Kumar J. Patel and Shahrokh C. Bagheri︎ Justi︎ne Moe, Marti︎n B. Steed, and Shahrokh C. Bagheri︎
37 Using a Dynamic Navigation System for Placing 55 Naso-Orbital-Ethmoid Fracture, 269
Dental Implants, 181 Marti︎n B. Steed and Shahrokh C. Bagheri︎
Mazi︎ar Shahzad Dowlatshahi︎ and Rahul Manhar Shah 56 Le Fort I Fracture, 274
38 Alveolar Ridge Preservation Following Marti︎n B. Steed and Shahrokh C. Bagheri︎
Extraction for Implant Placement, 185 57 Le Fort II and III Fractures, 278
Clai︎re Mi︎lls, Pi︎yushkumar Patel, A. Mi︎chael Sodei︎fi, and Justi︎ne Moe and Marti︎n B. Steed
Shahrokh C. Bagheri︎ 58 Orbital Trauma: Fracture of the Orbital Floor, 283
39 Implants in the Esthetic Zone, 192 Marti︎n B. Steed, Robert S. Atti︎a, and Shahrokh C. Bagheri︎
Edward R. Schli︎ssel 59 Panfacial Fracture, 290
Chri︎s Jo, Marti︎n B. Steed, and Shahrokh C. Bagheri︎

Section VII: Head and Neck Pathology, 197

Section IX: Orthognathic Surgery, 296
Shahrokh C. Bagheri︎ and Deepak Kademani︎
Shahrokh C. Bagheri︎
40 Pleomorphic Adenoma, 198
Deepak Kademani︎, James C. Melvi︎lle, Si︎mon Young, Chi︎ T. Vi︎et, 60 Mandibular Orthognathic Surgery, 297
Mi︎chael R. Marki︎ewi︎cz, Ashi︎sh Patel, Audra Alexandra Boehm, Suzanne Barnes and Jonathan Gri︎ffin
and Jo-Lawrence Marti︎nez Bi︎gcas 61 Maxillary Orthognathic Surgery, 302
41 Acute Herpetic Gingivostomatitis, 205 Arash Khojasteh, Sadra Mohaghegh, and Heli︎a Sadat Haeri︎
Scott Steward-Tharp, Kelly Magli︎occa, Ketan Patel, and Deepak Boroojeni︎
Kademani︎

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62 Maxillomandibular Surgery for 79 Iliac Crest Bone Graft: Mandibular

Apertognathia, 313 Reconstruction, 411
Jai︎ K. Medi︎ratta and Kevi︎n L. Ri︎eck Mari︎ah Aron, R. Bryan Bell, and Ashi︎sh Patel
63 Distraction Osteogenesis, 319 80 Anterolateral Free Flap, 416
Cesar A. Guerrero and Gi︎sela Contasti︎ Bocco Chi︎ T. Vi︎et, Koli︎na Mah-Gi︎nn, Cai︎tlyn McGue, and Anastasi︎ya
64 Virtual Surgical Planning for Orthognathic Qui︎mby
Surgery, 325 81 Pectoralis Major Myocutaneous Flap, 422
Jai︎ K. Medi︎ratta and Kevi︎n L. Ri︎eck Allen Cheng
65 Inferior Alveolar Nerve Injury, 332
Sepi︎deh Sabooree, Roger A. Meyer, and Shahrokh C. Bagheri︎ Section XIII: Facial Cosmetic Surgery, 428
Section X: Temporomandibular Joint Behnam Bohluli︎

Disorders, 339 82 Botulinum Toxin, 430

Behnam Bohluli︎
Shahrokh C. Bagheri︎ and Bedretti︎n Cem Sener 83 Facial Resurfacing, 435
66 Myofascial Pain Dysfunction, 341 Landon McLai︎n
Bedretti︎n Cem Sener 84 Fat Grafting and Fillers, 438
67 Internal Derangement of the Behnam Bohluli︎
Temporomandibular Joint, 345 85 Rhinoplasty, 442
Si︎na Hashemi︎ and Davi︎d J. Psutka Behnam Bohluli︎
68 Arthrocentesis and Arthroscopy, 350 86 Nasal Septoplasty, 447
Bedretti︎n Cem Sener Shahrokh C. Bagheri︎ and Evan Busby
69 Idiopathic Condylar Resorption, 354 87 Otoplasty, 452
Davi︎d Y. Ahn, Eli︎se Ehland, Jae H. Jun, and Jason Ki︎m Behnam Bohluli︎
70 Degenerative Joint Disease of the 88 Cervicofacial Lifting, 456
Temporomandibular Joint, 359 Ti︎rbod Fattahi︎ and Evan Busby
Mi︎chael Mi︎loro 89 Upper and Lower Blepharoplasty, 462
71 Temporomandibular Joint Ankylosis, 363 Marawan El Naboulsy, Fai︎sal A. Quereshy, and Vi︎ctori︎a A.
Si︎na Hashemi︎ and Davi︎d J. Psutka Mañón
90 Genioplasty, 467
Sei︎ed Omi︎d Keyhan, Houra Astaneh, and Hami︎d Reza Fallahi︎
Section XI: Oral Cancer, 368 91 Endoscopic Eyebrow Lift, 474
Deepak Kademani︎ and Shahrokh C. Bagheri︎ Kei︎th A. Sonneveld and Eli︎e M. Fernei︎ni︎

72 Squamous Cell Carcinoma, 370 Section XIV: Syndromes of the Head and
Kaushi︎k H. Sharma and Deepak Kademani︎
73 Verrucous Carcinoma, 375 Neck, 477
Alex Afshar, Deepak Kademani︎, Ketan Patel, and Anthony Shahrokh C. Bagheri︎
Morlandt
74 Malignant Salivary Gland Tumors, 378 92 Cleft Lip and Palate, 479
James Murphy, Mohammed Qai︎si︎, and Ketan Patel Marshall F. Newman, Chri︎s Jo, and Shahi︎d R. Azi︎z
75 Neck Dissections, 385 93 Nonsyndromic Craniosynostosis, 485
Scott T. Clai︎borne and Deepak Kademani︎ Marshall F. Newman and Shahrokh C. Bagheri︎
94 Syndromic Craniofacial Synostosis, 490
Section XII: Reconstructive Oral and Marshall F. Newman and Shahrokh C. Bagheri︎
95 Hemifacial Microsomia, 495
Maxillofacial Surgery, 391 Mi︎chael Mi︎loro
Ashi︎sh Patel 96 Obstructive Sleep Apnea Syndrome, 501
Kyle Frazi︎er, Marshall F. Newman, and Shahrokh C. Bagheri︎
76 Posterior Mandibular Augmentation, 393
Wi︎lli︎am Stuart McKenzi︎e and Patri︎ck J. Loui︎s Section XV: Medical Conditions, 505
77 Radial Forearm Free Flap, 398
Marcus A. Couey, Ashi︎sh Patel, and Jonathan Shum Husai︎n Ali︎ Khan and Shahrokh C. Bagheri︎
78 Free Fibula Flap for Mandibular
Reconstruction, 404 97 Congestive Heart Failure, 506
James R. Dani︎ell and Feli︎x Si︎m Sepi︎deh Sabooree, Mi︎chael R. Marki︎ewi︎cz, Farangi︎s Farsi︎o, and
Kevi︎n C. Lee

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98 Cardiac Arrest, 511 105 Alcohol Withdrawal Syndrome and Delirium

Stanford Plavi︎n, Pi︎yushkumar P. Patel, and Clai︎re Mi︎lls Tremens, 544
99 Acquired Immunodeficiency Syndrome, 517 Fari︎ba Farhi︎dvash and Chri︎s Jo
Pooyan Sadr-Eshkevari︎, Mehran Mehrabi︎, 106 Acute Asthmatic Attack, 548
and Shahrokh C. Bagheri︎ Joyce Xu, Joyce T. Lee, Shahrokh C. Bagheri︎, and Ali︎ R. Rahi︎mi︎
100 End-Stage Renal Disease, 523 107 Stroke and Cerebrovascular Disease, 551
Frederi︎c F. Rahbari︎- Oskoui︎ and Shahrokh C. Bagheri︎ Branko N. Hui︎sa
101 Liver Disease, 527 108 Diabetes Mellitus, 555
Mehran Mehrabi︎, Gary F. Bouloux, and Sung Cho Pooyan Sadr-Eshkevari︎, Mehran Mehrabi︎,
102 SARS-CoV-2 and Oral and Maxillofacial Surgery and Shahrokh C. Bagheri︎
Considerations, 530 109 Diabetic Ketoacidosis, 561
Sei︎ed Omi︎d Keyhan, Ji︎na Yavari︎far, and Pari︎sa Yousefi Mehran Mehrabi︎ and Shahrokh C. Bagheri︎
103 Von Willebrand’s Disease, 537 110 Acute Myocardial Infarction, 564
Dani︎elle M. Cunni︎ngham, Shahrokh C. Bagheri︎, Nam H. Nguyen, Joyce T. Lee, and Shahrokh C. Bagheri︎
and Kambi︎z Mohammadzadeh 111 Hypertension, 568
104 Oral Anticoagulation Therapy in Oral and Pooyan Sadr-Eshkevari︎ and Mehran Mehrabi︎
Maxillofacial Surgery, 540
Suzanne Barnes, DMD, Nashwi︎n Laungani︎, DMD, MD and Index, 574
Austi︎n Way, DMD, MD

t.me/Dr_Mouayyad_AlbtousH
Video Contents

Video 68.1 Irrigation solution leaves the

temporomandibular joint space
from second needle at point B.

xxii
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1
Multilocular Radiolucent Lesion
in the Pericoronal Region
(Odontogenic Keratocyst)
C L A IR E M I L L S a n d PIY U SH K U M A R P. PAT E L

CC MHX/PDHX/Medications/Allergies/SH/FH
A 20-year-old male is referred for evaluation of a swelling on his Noncontributory. There is no family history of similar presentations.
right mandible. Nevoid basal cell carcinoma syndrome (NBCCS), also known
as Gorlin syndrome, is an autosomal dominant inherited condi-
Odontogenic Keratocyst tion with features that can include multiple basal cell carcinomas
of the skin, multiple OKCs, intracranial calcifications, and rib
Odontogenic keratocysts (OKCs) show a slight predilection for and vertebral anomalies. Up to 5% of OKC cases occur as part of
males and are predominantly found in individuals of Northern NBCCS. Many other anomalies have been reported with this
European descent. The peak incidence is seen between 11 and syndrome (Box 1.1). The prevalence of NBCCS is estimated to be
40 years of age. Patients with larger lesions may present with pain 1 in 31,000 to 1 in 164,000 persons.
secondary to infection of the cystic cavity. Smaller lesions are usu-
ally asymptomatic and are frequently diagnosed during routine Examination
radiographic examination.
The World Health Organization (WHO) defines OKCs as Maxillofacial. The patient has slight lower right facial swelling
an odontogenic cyst characterized by a thin, regular lining of isolated to the lateral border of the mandible and not involving
parakeratinized stratified squamous epithelium with palisading the area below the inferior border. The mass is hard, nonfluctuant,
hyperchromatic basal cells. From 2005 to 2017, the WHO rec- and nontender to palpation. (Large cysts may rupture and leak
ommended use of the term keratocystic odontogenic tumor rather keratin into the surrounding tissue, provoking an intense inflam-
than odontogenic keratocyst based on the suspected neoplastic matory reaction that causes pain and swelling.) There are no facial
nature of the lesion, including its propensity for recurrence and or trigeminal nerve deficits. (Paresthesia of the inferior alveolar
common genetic chromosomal abnormality of the PTCH gene nerve would be more indicative of a malignant process.) The in-
on chromosome 9q22.3-q31. However, in 2017, the WHO tercanthal distance is 33 mm (normal), and there is no evidence
changed the classification back to OKC. The WHO determined of frontal bossing. His occipitofrontal circumference is normal
that there was insufficient evidence to justify classification as a (an intercanthal distance [the distance between the two medial
neoplasm because not all OKCs possess PTCH mutations, and canthi of the palpebral fissures] of greater than 36 mm is indica-
the mutation is also found in other types of cysts, including den- tive of hypertelorism, and an occipitofrontal circumference greater
tigerous cysts. than 55 cm is indicative of frontal bossing; both can be seen with
NBCCS).
HPI Neck. There are no palpable masses and no cervical or sub-
mandibular lymphadenopathy. Positive lymph nodes would be
The patient complains of a 2-month history of progressive, non- indicative of an infectious or a neoplastic process. A careful neck
painful swelling of his right posterior mandible. (Approximately examination is paramount in the evaluation of any head and neck
80% of OKCs occur in the mandible, most often in the posterior pathology.
body and ramus region. OKCs account for 10%–20% of all Intraoral. Occlusion is stable and reproducible. The right
oral cystic lesions.) The patient denies any history of pain in his mandibular third molar appears to be distoangularly impacted.
right lower jaw, fever, purulence, or trismus. He does not report (OKCs do not typically alter the occlusion.) The interincisal
any neurosensory changes (which are generally not seen with opening is within normal limits. There is buccal expansion of the
OKCs). right mandible, extending from the right mandibular first molar

4
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 CHAPTER 1 Multilocular Radiolucent Lesion in the Pericoronal Region (Odontogenic Keratocyst) 5

• BOX 1.1 Diagnostic Criteria for Nevoid Basal Cell lesions are found. CT scans are valuable in that they provide ad-
Carcinoma Syndrome ditional information, such as the proximity of adjacent structures
(e.g., the mandibular canal), the integrity of cortical plates, and
Diagnosis: The diagnosis of BCNS can be established based on: the presence of perforations into adjacent soft tissues. CT scans
1. One major criterion and genetic confirmation provide accurate assessment of the size of the lesion and can dem-
2. Two major criteria onstrate additional anatomic details (or lesions) that do not ap-
3. One major criterion and two minor criteria pear on panoramic radiographs.
A cone-beam computed tomography (CBCT) scan is appro-
Major Criteria
priate for the evaluation of this lesion. Given its higher resolution,
1. BCCs before age 20 years or multiple BCCs
2. OKCs before age 20 years lower radiation dose ( 20% of the radiation of a conventional
3. Palmar or plantar pitting [helical] CT), and lower cost, a CBCT can replace helical CT for
4. Lamellar calcification of the falx cerebri evaluation and follow up of such a lesion. The CBCT scan can
5. Medulloblastoma (desmoplastic variant) also be used to create a stereolithic model of the area of interest.
6. First-degree relative with BCNS It has been demonstrated that T2-weighted magnetic reso-
nance imaging (MRI) can detect OKCs in 85% of new cases with
Minor Criteria a readily recognizable pattern. Several studies have found that
1. Rib anomalies MRI signal intensity can be useful in distinguishing OKCs from
2. Macrocephaly ameloblastomas. However, the use of MRI for management of
3. Cleft lip or palate
4. Ovarian or cardiac fibroma
suspected OKCs is not routine and is mainly used as a comple-
5. Lymphomesenteric cysts mentary technique to CT in select cases to better visualize soft
6. Ocular abnormalities (i.e., strabismus, hypertelorism congenital cataracts, tissue involvement and internal cystic features.
glaucoma, coloboma) In this patient, the panoramic radiograph reveals a large, well-
7. Other specific skeletal malformations and radiological changes (i.e., vertebral demarcated, multilocular radiolucent lesion with a corticated mar-
anomalies, kyphoscoliosis, short fourth metacarpals, postaxial polydactyly) gin and with possible displacement of the right mandibular third
Prevalence: 1 in 31,000–164,000 molar (Fig. 1.1). There are also several carious teeth and a retained
Incidence: 1 in 18,976 births root tip of the right mandibular second bicuspid (tooth #29). (In a
Genetic test: In 50%–70% of patients with a clinical diagnosis of BCNS, an patient with a radiolucent lesion of the mandible presumed to be
underlying PTCH1 mutation is found, and 64% of patients have an underlying
an odontogenic cystic lesion, a multilocular appearance is associated
SUFU mutation. In case of high clinical suspicion, postzygotic mosaicism can be
ascertained by finding an identical mutation in at least two BCCs.
with a 12-fold increased risk for the diagnosis of OKC; however,
Genetics: An autosomal dominant inheritance with 50% chance of passing on the majority of OKCs present as unilocular lesions [ 70%].)
the mutated gene to offspring
In 20%–40% of patients, the disorder is caused by a de novo mutation. Labs
BCC, Basal cell carcinoma; BCCS, basal cell carcinoma syndrome; BCN, basal cell carcinoma;
OKC, odontogenic keratocyst. No laboratory tests are indicated unless dictated by the medical
From Verkouteren BJA, Cosgun B, Reinders MGHC, et al: A guideline for the clinical management of history.
basal cell naevus syndrome (Gorlin–Goltz syndrome), Br J Dermatol 186(2):215-226, 2022. Fine-needle aspiration (FNA) is a relatively noninvasive tech-
nique used in diagnosis of many masses but has not been used
often for oral or jaw lesions because of diversity of lesion types and
heterogeneity of cell populations. However, FNA biopsy and
area posteriorly toward the ascending ramus. Resorption of bone
may include the cortex at the inferior border of the mandible, but
this is observed at a slower rate than in intermedullary bone,
which is less dense. For this reason, OKCs characteristically ex-
tend anteroposteriorly rather than buccolingually. This pattern of
expansion into less dense bone explains why maxillary OKCs
show more buccal than palatal expansion and often expand into
the maxillary sinus. There is no palpable thrill or audible bruit,
both of which are seen with arteriovenous malformations (AVMs).
The oral mucosa is normal in appearance with no signs of acute
inflammatory processes.
Thorax-abdomen-extremity. The patient has no findings sug-
gestive of NBCCS (e.g., pectus excavatum, rib abnormalities,
palmar or plantar pitting, skin lesions; see Box 1.1).

Imaging
A panoramic radiograph is the initial screening examination of
choice for patients presenting for evaluation of intraosseous man-
dibular pathology (10%–20% of OKCs are incidental radio-
graphic findings). This provides an excellent overview of the bony • Fig. 1.1 Preoperative panoramic radiograph showing a large multilocular
architecture of the maxilla, mandible, and associated structures. radiolucent lesion of the right mandible body and ramus associated with
Computed tomography (CT) scans can be obtained when large an impacted third molar.

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6 S E C TI O N Oral and Maxillofacial Radiology

cytokeratin-10 immunocytochemical staining have been shown or malignant) lesions, and vascular anomalies (least common).
to differentiate OKCs from dentigerous and other nonkeratiniz- The differential diagnosis of multilocular radiolucent lesions is
ing cysts. A study of FNA use in diagnosis of 72 oral and jaw cysts presented in Box 1.2 and can be further narrowed by the clinical
and neoplasms reported a 91.6% diagnostic accuracy rate for presentation. Special consideration should be given to radiolucent
FNA with 1 false-positive and 6 false-negative cases. Despite their lesions with poorly defined or ragged borders, which have a sepa-
availability, these techniques are not routinely ordered because of rate differential.
difficulty accessing and aspirating lesions and limited experience.
Biopsy
Differential Diagnosis
An incisional or excisional biopsy can be performed, depending
The differential diagnosis of multilocular radiolucent lesions can on the size of the lesion. A smaller cystic lesion can be completely
be divided into lesions of cystic pathogenesis, neoplastic (benign excised, whereas larger lesions require an incisional biopsy to

• BOX 1.2 Differential Diagnosis of Multilocular Radiolucent Lesions

• Ameloblastoma—The most frequent location is the posterior mandible, variant often shows a multilocular appearance. It is most commonly seen in
and the tumor’s most common radiographic appearance is that of a multi- the premolar canine areas.
locular radiolucent lesion. This is the most frequently diagnosed odonto- • Calcifying odontogenic cyst—Most commonly found in the incisor canine
genic tumor. region, this cyst is usually diagnosed in patients in the mid-30s. Although
• Keratocystic odontogenic tumor (KCOT)—This lesion cannot be differenti- the unilocular presentation is most common, multilocular lesions have been
ated on clinical and radiographic grounds from an ameloblastoma. KCOTs reported. Radiopaque structures are usually present in approximately one-
generally do not cause resorption of adjacent teeth. The orthokeratin variant third to one-half of the lesions.
is usually associated with an impacted tooth. • Intraosseous mucoepidermoid carcinoma—This is the most common sali-
• Dentigerous cyst—Large dentigerous cysts can have a multilocular ap- vary gland tumor arising centrally within the jaws. Most commonly found in
pearance on radiographs, given the existence of bone trabeculae within the the mandible of middle-aged adults, the tumors can appear radiographi-
radiolucency. However, they are histologically a unilocular lesion. There is a cally as unilocular or multilocular radiolucent lesions. Association with an
strong association with impacted mandibular third molars. Painless bony impacted tooth has been reported.
expansion and resorption of adjacent teeth are uncommon but can occur. • Hyperparathyroidism (brown tumor)—Parathyroid hormone (PTH) is nor-
• Ameloblastic fibroma—The posterior mandible is also the most common mally produced by the parathyroid gland in response to decreased serum
site for this lesion. It is predominantly seen in the younger population, and calcium levels. In primary hyperparathyroidism, uncontrolled production of
most lesions are diagnosed within the first 2 decades of life. Large tumors PTH is caused by hyperplasia or carcinoma of the parathyroid glands. Sec-
can cause bony expansion. The lesion can manifest as a unilocular or mul- ondary hyperparathyroidism develops in conditions of low serum calcium
tilocular radiolucent lesion that is often associated with an impacted tooth. levels (e.g., renal disease), resulting in a feedback increase in PTH. Patients
Ameloblastic fibro-odontomas are mixed radiopaque–radiolucent lesions. with hyperparathyroidism usually present with a classic triad of signs and
• Central giant cell tumor—Approximately 70% of these lesions occur in the symptoms, described as “stones, bones, and abdominal groans.” Patients
mandible, most commonly in the anterior region. The tumor’s radiographic ap- with primary hyperparathyroidism have a marked tendency to develop renal
pearance can be unilocular or multilocular. These lesions can contain large calculi (“stones”). “Bones” refers to the variety of osseous changes that are
vascular spaces that can lead to substantial intraoperative bleeding. The aneu- seen, including the brown tumor of hyperparathyroidism. These lesions can
rysmal bone cyst has been suggested to be a variant of the central giant cell appear as unilocular or multilocular radiolucent lesions, most commonly af-
tumor. The majority of these lesions are discovered before the age of 30 years. fecting the mandible, clavicle, ribs, and pelvis. “Abdominal groans” refers to
• Odontogenic myxoma—Although myxomas are seen in all age groups, the the tendency of these patients to develop duodenal ulcers and associated
majority are discovered in patients who are 20 to 40 years of age. The pos- pain. When dealing with any giant cell lesions, the clinician must rule out
terior mandible is the most common location, and the tumor’s radiographic the brown tumor of hyperparathyroidism by evaluating the patient’s serum
appearance can be unilocular or multilocular. At times, the radiolucent de- calcium level. (It is elevated in those with hyperparathyroidism.) Patients
fect may contain thin, wispy trabeculae of residual bone, given its “cob- with brown tumor also have elevated levels of PTH (which is confirmed by
web” or “soap bubble” trabecular pattern. radioimmunoassay of the circulating parathyroid levels).
• Aneurysmal bone cyst—Lacking a true epithelial lining, these cysts most • Cherubism—In this rare developmental inherited condition, painless bilat-
commonly occur in the long bones or the vertebral column. They rarely oc- eral expansion of the posterior mandible produces cherublike facies
cur in the jaws, but when they do, it is mostly in young adults. They can (plump-cheeked little angels depicted in Renaissance paintings). In addi-
present as a unilocular or multilocular radiolucent lesion with marked corti- tion, involvement of the orbital rims and floor produces the classic “eyes
cal expansion that usually displaces but does not resorb teeth. upturned toward heaven.” Radiographically, the lesions are usually bilateral
• Traumatic bone cyst—This lesion lacks a true epithelial lining and fre- multilocular radiolucent lesions. Although rare, unilateral involvement has
quently involves the mandibular molar and premolar region in young adults. been reported.
These cysts can cause expansion and usually show a well-defined unilocu- • Intrabony vascular malformations—Arteriovenous malformations are most
lar, scalloping radiolucency between the roots without resorption. The lesion often detected in patients between 10 and 20 years of age and are more
always exists above the inferior alveolar canal. commonly found in the mandible. Mobility of teeth, bleeding from the gingi-
• Calcifying epithelial odontogenic tumor (CEOT)—This is an uncommon tu- val sulks, an audible bruit, or a palpable thrill should alert the clinician. The
mor. The majority are found in the posterior mandible, mostly in patients radiographic appearance is variable, but the malformation most commonly
aged 30 to 50 years. A multilocular radiolucent defect is seen more often presents as a multilocular radiolucent lesion. The loculations may be small,
than a unilocular radiolucency. Although the tumor may be entirely radiolu- giving the honeycomb appearance that produces a “soap bubble” radio-
cent, calcified structures of varying sizes and density are usually seen graphic appearance. Aspiration of all undiagnosed intrabony lesions is war-
within the defect. CEOTs can also be associated with an impacted tooth. ranted to rule out the presence of this lesion because fatal hemorrhage can
• Lateral periodontal cyst (botryoid odontogenic cyst)—This is usually occur after an incisional biopsy.
found in older individuals (fifth to seventh decades of life). The botryoid

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 CHAPTER 1 Multilocular Radiolucent Lesion in the Pericoronal Region (Odontogenic Keratocyst) 7

guide final therapy. It is important to aspirate the lesion before with sterile petrolatum as a caution. Synchronous bone grafting is
incising into it (entering carefully through the cortical bone) to not carried out with this technique. However, this solution is no
rule out a vascular lesion. The aspiration of bright red blood alerts longer recommended because of chloroform’s carcinogenic poten-
the surgeon to the presence of a high-flow vascular lesion, such as tial. Instead of Carnoy’s solution, some surgeons have used the
an AVM, which could result in uncontrollable hemorrhage. In non-chloroform containing modified Carnoy’s solution with suc-
such a case, the procedure should be aborted to allow for further cess. A recent study found that there were similar recurrence rates
radiographic and angiographic studies to characterize the vascula- and distribution of time to recurrence in patients treated with
ture of the area. The aspiration of straw-colored (or clear) fluid is adjuvant Carnoy’s (13.9% recurrence) and modified Carnoy’s
characteristic of a cystic lesion, and the absence of any aspirate (14.6% recurrence) solutions.
may be seen with a solid mass (tumors). Cryotherapy with liquid nitrogen is also an acceptable alterna-
tive to the use of Carnoy’s solution. Liquid nitrogen is sprayed
Assessment within the cavity and penetrates to a depth of about 1.5 mm.
Suggested protocols include spraying the cavity for 1 minute and
Expansile multilocular radiolucent mass of the posterior right man- then allowing the bone to thaw. This can be repeated two or three
dible associated with an impacted right mandibular third molar times.
(25%–40% of cases are associated with an unerupted tooth). Synchronous grafting with cancellous bone can be accom-
With this patient under intravenous anesthesia, an incisional plished after cryotherapy. Patients should be cautioned because
biopsy was performed after aspiration of straw-colored fluid that liquid nitrogen weakens the mandible, and this may result in a
showed the classic histopathology of the OKC. Histologic fea- pathologic fracture. Sensory nerves within the field may show
tures include a thin squamous cell epithelial lining (five to eight paresthesia; however, the majority recover within 3 to 6 months.
cell layers thick). Because of the lack of rete ridges, the epithelial– With both techniques, adjacent soft tissue needs to be pro-
connective tissue interface is flat. The epithelial surface is parake- tected. An alternate technique is used in cases of buccal or lingual
ratinized and often corrugated (wavy). The basal cell layer is plate perforation and with sinus involvement.
hyperchromatic and composed of cuboidal cells, which show Topical 5-fluorouracil (5-FU) has also been suggested as an
prominent palisading, giving a “tombstone” effect. The fibrous adjuvant treatment to reduce the risk of OKC recurrence. 5-FU is
wall is usually thin and at times shows a mixed inflammatory an antimetabolite of the pyrimidine synthesis pathway that has
response. Keratinization of the lumen is not a pathognomonic also been used topically to treat patients with basal cell carcinoma
finding. The fibrous wall may contain epithelial islands that show by inducing DNA damage that reduces cell proliferation. A sys-
central keratinization and cyst formation; these are known as tematic review including three studies of a total of 129 patients
daughter-satellite cells. found that patients treated with adjuvant topical 5-FU in addi-
tion to enucleation and peripheral ostectomy had a recurrence
Treatment rate of 0% compared with 25% in the group treated with enucle-
ation and peripheral ostectomy alone and 19% to 66% treated
Options that have been used to treat OKCs include the following: with enucleation, peripheral ostectomy, and modified Carnoy’s
• Decompression by marsupialization solution. These results are promising for the use of 5-FU and sug-
• Marsupialization followed by enucleation (surgical decompres- gest a significant benefit of adjuvant 5-FU in OKC management,
sion of the cyst followed by several months of daily irrigation though should be followed up with larger scale studies.
with chlorhexidine via stents secured in the cystic cavity fol- Odontogenic keratocysts do not invade the epineurium; there-
lowed by cystectomy) fore, the inferior alveolar nerve can be separated and preserved.
• Enucleation with curettage alone Furthermore, any perforations of the keratinized mucosa should
• Enucleation followed by chemoablation or cryotherapy be excised because they may contain additional epithelial rests,
• Enucleation with peripheral ostectomy which can lead to recurrences. Aggressive soft tissue excision is not
• Enucleation with peripheral ostectomy and chemoablation or required because OKCs do not usually infiltrate adjacent struc-
cryotherapy tures. If the cyst is removed in one unit, there is no need for curet-
• En bloc resection or mandibular segmental resection tage unless the lining has been shredded or torn.
Resection is advocated only if there have been multiple recur- Some controversy exists regarding the optimal management
rences after enucleation with an adjunctive procedure (e.g., cryo- (extraction vs retention) of teeth involved with an OKC. It is
therapy, Carnoy’s solution, or peripheral ostectomy) or for a large generally accepted that an OKC with a scalloped radiographic
OKC exhibiting aggressive behavior, such as destruction of adja- appearance should have the associated teeth removed because it is
cent tissues. Several studies demonstrate that enucleation alone considered impossible to completely remove the thin-walled cys-
(when the diagnosis of OKC has been established) has a high re- tic lining. However, if the OKC is successfully removed in one
currence rate ( 28%); therefore, many surgeons advocate enucle- unit, the teeth may be spared without compromising recurrence.
ation with a local adjunctive procedure, such as cryotherapy, In most instances, there is no need for endodontic therapy despite
Carnoy’s solution, or peripheral ostectomy. surgical denervation. The teeth may not become devitalized be-
Some surgeons advocate the application of Carnoy’s solution cause of perfusion of the pulp via accessory canals through the
after enucleation and peripheral ostectomy with application of periodontal ligaments.
methylene blue. Carnoy’s solution is composed of 1 g of ferric This patient was treated under general anesthesia with enucle-
chloride dissolved in 6 mL of absolute alcohol, 3 mL of chloro- ation of the lesion followed by the application of methylene blue
form, and 1 mL of glacial acetic acid. Carnoy’s solution penetrates to guide peripheral ostectomy. The patient was placed on a soft
the bone to a depth of 1.54 mm after a 5-minute application. It diet to reduce the risk of jaw fracture. The postoperative pan-
is difficult to obtain and needs to be mixed fresh. It does not fixate oramic radiograph confirmed that the inferior border of the man-
the inferior alveolar nerve, but some clinicians cover the nerve dible remained intact.

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8 S E C TI O N Oral and Maxillofacial Radiology

The final pathology report confirmed the diagnosis of OKC parakeratinized variant compared with 12.2% for the orthokera-
consistent with the initial incisional biopsy specimen. The patient tinized variant); 1.6% of cysts had both orthokeratin and para-
was placed on a strict recall schedule—every 6 months for the first keratin features.
5 years and then yearly. The recurrence rate for OKCs has been These researchers also found that the parakeratinized variant
reported to range from 5% to 60%. It has been reported that demonstrated a 42% recurrence rate compared with only 2.2%
most recurrences are seen within 5 years, although they can de- for the orthokeratinized variant. In addition, the orthokeratinized
velop at any time. Recurrences that arise secondary to residual variant was more frequently associated with impacted teeth.
cyst left in the bone may be apparent within 18 months of sur- Given the different clinical behaviors of these two entities, many
gery. authors designate them as separate pathologic lesions, with the
orthokeratinized variant known as an orthokeratinized odontogenic
Complications cyst. A lesion with both orthokeratin and parakeratin features
should be treated as a parakeratinized OKC.
Odontogenic keratocysts have been described as having clinical Stimulation of residual epithelial cells is a common feature in
features that include potentially aggressive behavior and a high the development of any cyst. In the case of the OKC, the most
recurrence rate. Because recurrence is a major concern, clinicians accepted theory of origin is from remnants of the dental lamina.
vary in their surgical approach. Resection results in the lowest There is also frequent association with mutation or inactivation of
recurrence rate; however, considerable morbidity is associated the PTCH1 gene, which results in aberrant cell epithelial prolif-
with this radical treatment. The primary mechanisms for recur- eration of the OKC. Collagenase activity in the cyst’s epithelium,
rence have been postulated to be incomplete removal of all the with its resorptive properties, appears to regulate the ability of the
cystic lining, new primary cyst formation from additional acti- lesion to grow expansively in bone.
vated rests, or the development of a new OKC in an adjacent area Identification of individuals who may have NBCCS allows the
that is interpreted as a recurrence. clinician to arrange appropriate referrals. NBCCS should be sus-
Odontogenic keratocysts have been reported to undergo trans- pected when multiple lesions exist. The diagnosis is confirmed
formation into ameloblastoma and squamous cell carcinoma upon finding (1) one major criteria and genetic confirmation, (2)
(0.13%–3%), although this occurrence is rare. Other common two of the major criteria, or (3) one major criterion plus two mi-
postprocedural complications include inferior alveolar nerve par- nor criteria (see Box 1.1). Some abnormalities are pertinent only
esthesia; postoperative infection; and with larger lesions, patho- to the diagnosis and do not require any specific therapy. Other
logic mandibular fracture. (The highest risk is during the first few abnormalities may pose further risk to the patient and require the
weeks after enucleation.) input of other specialists. Patients with spina bifida or central ner-
vous system tumors require referral to a neurosurgeon. In addition,
Discussion genetic counseling for all patients with NBCCS is recommended.
OKCs associated with this syndrome are treated in the same man-
Ever since the histologic features of the OKC were established, ner as an isolated OKC; however, these lesions have a higher rate
many investigators have recognized that two major variants exist of recurrence when associated with NBCCS (which may represent
based on microscopic findings: a cyst with a parakeratinized epi- new lesions). OKCs are often associated with the follicle of a
thelial lining and a cyst with an orthokeratinized epithelial lining. potentially functional tooth, so when possible, marsupialization
Crowley and colleagues (1992) undertook a comparison of the with orthodontic guidance should be considered.
orthokeratin and parakeratinized variants. In their review, they
found that the parakeratinized variant occurred more commonly ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
than the orthokeratinized variant (frequency of 86.2% for the complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 8.e1

Bibliography Johnson NR, Batstone MD, Savage NW: Management and recurrence of
keratocystic odontogenic tumor: a systematic review, Oral Surg Oral
Med Oral Pathol Oral Radiol 116(4):e271-e276, 2013.
August M, Caruso PA, Faquin WC: Report of a case: an 18-year-old man Kennedy RA: WHO is in and WHO is out of the mouth, salivary glands,
with a one-month history of nontender left mandibular swelling, N and jaws sections of the 4th edition of the WHO classification of head
Engl J Med 353:2798-2805, 2005. and neck tumours, Br J Oral Maxillofac Surg 56(2):90-95, 2018.
August M, Faquin WC, Troulis M, et al: Differentiation of odontogenic Kolokythas A: OKC: to decompress or not to decompress—a compara-
keratocysts from nonkeratinizing cysts by use of fine-needle aspiration tive study between decompression and enucleation vs resection/pe-
biopsy and cytokeratin-10 staining, J Oral Maxillofac Surg 58:935- ripheral ostectomy, J Oral Maxillofac Surg 65(4):640-644, 2007.
940, 2000. Kumchai H, Champion AF, Gates JC: Carcinomatous transformation of
Barnes L, Eveson JW, Reichart P, et al (eds): Pathology and Genetics: Head odontogenic keratocyst and primary intraosseous carcinoma: a sys-
and Neck Tumours (IARC World Health Organization Classification of tematic review and report of a case, J Oral Maxillofac Surg 79(5):1081.
Tumors), Lyon, France, 2005, IARC Press. e1-1081.e9, 2021.
Borghesi A, Nardi C, Giannitto C, et al: Odontogenic keratocyst: imag- Madras J: Keratocystic odontogenic tumor: reclassification of the odon-
ing features of a benign lesion with an aggressive behavior, Insights togenic keratocyst from cyst to tumor, J Can Dent Assoc 74:2, 2008.
Imaging 9(5):883-897, 2018. Marx RE, Stern D: Oral and Maxillofacial Pathology: A Rationale for Di-
Buckley P, Seldin E, Dodson T, et al: Multilocularity as a radiographic agnosis and Treatment, Chicago, 2003, Quintessence.
marker of the keratocystic odontogenic tumor, J Oral Maxillofac Surg Pindborg JJ, Hansen J: Studies on odontogenic cyst epithelium: clinical
70:320, 2012. and roentgenologic aspects of odontogenic keratocysts, Acta Pathol
Caminiti MF, El-Rabbany M, Jeon J, et al: 5-fluorouracil is associated Microbiol Scand 58:283, 1963.
with a decreased recurrence risk in odontogenic keratocyst manage- Pogrel MA, Jordan RC: Marsupialization as a definitive treatment for the
ment: a retrospective cohort study, J Oral Maxillofac Surg 79(4):814- odontogenic keratocyst, J Oral Maxillofac Surg 62:651-655, 2004.
821, 2021. Pogrel MA, Schmidt BL: The odontogenic keratocyst, Oral Maxillofac
Crowley T, Kaugras GE, Gunsolley JC: Odontogenic keratocysts: a Surg Clin North Am 15(3):xi, 2003.
clinical and histologic comparison of the parakeratin and orthokeratin Pogrel MA: Keratocystic odontogenic tumor. In Bagheri S (ed): Current
variants, J Oral Maxillofac Surg 50:22-26, 1992. Therapy in Oral and Maxillofacial Surgery, St. Louis, 2012, Mosby.
Donnelly L, Simmons TH, Blitstein BJ, et al: Modified Carnoy’s com- Quereshy F, Barnum G, Demko C, et al: Applications of cone beam
pared to Carnoy’s solution is equally effective in preventing recurrence computed tomography in the practice of oral and maxillofacial sur-
of odontogenic keratocysts, J Oral Maxillofac Surg 79(9):1874-1881, gery, J Oral Maxillofac Surg 66:791, 2008.
2021. Shear M: Primordial cysts, J Dent Assoc S Afr 152:1, 1960.
El-Naggar AK, Chan JKC, Grandis JR, et al (eds): WHO Classification of Singh AK, Khanal N, Chaulagain R, et al: How effective is 5-Fluoroura-
Head and Neck Tumours, Lyon, France, 2017, International Agency cil as an adjuvant in the management of odontogenic keratocyst? A
for Research on Cancer IARC. systematic review and meta-analysis, Br J Oral Maxillofac Surg
Evans DG, Ladusans EJ, Rimmer S, et al: Complications of the naevoid 60(6):746-754, 2022.
basal cell carcinoma syndrome: results of a population based study, Tolstunov L, Treasure T: Surgical treatment algorithm for odontogenic
J Med Genet 30:460-464, 1993. keratocyst: combined treatment of odontogenic keratocyst and man-
Goyal S, Sharma S, Diwaker P: Diagnostic role and limitations of FNAC dibular defect with marsupialization, enucleation, iliac crest bone
in oral and jaw swellings, Diagn Cytopathol 43(10):810-818, 2015. graft and dental implants, J Oral Maxillofac Surg 66:1025, 2008.

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2
Unilocular Radiolucent Lesion
of the Mandible
SE PID E H S A B O O R E E , M I C H A E L R. M A R K I E W I C Z , J AM E S C . M E LV IL L E , a n d
K E V I N C . L EE

CC Neck. The patient does not have cervical or submandibular

lymphadenopathy. Lymphadenopathy would be indicative of an
A 68-year-old White male is referred for evaluation of “swelling of infectious or neoplastic etiology, so a careful neck examination is
my right lower jaw.” paramount in the evaluation of any head and neck pathology.
Intraoral. The occlusion is stable and reproducible. There does
Dentigerous Cyst not appear to be displacement of the dentition in the involved
area. (Dentigerous cysts do not typically alter the occlusion.) In-
Dentigerous cysts, also known as follicular cysts, are typically as- terincisal opening is within normal limits. There is significant
sociated with an impacted tooth, most commonly the mandibular buccal expansion of the right mandible, extending posteriorly
third molar. It is more prevalent in White people, has a slight male from the mental foramen and into the ascending ramus. (Large
predilection, and is usually seen in the age range of 10 to 30 years. cysts may be associated with a painless expansion of the bone, but
most are asymptomatic and do not cause expansion.) The patient
HPI does not have a palpable thrill or an audible bruit (both of which
are signs of arteriovenous malformations). The oral mucosa is
Approximately 2 months earlier, the patient noticed a nonpainful normal in appearance with no signs of any acute inflammatory
swelling of the right posterior mandible. (Dentigerous cysts can processes.
cause expansion but are typically not painful unless secondarily
infected.) He was seen by the referring general dentist who had Imaging
discovered a radiolucent lesion on a periapical radiograph. The
patient denies any history of pain or sensory changes, drainage When evaluating intraosseous lesions of the mandible, the pan-
from the site, or trismus. He has not experienced any fevers, chills, oramic radiograph is an excellent initial study to assess the under-
night sweats, or unintentional weight loss. lying bony and dental anatomy.
Dentigerous cysts are pericoronal lesions that attach to the
PMHX/PDHX/Medications/Allergies/SH/FH cementoenamel junction of the associated tooth. However, large
dentigerous cysts may radiographically encompass the roots of the
Noncontributory. There is no history of similar presentations in impacted tooth; other pathologies may appear to be pericoronal
his family. (There is no familial predisposition.) radiolucencies on imaging. Therefore, imaging is a not a diagnos-
tic tool for evaluation of lesions, and a histologic assessment is
Examination required for final diagnosis. When the pericoronal radiolucency of
an impacted tooth is 3 mm or smaller, the tissue is deemed to be
General. The patient is well-appearing but anxious (patients are an enlarged dental follicle and can be discarded. However, when
often anxious because they fear a malignant process). the pericoronal radiolucency of an impacted tooth is larger than
Maxillofacial. There is noticeable right lower facial swelling 3 mm, cystic development should be considered, and tissue
isolated to the lateral border of the mandible that does not extend should be submitted for histological evaluation.
below the inferior border. Consistent with a noninflammatory A computed tomography scan (Fig. 2.1) is not essential but
process, the mass is hard, nonfluctuant, and nontender to palpa- helps delineate the three-dimensional extent and regional archi-
tion. There are no facial or trigeminal nerve deficits. (Paresthesia tecture, including involvement of the mandibular cortices (corti-
of the right inferior alveolar nerve would raise the suspicion for an cal perforation is seen with some tumors and locally aggressive
infiltrative or malignant process.) cysts) and the lesion’s proximity to the inferior alveolar canal.

9
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10 S E C TI O N Oral and Maxillofacial Radiology

A B

• Fig. 2.1 Cone-beam computed tomography demonstrating right unicystic radiolucency of posterior
mandibular body without cortical perforation (A, axial view) and tooth #32 located within the lesion (B,
sagittal view).

In this patient, a panoramic radiograph (Fig. 2.2A) demon- Biopsy

strates a well-corticated unilocular radiolucent lesion of the right
posterior mandible extending from the area of tooth #31 up to An incisional biopsy would be indicated to guide the final therapy
the sigmoid notch and coronoid process. The right mandibular for this lesion. This can be done under local anesthesia, intrave-
third molar (tooth #32) is displaced inferiorly, and the lesion in- nous (IV) sedation, or general anesthesia depending on surgeon
volves the roots of tooth #31 with some resorption and superior and patient preference. It is important to aspirate the bony cavity
displacement of the tooth. After aspiration and incisional biopsy, before perforating the cortex. Bright red blood indicates the pres-
teeth #31 and #32 were extracted, and the cyst was enucleated ence of a high-flow vascular lesion that has the potential for un-
(Fig. 2.2B–E). Six- and 16-week postoperative panoramic imag- controllable hemorrhage. In such a case, the biopsy procedure
ing demonstrate good progressive bony fill of the defect (Fig. 2.2F should be aborted to allow for further imaging studies to charac-
and G). terize the vasculature of the area. Straw-colored fluid is suggestive
of a cystic lesion, thick white content is suggestive of an odonto-
Labs genic keratocyst, and the absence of a fluid aspirate may be seen
with traumatic bone cysts or jaw neoplasms.
No laboratory tests are indicated unless dictated by the medical
history. If a brown tumor of hyperparathyroidism is on the dif- Assessment
ferential diagnosis, serum calcium, phosphate, and parathyroid
hormone levels should be obtained. Brown tumors are sequalae of Expansile radiolucent mass of the posterior mandible associated with
primary hyperparathyroidism, leading to bony lesions with abun- impacted right mandibular second and third molars.
dant hemorrhage and hemosiderin deposition (giving it a brown In this case, an incisional biopsy was performed under IV
color). Removal of the hyperplastic parathyroid tissue is the de- anesthesia after aspiration (straw-colored fluid), demonstrating
finitive treatment. classic dentigerous cyst histopathology (epithelial lining of nonke-
ratinized, stratified squamous epithelium and a loosely arranged
Differential Diagnosis fibrous connective tissue wall).

The differential diagnosis for a unilocular radiolucency includes Treatment

odontogenic and non-odontogenic cysts, benign and malignant
tumors, and (less commonly) vascular anomalies. In general, Complete removal of the cyst by enucleation along with removal
large radiolucencies with multiple septations should raise the of the unerupted tooth is the preferred treatment for dentigerous
suspicion for other more aggressive entities because most dentig- cysts. If eruption of the involved tooth into a functional position
erous cysts are small and unilocular. A recent study found that is feasible (with or without orthodontic guidance), enucleation can
among pericoronal radiolucencies, lesion size 2 cm or larger was be performed without extraction of the associated tooth. The infe-
predictive of a nondentigerous cyst diagnosis on final pathology. rior alveolar neurovascular bundle is commonly displaced by the
The presence of loculations on presurgical imaging indepen- cyst and should be preserved if possible. Large cysts may be treated
dently increases the risk for a nondentigerous cyst diagnosis by with marsupialization when enucleation and curettage would
12-fold. When considering possible diagnostic alternatives, the likely result in neurosensory dysfunction or a pathologic fracture
lesions presented in Box 2.1 should be considered with the first of the mandible. Postoperative maxillomandibular fixation may be
three being the most likely. prudent to permit remodeling of the bone before function.

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 CHAPTER 2 Unilocular Radiolucent Lesion of the Mandible 11

B C

D E

F G

• Fig. 2.2 A, Unilocular radiolucency from posterior mandibular body to sigmoid notch. B, Preoperative
photograph demonstrating absence of tooth #32. C, Initial exposure of the lesion. D, Unroofing of the
lesion and exposure of tooth #32. E, Surgical defect after enucleation and curettage of the lesion. F, Or-
thopantogram 6 weeks after enucleation and curettage of the lesion. G, Orthopantogram 16 weeks after
enucleation and curettage of the lesion.

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12 S E C TI O N Oral and Maxillofacial Radiology

• BOX 2.1 Differential Diagnosis of a Unilocular Radiolucency

• Dentigerous cyst—This cyst is considered first on the differential diagnosis • Central giant cell granuloma—This lesion is more common in the anterior
list, given the patient’s age and the location of the lesion and its radio- mandible. It is a benign lesion that may be unilocular or multilocular shows
graphic presentation. This cannot be differentiated on clinical and radio- a female predilection. In addition to aggressive curettage, treatment alter-
graphic presentation alone. natives include intralesional steroid injection, systemic calcitonin, and treat-
• Calcifying odontogenic cyst—These cysts have a unilocular radiolucency, and ment with interferon-a.
calcifications in the lining sometimes makes them partially radiopaque. Treat- • Calcifying epithelial odontogenic tumor (Pindborg tumor)—This tumor is
ment is by enucleation. Show “ghost cells” of histopathologic examination. less likely, given the patient’s radiographic presentation. It is a slow-growing
• Keratinizing odontogenic tumor (KCOT)—Formerly known as an odonto- mass and usually has a mixed radiolucent-radiopaque appearance, although
genic keratocyst, this cyst also is most commonly found in the posterior early lesions may be entirely radiolucent.
mandible; it can grow to a considerable size and must be distinguished • Ameloblastic fibroma—This is an uncommon expansile tumor that usually
from a dentigerous cyst. Frequently, large unilocular lesions that are is seen in younger patients (i.e., during the first 2 decades of life). It may be
thought to be dentigerous cysts prove to be KCOTs. The orthokeratinizing treated with enucleation and curettage, although larger tumors may require
odontogenic cyst can have a similar presentation. These cysts can be resection.
treated by decompression or marsupialization, cystectomy with peripheral • Adenomatoid odontogenic tumor—This tumor may show calcifications in
ostectomy, liquid nitrogen, or Carnoy’s solution. the lining, much like a calcifying odontogenic cyst. The lesion is most often
• Ameloblastoma—Given the patient’s radiographic presentation (most com- seen in females, in the anterior maxilla, and in younger patients. However, it
mon in the posterior mandible), a unicystic variant is most likely. Amelo- cannot be ruled out without a biopsy. Treatment is enucleation.
blastomas occur equally in males and females and typically cause a pain- • Arteriovenous aneurysm of bone and other vascular bone tumors—Clinicians
less bony expansion. This is the most common noncystic pathology for this should always consider vascular tumors because of the obvious surgical impli-
radiographic and clinical presentation. Histologically, it is characterized by cations. Aspiration before any surgical incision is essential.
benign proliferation of odontogenic epithelium, with stellate reticulum ac- • Carcinoma arising in a dentigerous cyst—Although this is rare, it is well
companied by a varying composition of solid or cystic features. documented. Radiographically, the borders may be more irregular, with
• Odontogenic myxoma—This lesion arises from the papilla of the primitive den- ragged edges.
tal pulp. Radiographically, it can present as a unilocular or multilocular lesion. • Intraosseous mucoepidermoid carcinoma—This is also a rare condition,
Larger lesions tend to be multilocular and have a “soap bubble” appearance. but it should be ruled out because early diagnosis of malignant neoplasms
The lesions are treated with resection, and they have a high recurrence rate. is essential for improved survival.

For larger lesions, in which damage to adjacent structures and extensive bone destruction as they increase in size, and pathological
risk of pathologic fracture is high, staged treatment by marsupi- fracture of the mandible. The most common complications include
alization of the lesion before enucleation may be the better treat- postoperative infection, inferior alveolar nerve paresthesia, and
ment approach. Marsupialization permits decompression and mandibular fracture. Neoplastic transformation into an ameloblas-
shrinkage of the cyst, as well as filling of the bony defect. After toma, a primary intraosseous squamous cell carcinoma, or a muco-
the cyst shrinks, it can be enucleated with a reduced chance of epidermoid carcinoma all have been reported. For this reason, a
injury to adjacent structures or pathologic fracture. A disadvan- complete histopathologic examination with enucleation may be
tage of marsupialization is the need for greater patient compli- preferable to marsupialization, which could delay the diagnosis of a
ance with an open cystic cavity between treatments. Daily irriga- neoplastic transformation.
tions of the site and routine follow-up visits are needed to
maintain patency of the decompression drain to ensure success of Discussion
the procedure. Additionally, marsupialization does not reliably
ensure a reduction in the size of the cyst or migration of the Dentigerous cysts are the most common developmental odonto-
displaced tooth. genic cysts and the second most common odontogenic cysts fol-
This patient was taken to the operating room and underwent lowing periapical (radicular) cysts. Approximately one in five cysts
enucleation and curettage via an intraoral approach. The right of the jaw are ultimately diagnosed as dentigerous cysts. Dentiger-
mandibular second and third molars were maintained because of ous cysts are lined by reduced enamel epithelium (REE), which
the high risk of fracture and inferior alveolar nerve paresthesia normally merges with the overlying oral mucosa during tooth
(although this may increase the possibility of recurrence). eruption. Fluid accumulation between the REE and the crown of
The patient was placed on a soft diet to reduce the risk of jaw an unerupted tooth creates the cystic cavity. Progressive buildup
fracture. The postoperative panoramic radiograph confirmed that of intraluminal pressure stimulates subsequent epithelial prolifer-
the inferior border of the mandible remained intact. ation. Given the pathophysiology, dentigerous cysts are always
The final pathology report confirmed the diagnosis of a associated with impacted teeth. As a result, their location distribu-
dentigerous cyst consistent with the initial incisional biopsy tion mirrors that observed for dental impactions. They are most
specimen. often seen with impacted mandibular third molars; however, they
may also involve the maxillary third molars, maxillary canines,
Complications and mandibular second premolars.
Dentigerous cysts are typically asymptomatic on presentation.
With adequate treatment, the prognosis for a dentigerous cyst is Long-standing cysts can expand significantly, resulting in painless
excellent, and recurrence is rare. When left untreated, these cysts expansion of the bone in the involved area. The external pressure
may lead to tooth displacement, resorption of adjacent tooth roots, exerted by the cystic lining can displace teeth or cause adjacent

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 CHAPTER 2 Unilocular Radiolucent Lesion of the Mandible 13

root resorption, both of which are nonspecific characteristics that as a multilocular lesion because of bony trabeculations and extend
can be seen with other pathologies. These cysts can become sec- beyond the crown portion of the impacted tooth. However, these
ondarily infected, with associated pain and swelling. cysts are still grossly and histopathologically a unilocular process.
Radiographically, dentigerous cysts usually show a unilocular ra-
diolucent area that encircles the crown of an impacted tooth attached ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
at the cementoenamel junction. A larger dentigerous cyst may appear complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 13.e1

Bibliography Gbolahan O, Fatusi O, Owotade F, et al: Clinicopathology of soft tissue

lesions associated with extracted teeth, J Oral Maxillofac Surg 66(11):
2284-2289, 2008.
Angadi PV, Rekha K: Calcifying epithelial odontogenic tumor (Pindborg Gomes CC, Diniz MG, Duarte AP, et al: Molecular review of odonto-
tumor), Head Neck Pathol 5(2):137-139, 2011. genic myxoma, Oral Oncol 47(5):325-328, 2011.
Benn A, Altini M: Dentigerous cysts of inflammatory origin: a clinico- Koca H, Esin A, Aycan K: Outcome of dentigerous cysts treated with
pathologic study, Oral Surg Oral Med Oral Pathol Oral Radiol Endod marsupialization, J Clin Pediatr Dent 34(2):165-168, 2009.
81(2):203-209, 1996. Marciani RD: Is there pathology associated with asymptomatic third
Boffano P, Gallesio C, Barreca A, et al: Surgical treatment of odontogenic molars? J Oral Maxillofac Surg 70(9 Suppl 1):S15-S19, 2012.
myxoma, J Craniofac Surg 22(3):982-987, 2011. Peacock ZS, Jordan RC, Schmidt BL: Giant cell lesions of the jaws: does
Buckley PC, Seldin EB, Dodson TB, et al: Multilocularity as a radio- the level of vascularity and angiogenesis correlate with behavior?
graphic marker of the keratocystic odontogenic tumor, J Oral Maxil- J Oral Maxillofac Surg 70(8):1860-1866, 2012.
lofac Surg 70(2):320-324, 2012. Sandhu SV, Narang RS, Jawanda M, et al: Adenomatoid odontogenic
Carneiro JT Jr, Carreira AS, Felix VB, et al: Pathologic fracture of jaw in tumor associated with dentigerous cyst of the maxillary antrum: a rare
unicystic ameloblastoma treated with marsupialization, J Craniofac entity, J Oral Maxillofac Pathol 14(1):24-28, 2010.
Surg 23(6):e537-e539, 2012. Simiyu BN, Butt F, Dimba EA, et al: Keratocystic odontogenic tumours
Caruso DP, Lee CC, Peacock ZS: What factors differentiate dentigerous of the jaws and associated pathologies: a 10-year clinicopathologic
cysts from other pericoronal lesions? Oral Surg Oral Med Oral Pathol audit in a referral teaching hospital in Kenya, J Craniomaxillofac Surg
Oral Radiol 133(1):8-14, 2022. 41(3):230-234, 2013.
Curran AE, Damm DD, Drummond JF: Pathologically significant peri- Smith JL II, Kellman RM: Dentigerous cysts presenting as head and neck
coronal lesions in adults: histopathologic evaluation, J Oral Maxillofac infections, Otolaryngol Head Neck Surg 133(5):715-717, 2005.
Surg 60(6):613-617; discussion 618; 2002. Tabrizi R, Ozkan BT, Dehgani A, et al: Marsupialization as a treatment option
de Matos FR, Nonaka CF, Pinto LP, et al: Adenomatoid odontogenic for the odontogenic keratocyst, J Craniofac Surg 23(5):e459-e461, 2012.
tumor: retrospective study of 15 cases with emphasis on histopatho- Williams MD, Hanna EY, El-Naggar AK: Anaplastic ameloblastic fibrosar-
logic features, Head Neck Pathol 6(4):430-437, 2012. coma arising from recurrent ameloblastic fibroma: restricted molecular
Elo JA, Slater LJ, Herford AS, et al: Squamous cell carcinoma radio- abnormalities of certain genes to the malignant transformation, Oral
graphically resembling a dentigerous cyst: report of a case, J Oral Surg Oral Med Oral Pathol Oral Radiol Endod 104(1):72-75, 2007.
Maxillofac Surg 65(12):2559-2562, 2007.

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3
Multilocular Radiolucent Lesion in the
Periapical Region (Ameloblastoma)
ER I C P. H O L MG R E N a n d S H A H R O K H C . B AG H ER I

CC
An 86-year-old male presents with concern of pain and swelling
in the lower left jaw adjacent to a previous premolar extraction
site that was performed years ago. (Typically, ameloblastomas are
often asymptomatic until bone perforation occurs, causing swell-
ing of adjacent mucosa.) He is referred by his general dentist for
a suspicious bone lesion.

Ameloblastoma
Ameloblastomas are usually diagnosed in the third to fourth de-
cade of life (this patient’s age of presentation falls outside of what
is typically encountered), with no gender or racial predilection;
however, unicystic variants tend to occur earlier in life.

HPI
For the past 2 months, the patient has noticed a progressively
enlarging “hard mass” in his mandible and a “raw” area on the
gums next to the previous extraction site, and he is concerned
about a retained root tip. According to his new dentist, the
extraction was performed because of radiography findings
similar to those seen in Fig. 3.1 (which shows an apical radio-
lucency on an isolated periapical film that can be mistaken for
apical periodontitis associated with necrotic pulp, hence the
importance of using orthopantogram imaging). There have
been no neurosensory changes associated with the swelling.
(Sensory changes are particularly common in malignancies and • Fig. 3.1 Apical radiolucency on an isolated periapical film mistaken for
are not usually seen in benign lesions such as ameloblastomas.) apical periodontitis associated with necrotic pulp.
On consultation and after reviewing an orthopantogram film
(Fig. 3.2), the patient’s general dentist noticed a significant ex- Examination
pansile bony lesion adjacent to the lower left first molar extend-
ing toward the left central incisor and swelling of the gingiva General. The patient is well developed and well nourished and
near the lower left first premolar. (Ameloblastomas occur most appears distressed about his possible diagnosis.
frequently in the mandible [80% of the time], often in the Vital signs. Vital signs are stable, and the patient is afebrile.
posterior mandible.) Maxillofacial. There is mild left facial enlargement that is
most pronounced at the parasymphyseal region of the mandible,
PMHX/PDHX/Medications/Allergies/SH/FH with no evidence of trismus. No cervical lymphadenopathy is
present. (Ameloblastomas are benign tumors and in general do
He has hypertension and high cholesterol for which he takes not cause lymphadenopathy, which may be seen with malignant
lisinopril and atorvastatin. tumors.) Neurosensory testing reveals normal mandibular nerve

14
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 3 Multilocular Radiolucent Lesion in the Periapical Region (Ameloblastoma) 15

• Fig. 3.2 Orthopantogram film showing expansile bony lesion adjacent to

the lower left first molar extending toward near the lower left central incisor.

(V3) function bilaterally and no other focal neurologic deficits.

(Ameloblastomas generally do not invade the neurovascular bun-
dle, but paresthesia can be present if pathologic fracture exists
because of excessive tumor growth.)
Intraoral. There is buccal and lingual expansion of the posterior
left mandible with mild tenderness along the gingiva in the edentu- • Fig. 3.3 Axial view of bony window computed tomography scan shows
lous lower left first premolar location but no evidence of fluctuance an expansile lesion of the left body of the mandible extending to the para-
or purulent secretions. No palpable thrill is present (which may symphysis region, with cortical perforation.
suggest underlying vascular anomaly, if present). The lower left
second premolar has 11 mobility with vertical bone loss and reces-
sion on the mesial aspect, and the lower left first molar is heavily
restored. There is no sign of fracture with bimanual manipulation.
(It is important to test for pathologic fracture.)

Imaging
The panoramic radiograph (see Fig. 3.2) is the initial imaging study
of choice for evaluation of a mandibular mass. Computed tomog-
raphy (CT) scans are particularly useful for outlining the three-di-
mensional anatomy to demonstrate the amount of expansion and
areas of bony perforation implying subsequent soft tissue involve-
ment. Computerized planning and surgery simulation as well as
stereolithographic models can be fabricated from the CT scan and
can assist in surgical planning, resection, and reconstruction.
In this patient, the panoramic radiograph demonstrates a mul-
tilocular, cystic-appearing lesion extending from the distal aspect
of the left first mandibular molar to the lower left central incisor
extending inferiorly to the middle aspect of the mandible. The
bone at the inferior border of the mandible has a normal appear-
ance, without loss of continuity (see Fig. 3.2).
The CT scan in the axial view (Fig. 3.3) and coronal view
(Fig. 3.4) shows an expansile lesion of the left body of the mandible
extending to the parasymphysis region, with cortical perforation seen
on axial and coronal sections. There is no evidence of lymphade-
nopathy, and no areas of abnormal enhancement are seen. (Contrast-
enhanced imaging provides improved delineation of soft tissue and
can aid in determining any associated vascular malformations.) • Fig. 3.4 Coronal view of bony window computed tomography scan.

Labs
No specific labs were evaluated. Other laboratory tests are ob- neoplastic, or vascular origin, with the latter being less common.
tained as dictated by the medical history and anesthesia protocol. Although the presentation just described is classic for an amelo-
blastoma (i.e., bony expansion of the posterior mandible with a
Differential Diagnosis multilocular or “soap bubble” appearance), this lesion cannot be
distinguished on clinical and radiographic parameters. A com-
The differential diagnosis of a multilocular radiolucent lesion of plete differential diagnosis should be considered (see Differential
the posterior mandible is best categorized as lesions of cystic, Diagnosis in Chapter 1).

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16 S E C TI O N Oral and Maxillofacial Radiology

Biopsy healing to allow for soft tissue maturity followed by devascularized

bone grafting. During resection, special attention was paid to the
For diagnosis of this multilocular and expansile lesion, aspiration site of perforation, in which a supraperiosteal resection was per-
followed by an incisional biopsy was performed with local anes- formed, and the overlying mucosa and periosteum were resected
thesia in the clinic. (Intravenous sedation can also be considered with the specimen. The inferior alveolar nerve was dissected free
for patient comfort.) Needle aspiration was negative for blood or and preserved during both the resection and inset of the vascular-
any clear fluids and therefore suggestive of a mass lesion. (It is ized free fibula flap. (Ameloblastoma cells do not necessarily
always good practice to perform aspiration to ensure no vascular penetrate the nerve unless there is gross involvement of the infe-
anomaly is present even when no palpable thrill is appreciated.) rior alveolar canal, which can theoretically allow the tumor cells
An incision overlying the attached tissue in the lower left first to penetrate the perineural tissue.)
premolar region was performed and carried past the second pre- Other reported treatment alternatives include enucleation,
molar beyond the distal aspect of the first molar reflected and re- curettage and cryotherapy with or without bone grafting, and
flected anteriorly around the canine and central incisor to allow excision of the tumor with peripheral ostectomy. Marsupialization
for adequate access. (It is important to make the incision where of unicystic variants have also been reported. These treatments
the definitive surgical incision would ultimately be made to have not been proved to be curative, are not widely advocated,
minimize dehiscence at the time of definitive surgery.) No puru- and have a higher recurrence rate compared with resection.
lence was noted. A cystic lesion with a keratin-like substance was
encountered in the bony concavity. A sample of the cyst lining Complications
was taken from two different locations. After irrigation the wound
was closed with 3-0 chromic interrupted sutures, and a specimen General complications associated with resection and reconstruction
was sent for histopathologic examination. of this tumor include mandibular nerve anesthesia, graft failure,
unacceptable facial symmetry, and donor site morbidity. Plate expo-
Assessment sure, plate fracture, and intraoral dehiscence are also possibilities but
typically less of an issue when a vascularized soft tissue pedicle is well
Microscopic evaluation reveals islands of epithelium that resemble managed. Recurrence is the most worrisome long-term complica-
enamel organ in a fibrous connective tissue stroma; attached to the tion and can be caused by persistence of the original tumor that was
basement membrane surrounding the islands are tall columnar cells not resected or actual recurrence of new neoplastic cells. Aggressive
exhibiting reversed polarity. surgical therapy does not necessarily eliminate the chance of tumor
This is consistent with the diagnosis of a multicystic, follicular recurrence. In theory, the more aggressive the initial treatment, the
ameloblastoma. lesser the likelihood of tumor recurrence. However, this comes at the
expense of a larger residual defect and more complicated reconstruc-
Treatment tive measures. Surgeons need to determine the extent of the resec-
tion and preservation of structures based on the available evidence,
The treatment of ameloblastomas has raised some controversy. tumor biology, patient’s preference and availability for follow-up,
In general, treatment must focus on the ability of the tumor to surgeon experience, and other individual factors.
invade surrounding bone tissue. The average extension into sur-
rounding bone beyond the normal tumor margin is 4.5 mm, Discussion
with a range of 2 to 8 mm. With this in mind, resection must
be at least 10 mm beyond the bony (and radiographic) margin In 1945, Robinson described the ameloblastoma as “usually uni-
of the tumor for large, multicystic-type ameloblastomas. Re- centric, non functional, intermittent in growth, anatomically be-
sected tumors seldom recur; the cure rate for primary tumors is nign, and clinically persistent.” This description holds true today.
95% to 98%. In contrast, there is a high incidence of recurrence There are seven histologic types of ameloblastomas: Follicular,
( 70%) for treatment with enucleation and curettage alone. plexiform, acanthomatous, granular cell, desmoplastic, basal cell,
Regardless of the reconstructive measure, close patient follow-up and unicystic variant; the first two types are the most common.
is necessary to monitor for recurrence, especially in patients who The desmoplastic variant often presents in the anterior maxilla or
do not undergo a resection. Because ameloblastomas can recur mandible and can appear more radiopaque because of the high
within a variable time frame, a cure rate for an ameloblastoma amount of dense connective tissue. Ameloblastomas can be either
does not necessarily correlate with a 5-year disease-free period solid or multicystic, but they frequently demonstrate both charac-
compared with other neoplastic processes. Long-term follow-up teristics. The tumor can arise from embryonic remnants of odon-
is necessary. togenic cysts, dental lamina, enamel organ, or stratified squamous
For this patient, several options were considered, especially epithelium of the oral cavity.
given his age. Observation certainly can be considered in patients Although the majority of the tumors originate from within the
with advanced age, but because he was having symptoms and maxilla or mandible, they can also be peripheral. The different
bony expansion was visually apparent, the option to have surgery histological variants do not significantly alter treatment consider-
was decided. Marginal resection was considered but would put ations except for the unicystic and the peripheral types, which can
him at risk of fracture to obtain the necessary margin needed to typically be treated with enucleation and curettage. Unicystic
remove the entire lesion. Thus, a segmental resection was recom- ameloblastomas represent about 10% to 15% of intraosseous
mended. Options for reconstruction were reviewed, and he opted ameloblastomas and can be misdiagnosed as dentigerous cysts.
for a vascularized free fibula flap with a reconstruction plate and These lesions commonly occur in younger patients and have three
immediate dental implant placement that would allow him to distinct variants (luminal, intraluminal, and mural). Luminal and
ultimately have an implant-supported prosthesis fabricated. This intraluminal types can typically be treated with enucleation and
was opposed to a staged approach with resection and a period of close observation, whereas mural types should be treated more

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 3 Multilocular Radiolucent Lesion in the Periapical Region (Ameloblastoma) 17

aggressively because of the progression of the ameloblast cells ex- aspiration of oral tumor). The malignant variant has a poor prog-
isting throughout the entire cyst wall as opposed to being con- nosis. Recent evidence has suggested that large unresectable le-
tained within the luminal side of the cyst. However, recurrence sions, recurrent ameloblastomas, or metastatic ameloblastomas
rates for unicystic ameloblastoma in general have been reported to may respond to molecular targeted therapies aimed at genetic
be 21% with conservative treatment compared with 3% for more mutations involving the mitogen-activated protein kinase and
radical treatment. Peripheral ameloblastomas are very uncom- sonic hedgehog signaling pathways that exist within the amelo-
mon, representing approximately 1% of all ameloblastomas, and blastoma as neoadjuvant treatment.
are usually successfully treated with local surgical excision because
of their nonaggressive behavior. Malignant ameloblastomas are ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
extremely rare and usually metastasize to the lungs (probably from complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 17.e1

Bibliography Laskin DM, Giglio JA, Ferrer-Nuin LF: Multilocular lesion in the body
of the mandible: clinicopathologic conference, J Oral Maxillofac Surg
60:1045-1048, 2002.
Anpalagan A, Tzortzis A, Twigg J, et al: Current practice in the manage- Nakamura N, Mitsuyasu T, Higuchi Y, et al: Growth characteristics of
ment of peripheral ameloblastoma: a structured review, Br J Oral ameloblastoma involving the inferior alveolar nerve: a clinical and
Maxillofac Surg 59:e1-e8, 2021. histopathologic study, Oral Surg Oral Med Oral Pathol Oral Radiol
Bianchi B, Ferri A, Ferrari S, et al: Mandibular resection and reconstruc- Endod 91:557-562, 2001.
tion in the management of extensive ameloblastoma, J Oral Maxillofac Neville BW, Damm DD, Allen CM, et al: Oral and maxillofacial pathol-
Surg 71:528-537, 2013. ogy, ed 2, New York, 2002, Saunders.
Carlson ER, Marx RE: The ameloblastoma: primary, curative surgical Robinson HBG, Koch WE: Classifications of cysts of jaw, Am J Orthod
management, J Oral Maxillofac Surg 64:484-494, 2006. Oral Surg 31(6):A370-A372, 1945.
Carlson ER, Monteleone K: Analysis of inadvertent perforations of mu- Sachs SA: Surgical excision with peripheral ostectomy: a definitive, yet
cosa and skin concurrent with mandibular reconstruction, J Oral conservative, approach to the surgical management of ameloblastoma,
Maxillofac Surg 62:1103-1107, 2004. J Oral Maxillofac Surg 64:476-483, 2006.
Chapelle K, Stoelinga P, de Wilde P, et al: Rational approach to diagnosis Sampson DE, Pogrel MA: Management of mandibular ameloblastoma:
and treatment of ameloblastoma and odontogenic keratocysts, Br J the clinical basis for a treatment algorithm, J Oral Maxillofac Surg
Oral Maxillofac Surg 42:381-390, 2004. 57:1074-1077, 1999.
Gerzenshtein J, Zhang F, Caplan J, et al: Immediate mandibular recon- Shi HA, Ng CWB, Kwa CT, et al: Ameloblastoma: a succinct review of
struction with microsurgical fibula flap transfer following wide resec- the classification, genetic understanding and novel molecular targeted
tion for ameloblastoma, Plast Reconstr Surg 17:178-182, 2006. therapies, Surgeon 19(4):238-243, 2021.
Gold L, Williams TP: Odontogenic tumors: surgical pathology and man- Tung-Yiu W, Jehn-Shyun H, Ching-Hung C: Epineural dissection to
agement. In Fonseca RJ (ed): Oral and maxillofacial surgery, ed 2, preserve the inferior alveolar nerve in excision of an ameloblastoma of
Philadelphia, 2009, Saunders/Elsevier, pp 466-538. mandible: case report, J Oral Maxillofac Surg 58:1159-1161, 2000.
Hendra FN, Natsir Kalla DS, Van Camm EN, et al: Radical vs conserva-
tive treatment of intraosseous ameloblastoma: systematic review and
meta-analysis, Oral Dis Oct 25(7):1683-1696, 2019.

t.me/Dr_Mouayyad_AlbtousH
4
Unilocular Radiolucent Lesion in a
Periapical Region (Periapical Cyst)
KEL LY R. M AGL IO C C A a n d S H A H R O K H C . B AG H E R I

CC Intraoral. The left mandibular first molar is restored with amal-

gam, and the left mandibular second molar is restored with a
A 52-year-old male is referred by his general dentist for evaluation crown; neither tooth is mobile or tender. There is no gingival swell-
of a periapical radiolucency associated with the left mandibular ing or palpation tenderness along the buccal or lingual cortices.
second molar, a new finding compared with features on a radio-
graph taken 1 year earlier. Imaging
Periapical Cyst A panoramic radiograph is the initial study of choice for any in-
traosseous lesion because it provides an excellent overview of the
Periapical cysts (also called radicular or apical cysts) are the most bony anatomy, symmetry, and architecture of the maxilla and
common jaw cysts. They develop secondary to the inflammatory mandible and demonstrates the relationship to adjacent anatomic
process associated with a nonvital tooth and are more common structures. A periapical radiograph can be obtained for small
after the third decade of life. lesions, providing a more detailed outline of the borders and
trabecular pattern. More extensive imaging, such as computed
HPI tomography scanning, is seldom required for management of a
periapical cyst unless the diagnosis is in question.
The patient provides the antecedent history of having “longstand- In this patient, the recently obtained panoramic radiograph
ing pain” in the left posterior mandible, which led to the discov- demonstrated a well-circumscribed, partially corticated radiolu-
ery of recurrent carious lesions under the existing restorations of cent lesion associated with the left mandibular second molar
teeth #18 and #19, approximately 2 years before the current pre- mesial root partially involving the left mandibular first molar
sentation. The referral note indicates the left first molar required distal root (Fig. 4.1). The lesion is approximately 1.5 cm in diam-
replacement of an existing amalgam restoration, and the left eter. (Periapical cysts are generally between 0.5 and 1.5 cm in di-
mandibular second molar required endodontic treatment. (Peri- ameter but may enlarge to fill an entire quadrant.) There is no
apical cysts are associated with pulpal necrosis secondary to either associated root resorption. (Although root resorption is uncom-
caries or trauma.) Treatment was completed, and the teeth have mon in association with a periapical cyst, it can be seen, especially
remained asymptomatic for the past 2 years. A panoramic radio- with larger cysts.). However, the periodontal ligament of the sec-
graph obtained 1 year ago showed no evidence of disease. The ond molar mesial root is widened. (Accuracy for cold testing of
patient denies any history of swelling or purulence in the region.
(Periapical cysts seldom present with any clinical symptoms, but
infected cysts can present with a draining fistula.)

PMHX/PDHX/Medications/Allergies/SH/FH
Noncontributory

Examination
Maxillofacial. There is no discernible facial asymmetry or swelling.
(Periapical cysts are rarely associated with any cortical expansion.)
Facial skin overlying the region is smooth without erythema.
Neck. No cervical or submandibular lymphadenopathy can be
detected. (Positive node findings could be indicative of an infec- • Fig. 4.1 Periapical radiolucent lesion associated with endodontic treat-
tious or neoplastic process.) ment of the left mandibular second molar seen on a panoramic radiograph.

18
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 CHAPTER 4 Unilocular Radiolucent Lesion in a Periapical Region (Periapical Cyst) 19

the pulp in presence of prosthetic crown is estimated at 87%. squamous epithelium of varying thickness. Isolated and detached
Pulp testing is essential, but results should be considered in com- bacterial aggregates suggestive of Actinomyces were identified. The
bination and context with radiology and other clinical signs and wall of the cyst showed dense fibrous connective tissue; weakly po-
symptoms.) larizable foreign material consistent with an endodontic treatment
adjunct; and a significant mixed inflammatory infiltrate of lympho-
Labs cytes, plasma cells, neutrophils, and histocytes (eFig. 4.2). Com-
monly, the central cyst lumen may contain proteinaceous fluid and
No routine laboratory tests are indicated for the workup of a necrotic cellular debris and may include cholesterol clefts. In addi-
periapical cyst unless dictated by the medical history. tion, a subset of cases may show curved and round hyaline bodies
known as Rushton bodies embedded within the cyst epithelium.
Differential Diagnosis The clinical, radiographic, and histologic findings are consistent
with a periapical cyst.
The differential diagnosis of a periapical radiolucent lesion is
greatly influenced by the clinical history and vitality of the associ- Treatment
ated tooth. If the associated tooth is nonvital and there is radio-
graphic evidence of pulpal pathology, an inflammatory-type Periapical cysts are treated by enucleation and curettage, either
odontogenic etiology (periapical cyst or periapical granuloma) is through an extraction socket or via a periapical surgical approach
the most likely diagnosis. However, a diagnosis based on histo- when the tooth is restorable or the lesion is greater than 2 cm in
pathologic examination is warranted because developmental diameter. If the tooth is to be preserved, endodontic treatment is
odontogenic cysts, developing fibro-osseous lesions, odontogenic necessary if it has not already been accomplished. In some cases,
tumors, squamous cell carcinoma, and deposits of metastatic dis- nonsurgical, conservative endodontic treatment of smaller periapi-
ease, among other entities, may also occur in a periapical location. cal lesions may be a treatment option, ensuring the complete
The differential diagnosis is outlined in Box 4.1. removal of causative organisms. If the latter scenario precludes his-
tologic sampling of the apical pathology, regular radiographic fol-
Biopsy low-up to evaluate for radiographic resolution of the defect and to
exclude lesion progression is warranted. A radiographic lesion that
Biopsy and treatment of small periapical cysts are usually synony- fails to resolve warrants biopsy sampling. If surgery is undertaken,
mous and excisional in nature and vary, depending on the restor- any tissue removed during the procedure should be sent for micro-
ative plan for the involved tooth. If extraction is planned, then the scopic evaluation. In some cases, one may observe white-yellow
cyst can be removed through the extraction socket. If the tooth is material during instrumentation of the lesion (purulence, necroin-
to be restored or the lesion is particularly large, a periapical ap- flammatory debris, cholesterol crystals or clefts, histocyte-rich
proach through the buccal cortex can be used. inflammation, bacterial aggregates, and keratin debris can clinically
appear as white or yellow material) and may further expand clini-
Assessment cal differential diagnosis. Recurrence of periapical cysts is uncommon.

Distinct periapical radiolucent lesion associated with the nonvital left Complications
mandibular second molar. The lesion is closely associated with the
inferior alveolar nerve. Few complications are associated with the treatment of a periapi-
In this case, the tooth was extracted, and the underlying lesion cal cyst. Extraction of a tooth without removal of the cyst or
was carefully removed to avoid injury to the inferior alveolar neuro- incomplete removal of the cystic lining can result in a residual
vascular bundle. The specimen was sent for histopathologic exami- cyst. As mentioned, residual cysts are histologically identical to
nation and demonstrated a cystic lining of nonkeratinized, stratified periapical cysts and are treated with enucleation. Failed conservative

• BOX 4.1 Differential Diagnosis of Periapical Radiolucent Lesions

• Periapical granuloma—This lesion is radiographically indistinguishable well-demarcated radiolucent lesion that can scallop between teeth without
from a periapical cyst and is treated in the same manner. Differentiation resorption. Associated teeth are asymptomatic and vital.
between periapical granulomas and a cyst has no clinical implication and is • Lingual salivary gland depressions (Stafne defect)—This well-circum-
discussed below. scribed radiolucent lesion is most commonly seen in the posterior mandible
• Residual cyst—This is a lesion that remains after the extraction of a tooth inferior to the mandibular canal of male patients and represents a develop-
or completion of endodontic treatment. It is radiographically and histologi- mental concavity of the lingual cortex containing normal salivary gland tis-
cally identical to a periapical cyst. sue. Teeth near this lesion are, of course, asymptomatic and vital because
• Cemento-osseous dysplasias (early)—The spectrum of lesions including the radiolucency is in fact superimposed in the periapical location.
focal, periapical, and florid cementoosseous dysplasia can be observed in • Other lesions—Neural lesions (schwannoma, neurofibroma) could present
the periapical region of teeth and are most commonly seen in middle-aged in a periapical location but are usually associated with the mandibular ca-
adult females of African descent. With serial observation, these lesions will nal. Other cysts and tumors, including the lateral periodontal cysts, amelo-
progress to mixed radiolucent-radiopaque lesions and eventually to radi- blastomas, odontogenic keratocysts, central giant cell tumors, intraosseous
opaque lesions. Associated teeth are asymptomatic and vital. mucoepidermoid carcinomas, and metastatic disease, could present in a
• Idiopathic bone cavity (simple bone cyst, traumatic bone cyst)—Most periapical location and should be investigated. For these lesions, the asso-
often seen in the body of the mandible of young adults, this lesion lacks an ciated tooth is usually vital unless there is prior endodontic therapy or con-
epithelial lining and has the potential for expansion. Radiographically, it is a comitant pathological processes.

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 CHAPTER 4 Unilocular Radiolucent Lesion in a Periapical Region (Periapical Cyst) 19.e1

A B

C D
• eFig. 4.2 Histology of periapical cyst. A, Low magnification of biopsy sample includes a small focus of
foreign material (open arrow) bacterial colonies (arrowhead). B, Nonkeratinizing stratified squamous epithe-
lial cyst lining. C, Actinomyces bacterial colonies. D, Foreign material related to prior root canal treatment.

t.me/Dr_Mouayyad_AlbtousH
20 S E C TI O N Oral and Maxillofacial Radiology

endodontic treatment shows a persistent periapical lesion and in TABLE Percentage of Non-endodontic
some cases is associated with localized actinomycosis (also known as 4.1 (Noninflammatory-Type Odontogenic) Lesions
periapical actinomycosis). Endodontic retreatment may be attempted
Identified in the Periapical Region
before a curative surgical apicoectomy and enucleation are per-
formed. When both the buccal and lingual cortices are involved, it is Percent Non-
possible for the area to heal with fibrous tissue (periapical scar). No endodontic Most Common
treatment is necessary for periapical scars. Study (year) Entities Entity
Complications associated with surgical removal of the cyst can Kontogiannis et al. (2015) 3.42 Odontogenic keratocyst
be related to the regional anatomy. Neurosensory disturbances
secondary to injury to the inferior alveolar nerve or branches of Sullivan et al. (2016) 2.80 Odontogenic keratocyst
the mental nerve can be seen, especially with larger lesions, but Huang et al. (2017) 2.95 Odontogenic keratocyst
these are usually temporary. Postoperative infection can occur
with any surgical intervention. Vieira et al. (2020) 4.22 Odontogenic keratocyst
Rudman et al. (2022) 2.88 Odontogenic keratocyst
Discussion
The periapical cyst, or radicular cyst, results from inflammatory
stimulation of the odontogenic rests of Malassez within the peri-
odontal ligament. It is common, accounting for at least 50% of all entities are possible. Studies performed within the past decade
gnathic cysts. Its development is often preceded by a periapical consistently show that an inflammatory-type odontogenic lesion
granuloma that forms at the tooth apex in response to pulpal bacte- (e.g., periapical cyst and granuloma) represent the most likely diag-
rial infection and necrosis. A periapical granuloma consists of an nosis in periapical lesions in the vast majority of cases (.95%;
outer dense fibrous tissue capsule surrounding a central area of Table 4.1). Most, but not all, of these studies suggest periapical
granulation tissue. Expansion of the granuloma leads to central granulomas are more common than periapical cysts. From a practi-
ischemic necrosis and development of a central lumen surrounded cal perspective, discerning whether the lesion is a periapical cyst
by an epithelial membrane. The necrotic cellular debris within the or periapical granuloma is of little clinical consequence because
lumen creates an osmotic gradient, drawing in fluid and causing the eventual treatment of the two lesions is identical. The small
enlargement of the cyst and resorption of surrounding bone sec- cohort of entities comprising the remaining 5% or less in the
ondary to hydrostatic pressure. There is debate regarding the imag- periapical location represents a spectrum of odontogenic and
ing techniques and features and whether they permit radiographic non-odontogenic lesions. Odontogenic keratocyst leads the group
distinction between periapical granulomas and cysts. Based on of benign lesions as the most common diagnosis followed by
imaging techniques available to surgeons on a daily basis, the fibro-osseous lesions of bone. Malignancy is quite uncommon.
consensus remains that periapical cyst and granuloma are radio- Malignancies that can localize to the periapical site include squa-
graphically indistinguishable. There is no significant relationship mous cell carcinoma, metastatic deposits of carcinoma to the jaw,
between preoperative symptoms and lesion type; however, lesions and occasionally salivary gland malignancy is reported.
that present with an associated swelling (increased local destruction) Periapical cysts and granulomas are commonly encountered
demonstrate delay in postoperative bone regeneration. In at least lesions in the practice of oral and maxillofacial surgeons. A careful
one study, endodontically treated teeth associated with histologic history; consideration of clinical and radiographic presentation;
evidence of periapical actinomycosis were radiographically larger and, most important, assessment of the vitality of the associated
than lesions without actinomycosis. In contrast to entrenched tooth aid in determining the appropriate diagnosis and manage-
cervicofacial actinomycosis, periapical actinomycosis is a localized, ment of this common pathologic lesion.
indolent process that responds to conservative measures.
With respect to histologic classification of the biopsy material ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
from the periapical region, both odontogenic and non-odontogenic complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 20.e1

Bibliography CBCT cross-sectional study with a worldwide overview, Eur Endod J

6:56-71, 2021.
Pak JG, Fayazi S, White SN: Prevalence of periapical radiolucency and
Almutairi W, Aminoshariae A, Williams K, et al: The validity of pulp root canal treatment: a systematic review of cross-sectional studies,
tests on crowned teeth: a clinical study, Eur Endod J 6:151-154, 2021. J Endod 38:1170-1176, 2012.
Gomes-Silva W, Pereira DL, Fregnani ER, et al: Clinicopathological and Pasupathy SP, Chakravarthy D, Chanmougananda S, et al: Periapical
ultrastructural characterization of periapical actinomycosis, Med Oral actinomycosis, BMJ Case Rep 2012, doi:10.1136/bcr-2012-0062.
Patol Oral Cir Bucal 25:e131-e136, 2020. Rudman J, He J, Jalali P, et al: Prevalence of nonendodontic diagnoses in
Huang HY, Chen YK, Ko EC, et al: Retrospective analysis of non- periapical biopsies: a 6-year institutional experience, J Endod 48:1257-
endodontic periapical lesions misdiagnosed as endodontic apical 1262, 2022.
periodontitis lesions in a population of Taiwanese patients, Clin Oral Sullivan M, Gallagher G, Noonan V: The root of the problem: occur-
Investig 21:2077-2082, 2017. rence of typical and atypical periapical pathoses, J Am Dent Assoc
Hwang MJ, Lee YP, Lang MJ, et al: Clinicopathological study of radicu- 147:646-649, 2016.
lar cysts with actinomycosis, J Dent Sci 16:825-830, 2021. Tekkesin MS, Olgac V, Aksakalli N, et al: Odontogenic and nonodonto-
Kontogiannis TG, Tosios KI, Kerezoudis NP, et al: Periapical lesions are genic cysts in Istanbul: analysis of 5088 cases, Head Neck 34:852-855,
not always a sequelae of pulpal necrosis: a retrospective study of 1521 2012.
biopsies, Int Endod J 48:68-73, 2015. Vieira CC, Pappen FG, Kirschnick LB, et al: A retrospective Brazilian
Kuklani RM, Bhattacharyya I, Nair MK: Radiographic evaluation of multicenter study of biopsies at the periapical area: identification of
periapical lesions with and without biopsy-proven actinomyces: a pi- cases of nonendodontic periapical lesions, J Endod 46:490-495, 2020.
lot study, Quintessence Int 42:301-306, 2011.
Meirinhos J, Martins J, Pereira B, et al: Prevalence of lateral radiolucency,
apical root resorption and periapical lesions in Portuguese patients: a

t.me/Dr_Mouayyad_AlbtousH
5
Mixed Radiolucent-Radiopaque Lesion
(Cemento-Ossifying Fibroma)
S A R A N A DA a n d DA NIE L L E C U N N I N G H A M

CC
A 38-year-old female is referred for evaluation of a mandibular
lesion. She states, “I have a tumor in my lower jaw.”

Cemento-Ossifying Fibroma
In the most recent World Health Organization (WHO) 2022
classification, cemento-ossifying fibroma (COF) is a neoplasm
under odontogenic tumors of mesenchymal origin. The word
cementum in COF is used to emphasize on its odontogenic origin
because it suggestively arises from the periodontal tissue. Accord-
ingly, COF mostly occurs in tooth-bearing areas with the mandible
being the most affected arch, particularly the premolar–molar
region. COFs are reported to have a distinct female predilection
and tend to occur in the second to fourth decades of life.

HPI
Approximately 3 years earlier, the patient noticed a painless bony
expansion in the posterior mandible. (COF is usually a painless, • Fig. 5.1 Intraoral photograph showing buccal expansion in the man-
slow-growing lesion of gnathic occurrence consistent with the dibular posterior area with the teeth displaced lingually and encroaching
posterior mandibular arch.) The patient stated that the swelling on the tongue space.
had been slowly enlarging over the past 3 years and that she was
previously scared to seek treatment. As the mass enlarged, it
started to interfere with function (chewing and talking), so the shows that the mental nerve distributions are intact bilaterally.
patient was encouraged to pursue treatment. (COFs that are left (Perineural invasion is not seen with ossifying fibroma.)
untreated can become very large.) Neck. No lymphadenopathy is noted. (Cervical lymphade-
nopathy is not seen in benign neoplastic processes.)
PMHX/PDHX/Medications/Allergies/SH/FH Intraoral. There is a considerable amount of bony expansion,
more evident on the buccal aspect of the posterior mandible, caus-
Noncontributory. ing lingual displacement of the posterior teeth and encroaching on
the tongue space (Fig. 5.1). (Larger lesions may cause tooth dis-
Examination placement and root divergence, resorption, or both.) The overlying
attached gingiva and mucosa are normal in appearance. (Mucosal
General. The patient is well developed and well nourished and in ulcerations can be a sign of a malignant process; however, traumatic
no apparent distress. ulcerations can occur within large, expansible, benign lesions.)
Maxillofacial. There is a noticeable enlargement of the poste-
rior mandible. A firm, bony mass is palpable extending from the Imaging
distal aspect of the lower left second premolar till the mesial as-
pect of the lower left second molar. The mass has expanded the A panoramic radiograph is a good initial screening. It does pro-
buccal and inferior cortices. (“Downward bowing” is common in vide an overview of the bony anatomy and architecture of the
large ossifying fibromas of the mandible.) Sensory examination maxilla and mandible. Osseous lesions are well characterized on a

21
t.me/Dr_Mouayyad_AlbtousH
22 S E C TI O N Oral and Maxillofacial Radiology

panoramic film, allowing the clinician to make a working differ-

ential diagnosis based on the lesion’s location, radiodensity, locu-
lar or trabecular pattern, border demarcation, size, and effect on
adjacent structures (i.e., root resorption, root divergence, scallop-
ing, cortical expansion, cortical erosion, or destruction). How-
ever, it lacks the buccolingual dimension and may be influenced
by magnification or distortion, as well as superimposition. This is
why cone-beam computed tomography (CBCT) is the imaging
modality of choice in this case to accurately assess the extent of
buccal and lingual expansion and provide accurate measurements • Fig. 5.2 Cone-beam computed tomography reconstructed panoramic
radiograph showing the mixed hyper- and hypodense lesion in the lower
of the lesion’s size and extensions, as well as the relation to vital left premolar molar area. The nerve tracing in red denotes the downward
structures (which is the inferior alveolar canal [IAC] in this par- displacement of the inferior alveolar canal.
ticular case). CBCT is exceedingly common in the office and of-
fers a great deal of information regarding the nature of the mass.
However, when there are radiographic signs of a malignant pro- separates the lesion from the surrounding bone. The lesion causes
cess (e.g., poorly defined radiolucency, mottled or “moth-eaten” concentric buccolingual expansion favoring the buccal cortex and
appearance, unilateral widening of the periodontal ligament causing thinning of both cortices. There is also an evident down-
space, floating teeth, cortical perforation, or “spiked roots”), CT ward displacement in the IAC (Figs. 5.2 and 5.3).
of the neck is also required to assess the nodal involvement, which
can help in tumor staging and indicate if there are any extensions Labs
into the surrounding soft tissue. CT provides additional informa-
tion (e.g., lingual or buccal cortex thinning or perforation, loca- There is one reported case in the literature that showed markedly
tion of the IAC) and is especially useful when the lesion is difficult high levels of serum parathyroid hormone. The exact reason was
to assess on plain films. A three-dimensional printed stereolitho- not mentioned in the reported case; we suggest that it may related
graphic model is useful to prebend a reconstruction plate in an- to the osseous calcifications.
ticipation of resection. It can also be used in surgery simulation Baseline hemoglobin and hematocrit levels can be obtained
and practice, identification of the incision lines, and osteotomy before tumor resection. No other laboratory tests are indicated
planes. This helps decreasing the surgery time and maximizing the unless dictated by the medical history.
patient’s standard of care.
The internal structure of ossifying fibroma varies, depending on Differential Diagnosis
the degree of maturity of the lesion. Early ossifying fibromas are
radiolucent, typically encapsulated at this point because they en- The differential diagnosis of COF includes mainly the mixed ra-
large in bone, and as they mature, they become mixed radiolucent– diolucent–radiopaque lesions. However, it is often challenging to
radiopaque and may eventually become predominantly radiopaque. differentiate COF, particularly from fibrous dysplasia (FD). Ra-
Untreated, these tumors are likely to reach large proportions as they diologic assessment plays a viable role in differentiation, in which
continue to grow. When the tumors become larger, they lose their COF shows more concentric expansion with a clear epicenter, but
encapsulation and invade for a few millimeters. FD has a fusiform to oval pattern of expansion. On the other
In this patient, the CBCT-reconstructed panorama, sagittal, hand, COF can be separated from the surrounding bone “shell
and serial cross-sectional images show a well-defined unilocular out”; on the contrary, FD tends to have a blending outline. Ad-
mixed hyper- and hypodense lesion (predominantly hyperdense ditionally, the internal structure and degree of mineralization are
with radiodensity close to that of teeth). The lesion extends me- more heterogenous in COF, in which FD shows a more homog-
siodistally from the distal aspect of the lower left second premolar enous pattern throughout the lesion. Regarding the effect on
to the mesial aspect of the lower left second molar and occluso- surrounding vital structures, whereas COF causes downward
gingivally from the alveolar crest to near the inferior mandibular displacement of the IAC, FD causes a pathognomonic upward
cortex. A radiolucent rim more expressed in the sagittal cut displacement. Another challenge is differentiating COF from

A B
• Fig. 5.3 A, Cone-beam computed tomography (CBCT) sagittal cut showing a faint radiolucent rim sur-
rounding the lesion denoting that the lesion is encapsulated. B, CBCT serial cross-sectional cuts showing
the concentric expansion with thinning of the buccal and lingual cortices.

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 CHAPTER 5 Mixed Radiolucent-Radiopaque Lesion (Cemento-Ossifying Fibroma) 23

• BOX 5.1 Mixed Radiolucent-Radiopaque Lesions

• Fibrous dysplasia—This lesion, which has a higher occurrence in younger • Osteomyelitis, osteoradionecrosis, and bisphosphonate-induced os-
patients, presents with a typical “ground glass” appearance on radiographs teonecrosis of the jaws—These three pathophysiologically distinct enti-
and a “Chinese script writing” appearance on histologic examination. It can ties can have a mixed radiolucent–radiopaque appearance (see the respec-
affect one (monostotic) or more (polyostotic) bones in the body. Monostotic tive sections for further details).
fibrous dysplasia is more common, and the jaws are the most common site. • Osteoblastomas—These are benign tumors of bone that typically present
• Cemento-osseous dysplasias (COD; periapical, focal, and florid)— in the second and early third decades of life, causing local expansion. The
These lesions are the most common type of fibro-osseous lesions. They de- key feature of this lesion that differentiates it from an ossifying fibroma is
velop in tooth-bearing areas of the jaws and are categorized into three the presence of pain. This tumor, which exhibits slow growth, is the result
groups (periapical, focal, and florid) based on their clinical and radiographic of a genetic alteration during osteoblastic differentiation. Radiographically,
features. Periapical cementoosseous dysplasia has a 14:1 female:male pre- the tumor is usually well circumscribed and can be treated by local resec-
dilection and occurs mostly in African Americans between the third and fifth tion with 5-mm margins. Osteoid osteoma and juvenile active ossifying fi-
decades of life. Focal COD also has a high female predilection (4:1) but is broma may be variants of this lesion.
seen mostly in Whites. Florid CODs occur mostly in African American adult • Calcifying odontogenic cyst (Gorlin cyst)—This lesion is more likely to
females. In each case, early lesions appear radiolucent (fibroblastic prolifer- occur in females than in males (2:1). It initially appears radiolucent but with
ation stage), and in later stages, the lesions become mixed and subse- maturation becomes mixed radiolucent–radiopaque. It is generally asymp-
quently radiopaque as bone and cementum-like materials are deposited. tomatic and may cause expansion as it enlarges. It has a predilection for
• Paget’s disease of bone (osteitis deformans)—In general, this disease the maxilla but can also occur in the mandible. Histologic examination
affects older patients (older than 40 years) and has a 2:1 male:female pre- shows “ghost cells.”
dilection. It is characterized by haphazard and abnormal bone resorption • Other—Adenomatoid odontogenic tumor (or cyst), calcifying epithelial
and deposition, causing bony expansion and bone pain (most cases are odontogenic tumor, ameloblastic fibro-odontoma, odontoma, and cemento-
polyostotic). Radiographically, the lesion appears similar to COD and is de- blastoma also present as well-demarcated, mixed radiolucent–radiopaque
scribed as having a “cotton wool” appearance (which is also seen in Gard- lesions.
ner syndrome and gigantiform cementoma).

cemento-osseous dysplasia (COD) because they can be histologi- Treatment

cally indistinguishable. The unifocal, regular pattern of COF is a
radiologic key of differentiation in which COD tends to be mul- Treatment varies, depending on the size and clinical appearance of
tifocal, irregular in appearance, and considered as an incidental the lesion. Small tumors may be treated with enucleation and
finding. Occasionally, cementoblastoma can be also considered, curettage with 1- to 2-mm margins as long as they have not lost
in which cementum has limitless capability of proliferation; how- their encapsulation and the margins remain well demarcated from
ever, radiologically, cementoblastoma mainly tends to obscure the the surrounding bone. Previously, it was believed that resection
root. Several mixed radiolucent–radiopaque lesions other than an with 5-mm margins was the definitive treatment. However, a re-
ossifying fibroma are listed in Box 5.1. cent review of the literature showed a very low recurrence rate
(6.7%) after curettage only in larger COFs. This appears to be
Biopsy adequate treatment, and it is recommended that a larger resection
be reserved for aggressive and recurrent lesions.
Benign tumors of bone cannot be distinguished on clinical and If enucleation and curettage is used, the defect can be left
radiographic information alone and require histologic assess- open to heal by secondary intent or closed primarily using re-
ment for a definitive diagnosis. In this case, an incisional biopsy sorbable packs to eliminate the dead space. Packing the defect
would be indicated to guide final therapy. This can be done with materials such as iodoform gauze or various bone regenera-
under local intravenous sedation or general anesthesia, depend- tion preparations to expedite bone regeneration has not been
ing on the surgeon’s preference and the medical indications. shown to be effective.
During biopsy, it is imperative to preserve the cortical–lesional When bony reconstruction is required, various techniques
relationship. (immediate or secondary cancellous marrow bone graft or
immediate vascularized free flap) can be used, depending on the
Assessment clinical situation. When cancellous marrow graft is used, sec-
ondary bony reconstruction is recommended at least 3 months
A large, expansile, mixed radiopaque–radiolucent lesion of the mandible. after the resection to allow for sufficient mucosal healing
In this case, upon gross examination, the lesion was well cir- and tensile strength to prevent mucosal perforation and graft
cumscribed, which enables it to be shelled out during surgical exci- contamination.
sion as an intact lesion. Histopathology showed tiny osteoid In this patient, a partial mandibulectomy with 5-mm margins
trabeculae and osteoblasts in addition to ovoid calcifying cement- was performed, with immediate stabilization using a prebent re-
icle-like structures in fibrous tissue stroma with varying amounts construction plate. Immediate bony reconstruction (cancellous
and sizes throughout the lesion. (COF usually shows a heteroge- marrow bone graft) would not be recommended in this case
nous pattern of calcification.) The lesion was encapsulated with a because the resection involved a dentate segment that would allow
thin layer of fibrous tissue that separated it from the surrounding oral contaminates to penetrate the graft site. Second-stage bony
native bone. (COF is usually encapsulated.) The absence of necro- reconstruction was performed after 3 months of adequate soft
sis or any mitotic activity denotes the benign nature. Radiographic, tissue healing. Although recurrence is unlikely, the patient should
clinical, history, and histopathologic findings are consistent with be followed for at least 10 years with serial CT scans because of
an ossifying fibroma. the slow-growing nature of this lesion.

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24 S E C TI O N Oral and Maxillofacial Radiology

Complications is more descriptive. Thus COF was considered as a separate entity in

benign odontogenic tumor of mesenchymal origin as well as an
With proper treatment, the prognosis for COF is excellent, and odontogenic variant of ossifying fibroma. With this classification,
recurrence is rare. The potential complications generally reflect the COF was clearly distinguished from OFs that are non-odontogenic
presenting size of the lesion. Smaller lesions often can be treated by in origin such as juvenile trabecular ossifying fibroma (JTOF) and
enucleation and curettage without complications. Larger lesions juvenile psammomatoid ossifying fibroma (JPOF). In the most re-
requiring resection and reconstruction have the potential for more cent WHO classification (fifth edition) in 2022, COF has become
complex complications (e.g., wound dehiscence, wound infection, an integral part of benign odontogenic tumors of mesenchymal ori-
hardware failure, graft failure, facial or trigeminal nerve injury, gin and is completely separated from non-odontogenic JTOF and
cosmetic deformity). In particular, reconstruction of a continuity POF (renamed POF instead of JPOF) that are currently individually
defect of the anterior mandible is challenging. discussed under the fibro-osseous tumors and dysplasia.
Comparing these three entities, they all show different clinical
Discussion presentation. COF has an exclusive gnathic occurrence in the
tooth-bearing area of the lower jaw predominantly in females
The terms COF and OF have been confusing and used interchange- from the second to fourth decade. JTOF occurs in a younger
ably for years. In the first WHO classification, they were both sepa- teenage population with a male predilection and favoring the up-
rate entities, and OF was considered as an osteogenic neoplasm, but per arch. Finally, POF occurs in children and young male adults
COF was a type of cementoma. However, in the second edition, in the sinonasal area with a locally aggressive presentation and a
both lesions were named COF. Then in 2005 with the third edition, higher rate of recurrence than JTOF. There have been case reports
the terminology changed again, and all the COFs were considered of a juvenile ossifying fibroma undergoing malignant transforma-
OFs considering that bone and cementum are almost histologically tion to a fibroblastic osteosarcoma.
the same and can only be differentiated by their relation to teeth
roots. Because ossifying fibromas agreeably arise in tooth-bearing ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
sites, in the fourth edition, there was a consensus that the term COF complete set of bibliography.

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 24.e1

Bibliography Parham DM, Bridge JA, Lukacs JL, et al: Cytogenetic distinction among
benign fibro-osseous lesions of bone in children and adolescents: value
of karyotypic findings in differential diagnosis, Pediatr Dev Pathol
Abrams AM, Melrose RJ: Fibro-osseous lesion, J Oral Pathol 4:158-165, 7:148, 2004.
1975. Reichart PA, Philipsen HP, Sciubba JJ: The new classification of head and
Barnes L, Eveson JW, Reichart P, et al (eds): Pathology and genetics: head neck tumours (WHO)—any changes? Oral Oncol 8(42):757-758,
and neck tumors (IARC World Health Organization classification of tu- 2006.
mors), Lyon, France, 2005, IARC Press, pp 319-322. Said AL, Surwillo E: Florid osseous dysplasia of the mandible: report of
Barrios-Garay K, Agudelo-Sánchez L, Aguirre-Urizar J, et al: Analyses of a case, Compendium 20:1017-1030, 1999.
odontogenic tumours: the most recent classification proposed by the Sciubba JJ, Younai F: Ossifying fibroma of the mandible and maxilla:
World Health Organization (2017), Med Oral Patol Oral Cir Bucal review of 18 cases, J Oral Pathol Med 18:315-321, 1989.
25(6):e732, 2020. Seifert G, Brocheriou C, Cardesa A, et al: WHO international histologi-
Brannon RB, Fowler CB: Benign fibro-osseous lesions: a review of cur- cal classification of tumours tentative histological classification of
rent concepts, Adv Anat Pathol 8:126-143, 2001. salivary gland tumours, Pathol Res Pract 186(5):555-581, 1990.
El-Naggar AK, Chan JKC, Takata T, et al: The fourth edition of the head Sissons HA, Steiner GC, Dorfman HD: Calcified spherules in fibro-os-
and neck World Health Organization blue book: editors’ perspectives, seous lesions of bone, Arch Pathol Lab Med 117:284-290, 1993.
Hum Pathol 66:10-12, 2017. Speight PM, Takata T: New tumour entities in the 4th edition of the
Eversole LR: Craniofacial fibrous dysplasia and ossifying fibroma, Oral World Health Organization Classification of Head and Neck Tu-
Maxillofac Surg Clin North Am 9:625-642, 1997. mours: odontogenic and maxillofacial bone tumours, Virchows Arch
Eversole LR, Leider AS, Nelson K: Ossifying fibroma: a clinicopathologic 472:331-339, 2018.
study of sixty-four cases, Oral Surg Oral Med Oral Pathol 60:505-511, Su L, Weathers SD, Waldron CA: Distinguishing features of focal ce-
1985. mento-osseous dysplasias and cemento-ossifying fibromas. I. A patho-
Eversole LR, Merrell PW, Strub D: Radiographic characteristics of cen- logic spectrum of 316 cases, Oral Surg Oral Med Oral Pathol Oral
tral ossifying fibroma, Oral Surg Oral Med Oral Pathol 59:522-527, Radiol Endod 84:301-309, 1997.
1985. Summerlin D, Tomich C: Focal cemento-osseous dysplasia: a clinico-
Eversole LR, Sabes WR, Rovin S: Fibrous dysplasia: a nosologic problem pathologic study of 221 cases, Oral Surg Oral Med Oral Pathol 78:
in the diagnosis of fibro-osseous lesions of the jaws, J Oral Pathol 611-620, 1994.
1:189-220, 1972. Titinchi F, Morkel J: Ossifying fibroma: analysis of treatment methods
Fechner RE: Problematic lesions of the craniofacial bones, Am J Surg and recurrence patterns, J Oral Maxillofac Surg, 74(12):2409-2419,
Pathol 13(Suppl 1):17-30, 1989. 2016.
Jih MK, Kim JS: Three types of ossifying fibroma: a report of 4 cases with Vered M, Wright JM: Update from the 5th Edition of the World Health
an analysis of CBCT features, Imaging Sci Dent 50(1):65, 2020. Organization classification of head and neck tumors: odontogenic and
Kramer IRH, Pindborg JJ, Shear M (eds): Histological typing of odonto- maxillofacial bone tumours, Head Neck Pathol 16(1):63-75, 2022.
genic tumors. In WHO international histological classification of tumors, Waldron C, Giansanti J: Benign fibro-osseous lesions of the jaws: a
ed 2, Geneva, 1992, WHO, pp 27-29. clinical-radiologic-histologic review of sixty-five cases. II. Benign fi-
Manon, VA, Chow C, Vigneswaran N, et al: Malignant transformation of bro-osseous lesions of periodontal ligament origin, Oral Surg Oral
ossifying fibroma to juvenile aggressive ossifying fibroma to fibroblastic Med Oral Pathol 35:340-350, 1973.
osteosarcoma: a case report, J Oral Maxillofac Surg 79(10):E54-E55, Waldron C: Fibro-osseous lesions of the jaws, J Oral Maxillofac Surg 51:
2021. 828-835, 1993.
Marx RE, Stern D: Oral and maxillofacial pathology: a rationale for diag- Wenig B: Atlas of head and neck pathology, Philadelphia, 1993, Saunders.
nosis and treatment, Chicago, 2003, Quintessence. Williams HK, Mangham C, Speight PM: Juvenile ossifying fibroma: an
Nagar SR, Mittal N, Rane SU, et al: Ossifying fibromas of the head and analysis of eight cases and a comparison with other fibro-osseous le-
neck region: a clinicopathological study of 45 cases, Head Neck Pathol sions, J Oral Pathol Med 29:13, 2000.
16(1):248-256, 2022. Wright JM, Vered M: Update from the 4th edition of the World Health
Nguyen S, Hamel MA, Chénard-Roy J, et al: Juvenile psammomatoid Organization classification of head and neck tumours: odontogenic
ossifying fibroma: a radiolucent lesion to suspect preoperatively, Ra- and maxillofacial bone tumors, Head Neck Pathol 11:68-77, 2017.
diol Case Rep 14(8):1014-1020, 2019.

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6
Cone-Beam Computed Tomography
C L A IR E M I L L S , PI YU SH K U M A R PAT E L , a n d M AYO O R PAT E L

CC
population. Approximately 60% to 85% of these impactions are
A 14-year-old female is referred for exposure and bracketing of palatal. Impacted canines are seen more commonly in females.
her impacted canines.
Imaging
HPI
Panoramic imaging revealed that teeth #6 and #11 were impacted
The patient’s parent states that she had her primary canines re- and in close association with the adjacent lateral incisors (Fig. 6.1).
moved at a younger age, with subsequent failure of her permanent The third molars, also present, were full bone impactions. Given
canines to erupt. Her orthodontist has recommended exposure these findings, the risks and benefits of additional imaging were
and bracketing of the impacted canines to facilitate correct erup- discussed with the patient’s parents, who agreed to a cone-beam
tion and to avoid possible root resorption of her adjacent lateral computed tomography (CBCT) scan to evaluate the maxillary
incisors. The patient is otherwise asymptomatic. canines (Fig. 6.2).
In approximately 38% to 67% of cases, impacted canines can
PMHX/PDHX/Medications/Allergies/SH/FH cause varying degrees of resorption of adjacent teeth, especially the
lateral incisor. Root resorption can be difficult to diagnose with tra-
Noncontributory. ditional two-dimensional (2D) radiography, especially when the ca-
nine is in a direct palatal or facial position to the lateral incisor roots.
Examination Two-dimensional imaging for surgical or orthodontic plan-
ning has several limitations, such as image magnification and
General. The patient is well developed, well nourished, and in no distortion, superimposition of structures, and misinterpretation.
apparent distress. Three-dimensional (3D) imaging allows the surgeon to determine
Intraoral. Teeth #6 and #11 are not visible in the mouth. the best clinical approach and reduces the invasiveness of surgery.
There is a questionable bulge of the maxillary anterior palate on Additionally, it allows the orthodontist to determine what orth-
the left and right sides; however, definitive localization of the odontic force vector should be applied to move the canine effi-
impacted canines by palpation is not readily apparent. ciently, thus reducing involvement of adjacent teeth.
Maxillary canines are the second most frequently impacted CBCT offers a 3D view that can provide more accurate
teeth, after the third molars. The prevalence is 1% to 3% of the information about the size, shape, angulation, associated

R L

• Fig. 6.1 Preoperative panoramic view showing impacted teeth #6 and #11. Note the close association
with the adjacent lateral incisors.

25
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26 S E C TI O N Oral and Maxillofacial Radiology

A B

C D
• Fig. 6.2 Axial view (A) and cone-beam computed tomography reconstruction (B–D) with different-col-
ored masks assigned to the different anatomic structures in the field of view. Segmentation of the adjacent
anatomy allows a better appreciation of the region of interest.

pathology (cysts, tumors, resorption of adjacent teeth), and understand the anatomic configuration of her problem; this in
relationship to adjacent structures (inferior alveolar nerve turn facilitated discussion of the procedure and its risks and ben-
canal, sinus). CBCT software allows anatomic entities in the efits with the patient and her parents. Subsequently, the impacted
3D image to be differentiated by assigning each a color canines were exposed and bracketed without incident in a stan-
(known as a mask). The masks can be turned off, allowing the dard fashion. (See Chapter 28.)
clinician a better appreciation of the anatomy. This type of
reconstruction can be time-consuming, but it can be referred Complications
to third-party companies.
Clinicians must abide by the “as low as reasonably achievable”
Assessment principle when ordering an imaging modality for a patient. Ex-
posing the patient to the radiation must provide an image with a
Impacted maxillary canines needing surgically assisted exposure and diagnostic value that is greater than the detriment the radiation
bracketing for orthodontic correction. exposure may cause. Not every patient requires CBCT because
the technique does expose the patient to radiation and results in
Treatment increased cost. The American Dental Association Council on
Scientific Affairs suggests that CBCT use should be based on
The precise location of the maxillary canines was determined. No professional judgment, and clinicians must optimize technical
readily apparent resorption of the lateral incisors was noted. (It is factors, such as using the smallest FOV possible for diagnostic
possible to underestimate root resorption, owing to inadequate purposes and using appropriate personal protective shielding.
visualization secondary to the limitations of CBCT, such as select- Although there was a sixfold increase in medical radiation ex-
ing a large field of view [FOV], which diminishes the resolution posure between 1980 and 2006 in the United States, radiation
of the image.) The 3D reconstruction served two important exposure per capita decreased 20% between 2006 and 2016.
purposes. It allowed the surgeon to easily appreciate the anatomy, However, ionizing radiation is also found in the natural environ-
and it also provided a visual aid that enabled the patient to easily ment in the form of cosmic rays or radon, which contributes to

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 CHAPTER 6 Cone-Beam Computed Tomography 27

overall exposure. At doses used in diagnostic and interventional fractures, canal identification, characterizing internal and exter-
procedures, ionizing radiation may cause DNA damage and in- nal resorption, facilitating apical surgery, and assessing out-
crease the risk for future cancer. The probability of effects arising comes of root canal treatment. In orthodontics, CBCT can be
from ionizing radiation (e.g., future cancer, cataracts) is a function used to evaluate the shape and function of the maxillofacial
of the total radiation dose, although the severity of such effects is complex, and it provides a powerful tool for the visualization of
also influenced by other factors, such as genetics. The linear no- root angulations.
threshold (LNT) model is the most widely used theoretical dose– Adjacent anatomy outside the region of interest is usually cap-
response model that assumes that any exposure to ionizing radia- tured with CBCT. Given the volume of tissue that is exposed and
tion can induce future cancer. However, the accuracy of the model readily available for review, there is a moral, ethical, and legal re-
has been called into question recently. This model proposes that sponsibility attached to the interpretation of the volumetric data
there is no threshold dose for radiation-induced cancer, and a set. Because of the complexity of the anatomy of the maxillofacial
small dose (0.1 mSv) is associated with an increased cancer risk. area, review of the images by an appropriately trained practitioner
The most credible studies comparing radiation dose–response is prudent.
with carcinogenesis mainly involve doses of 1 Sv or less, which are Computed tomographic scanners consist of an x-ray source
magnitudes greater than those encountered in diagnostic imaging. and detector mounted on a rotating gantry. A divergent cone-
How the LNT model applies to low-dose radiation exposure is shaped source of radiation is directed through a defined region of
still unclear and requires further investigation. interest (ROI) while the residual attenuated radiation beam is
The concentration of ionizing radiation in a specific volume of projected onto an area x-ray detector on the opposite side. The
air is a measure of radiation exposure and is expressed in roent- x-ray source and detector rotate around the rotation center within
gens (R). The amount of radiation absorbed by a specific tissue is the center of the ROI. The detector records the residual x-rays
measured in grays (Gy) or rads. The effective dose is measured in after attenuation by the patient’s tissues, which is known as the
sieverts (Sv) (1 Sv 5 1000 mSv 5 1,000,000 mSv), which pro- raw data. These raw data are reconstructed by a computer algo-
vides a quantification of the potential radiobiologic detriment rithm to generate a volumetric data set that can be used to provide
caused by radiation and takes into account tissue-weighting fac- primary reconstruction images into the three orthogonal planes:
tors defined by the International Commission on Radiological axial, sagittal, and coronal.
Protection (IRCP). Calculating the effective dose allows for com- The most common algorithm for reconstructing 3D objects
parison across different imaging modalities and from partial and (cone-beam reconstruction) from cone-beam projections is the
whole-body exposure. The IRCP estimates a 4% to 5% increased Feldkamp, Davis, and Kress (FDK) method, which is used by
relative risk of fatal cancer after an average person receives a many research groups and commercial vendors. This algorithm
whole-body radiation dose of 1 Sv. Some models predict that 1 in has some limitations, such as distortion in the noncentral trans-
1000 persons exposed to 10 mSv (10,000 mSv) will develop can- verse plane, resolution degradation in the longitudinal direction,
cer as a result of that single exposure. and a high computational time required to perform reconstruc-
For comparison purposes, consider the following estimated tions. To address these problems, other algorithms and cone-beam
effective doses: geometries are being developed that will likely be incorporated
• Single chest x-ray: 0.1 mSv into future machines. One such algorithm is the Neural Network
• United States coast-to-coast roundtrip flight: 0.03 mSv Feldkamp-Davis-Kress (NN-FDK) method. This algorithm uses
• Annual individual radiation dose from the natural back- machine learning to improve reconstruction accuracy and compu-
ground: 3 mSv tational efficiency even in cases with high-noise, low projection
• Intraoral radiograph: 0.043 mSv (43 mSv) angles, and large cone angles.
• Computed tomography (CT) scan of the head and neck: Gaêta-Araujo et al. describe the features of 279 currently and
1.4 mSv formerly available CBCT models in 2020 as well as a recom-
• CT scan of the chest: 5.4 mSv mended CBCT feature standardization method.
• CT angiography (noncardiac): 5.4 mSv
• CBCT (maxillofacial, standard settings): 0.176 mSv Discussion
The radiation risk with many newer CBCT machines is lower
than that for the most common intraoral full mouth series; there- Dedicated CBCT of the maxillofacial region has created a revolu-
fore, it may be possible, when indicated, to use CBCT with select tion in all fields of dentistry and has expanded the role of imaging
intraoral images as an option for dental treatment planning in the from diagnosis to image guidance for many surgical procedures.
future. CBCT has eliminated some of the inherent limitations of 2D im-
Currently, the results for the use of CBCT for caries detection ages, such as magnification, distortion, superimposition, and
are mixed. CBCT for this purpose is limited to nonrestored teeth misrepresentation.
and may be used diagnostically for occlusal caries and deep lesions CBCT uses a cone beam–shaped source of ionizing radia-
into the dentin. Because of beam hardening, CBCT for caries tion, and the beam is directed through the middle of the area of
detection has a high sensitivity. For periodontics, CBCT promises interest (FOV). The beam covers the entire FOV; therefore, only
to be superior to 2D imaging for the visualization of bone topog- one rotation of the gantry is required. Traditional medical CT
raphy and lesion architecture (intrabony defects and furcations) uses a fan-shaped beam to acquire individual image slices (each
and measurement of alveolar crest height, but defect width, slice requires a separate scan), which are then stacked to obtain
depth, and type (vertical vs horizontal defects) were similar in a 3D representation. CBCT usually results in a lower dose of
both CBCT and 2D imaging methods. Restorations within the radiation than CT, but doses vary widely among different sys-
dentition can obscure views of the alveolar crest. tems and among different imaging protocols (slice thickness,
CBCT for endodontic is gaining in popularity. It has been FOV, mAs, kVp, scan time). It is recommended that clinicians
shown to be useful for detecting apical lesions and root use appropriate selection criteria, along with imaging protocols

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TABLE
6.1 Summary of Key Advantages and Limitations of Cone-Beam Computed Tomography

Advantages Disadvantages and Limitations

Equipment has a smaller physical footprint than conventional CT equipment. Artifacts
Considerably cheaper than conventional CT. 1. X-ray beam artifacts: Beam hardening, which results in two types of
Rapid scan time: All projection images are acquired in a single rotation. artifacts:
Collimation limits radiation to the area of interest. In some machines, the FOV a. Distortion of metallic structures as a result of differential absorp-
can be adjusted to engage only the area of interest, further limiting the dose. tion; this is known as a cupping artifact
Superior image accuracy: Submillimeter isotropic voxel resolution ranges from b. Streaks and dark bands that can appear between two dense ob-
0.4 to 0.076 mm. jects (e.g., a dark band around an amalgam restoration, which can
Reduced patient radiation dose: Depending on the FOV and CBCT model, the be mistaken for recurrent caries)
dose can range from 29 to 477 mSv. (The dose for conventional CT for Limiting the FOV and separating the arches are some techniques that can
maxillofacial imaging is 2000 mSv.) be used to scan regions susceptible to beam hardening.
Interactive display modes, such as cursor-driven measurement algorithms, 2. Patient-related artifacts (e.g., patient motion): These can be mini-
provide the clinician with on-screen interaction free of distortion and mized by using a head restraint and short scan time. The presence of
magnification. dental restorations or jewelry can lead to severe streaking artifacts as
From the volumetric data set, distortion-free additional images can be gener- a result of beam hardening or of photon starvation (insufficient pho-
ated, such as panoramic and cephalometric images. tons reaching the detector).
3D volume rendering can be achieved by either indirect or direct volume ren- 3. Scanner-related artifacts: These present as circular artifacts and are
dering methods. usually caused by imperfect scanner detection or poor calibration.
Multimodal imaging devices are available. These can provide conventional 4. Cone beam–related artifacts: These include partial volume averaging
panoramic, cephalometric, and CBCT images. and undersampling.
Sophisticated third-party software is continuously being developed and Image noise: This is caused by scattered radiation. The scatter-to-primary
updated using data generated by CBCT. The capabilities of such soft- ratios are 0.05–0.15 for fan-beam and spiral CT and may be as large
ware usually exceed software supplied by CBCT machines. To use this as 0.4–2 in CBCT (i.e., CBCT appears grainier).
software, the volumetric data are exported from the CBCT manufactur- Poor soft tissue contrast: This is caused by the scattered radiation and
er’s software as a DICOM data set and imported into the third-party detector-based artifacts. Newer techniques and devices may improve this.
software. Currently, Hounsfield units cannot be used to assess density information reliably.

CBCT, Cone-beam computed tomography; DICOM, digital imaging and communication in medicine; FOV, field of view; 3D, three-dimensional.

that use the minimal doses that ensure acceptable diagnostic rotation, and the completeness of the trajectory arc. Most
qualities (Table 6.1). CBCT machines scan for a full 360 degrees to acquire pro-
CBCT image production requires four components. jection data. However, some machines limit the scanning
1. Acquisition configuration arc, thus reducing the time, radiation dose, and mechanical
a. X-ray generation: A pulsed or constant beam of radiation components required. The disadvantages of this approach
can be used. This is one of the reasons for variation in cone- are greater noise and a higher possibility of artifacts.
beam dosimetry between different units. It is preferable to 2. Image detection
use a pulsed beam of radiation because the actual exposure Current CBCT machines can be divided into two groups
time is up to 50% less than scanning time, which reduces based on the detector type: image intensifier tube/charge-
patient radiation. coupled device or flat panel imager. The flat panel imager,
b. FOV (also known as scan volume): This depends on the used by most CBCT units, is thought to create less distor-
detector size and shape (cylindrical or spherical), beam tion and have fewer artifacts. Flat panel performance limi-
projection geometry, and the ability to collimate the beam. tations are most noticeable at lower and higher exposures.
CBCT can be categorized by the available FOV, which 3. Image reconstruction
usually ranges from 4 to 30 cm. The larger the FOV, the The projection data must be reconstructed to create a usable volu-
poorer the resolution. There are methods to enable scan- metric data set. This is computationally complex and can in-
ning a region of interest greater than the FOV, including volve two computers (an acquisition computer and a process-
obtaining and overlapping two separate scans using refer- ing [workstation] computer). This phase is divided into two
ence landmarks or increasing the height or width of the stages: the acquisition stage (usually 160–600 basis images are
FOV with a small area detector, collimating the beam collected) and the reconstruction stage (in which algorithms
asymmetrically, and scanning only half the patient’s ROI such as the FDK algorithm are used to recombine the data for
in two scans. visualization). When analyzing anatomic structures that are
c. Scan factors: During the scan, single exposures (known as not well visualized and represented in orthogonal planes, such
basis, frame, or raw images) are made. (These are similar to as in the mandibular condyle, oblique reformatting can be
the lateral view of posteroanterior cephalometric images.) used. In addition, panoramic multiplanar reformation recon-
The complete series is known as projection data. The number structions can be useful for jaw evaluation because they are
of images comprising a projection data set is determined by familiar to clinicians and are free of distortions.
the frame rate (i.e., the number of images acquired per sec- 4. Image display
ond; a faster frame rate results in better image quality, but it The data set is presented to the clinician usually in three orthogo-
also exposes the patient to more radiation), the speed of nal planes (axial, sagittal, and coronal). It is recommended for

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 6 Cone-Beam Computed Tomography 29

clinicians to review each series of orthogonal images called • CBCT should be considered as the imaging modality of choice for
stacks craniocaudally and then in reverse in both the coronal the preoperative cross-sectional imaging of potential implant sites.
and axial planes. This approach of using stacks is beneficial • CBCT is also considered when the initial examination indicates
because there are many component orthogonal images in each the need for site development (e.g., block grafting, sinus lifting).
plane, and it would be impractical to display all the slices on a • CBCT should be considered for evaluating the results of site
single display format. development (if bone augmentation procedures were per-
CBCT is most widely used for implant planning. The American formed before implant placement). In the absence of clinical
Academy of Oral and Maxillofacial Radiology advocates for the use signs or symptoms, periapical radiographs are appropriate for
of cross-sectional imaging for all dental implant surgeries because it postoperative assessment.
offers significant advantages that impact treatment planning and • CBCT is indicated in the immediate postoperative period if
surgical outcomes. there is altered sensation or implant mobility. CBCT is not
Fusion of the CBCT scan data with 3D clinical data (e.g., indicated for periodic review of asymptomatic implants.
CBCT of a plaster cast, optical scan of the cast, or optical scan of • CBCT should be considered in cases of suspected peri-implantitis
the oral cavity) facilitates the fabrication of surgical guides (with because it superiorly detects peri-implant circumferential, in-
fiducial markers or, more recently, with corresponding anatomic trabony, and fenestration defects but not dehiscence.
points). Fusion is necessary to obtain an accurate guide because of • CBCT can be considered if implant retrieval is anticipated.
the presence of scatter artifact; fusion also allows more accurate In summary, the use of CBCT should be judged based on
visualization of the gingival level. A study comparing guides fab- sound clinical and radiographic parameters. It can provide very
ricated from dental models versus CBCT data found no differ- valuable information for diagnosis and treatment planning. How-
ence in crestal implant location deviation and more accurate an- ever, overzealous use of CBCT can result in unnecessary radiation
gulation in the CBCT guides. exposure and added cost.
If CBCT is used for implant planning, the radiographic ex-
amination of a potential implant site can include cross-sectional ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
imaging: complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 29.e1

Bibliography Palomo L, Palomo JM: Cone beam CT for diagnosis and treatment plan-
ning in trauma cases, Dent Clin North Am 53:717-727, 2009.
American Dental Association Council on Scientific Affairs: The use of Park YS, Ahn JS, Kwon HB, et al: Current status of dental caries diagno-
cone-beam computed tomography in dentistry, JADA 143(8): sis using cone beam computed tomography, Imaging Sci Dent
899-902, 2012. 41(2):43-51, 2011.
Bouwens D, Cevidanes L, Ludlow J, et al: Comparison of mesiodistal Patel S, Brown J, Pimentel T, et al: Cone beam computed tomography in
root angulation with posttreatment panoramic radiographs and cone- endodontics – a review of the literature, Int Endod J 52(8):1138-1152,
beam computed tomography, Am J Orthod Dentofacial Orthop 2019.
139:126-132, 2011. Pauwels R, Beinsberger J, Collaert B, et al: SEDENTEXCT Project
Calabrese E: The linear no-threshold (LNT) dose response model: a Consortium. Effective dose range for dental cone beam computed
comprehensive assessment of its historical and scientific foundations, tomography scanners, Eur J Radiol 81(2):267-272, 2012.
Chem Biol Interact 301:6-25, 2019. Radiology Society of North America: Radiation dose in X-ray and CT
Friedland B, Donoff B, Chenin D: Virtual technologies in dentoalveolar exams. Available from http://www.radiologyinfo.org/en/info/safety-
evaluation and surgery, Atlas Oral Maxillofacial Surg Clin North Am xray. Accessed August 26, 2022.
20:37-52, 2012. Scarfe W, Farman A: What is cone-beam CT and how does it work? Dent
Gaêta-Araujo H, Alzoubi T, Vasconcelos KF, et al: Cone beam computed Clin North Am 52:707-730, 2008.
tomography in dentomaxillofacial radiology: a two-decade overview, The SEDENTEXCT Project: Radiation protection: cone beam CT for
Dentomaxillofac Radiol 49(8):20200145, 2020. dental and maxillofacial radiology: evidence based guidelines 2011
Kim JW, Cha IH, Kim SJ, et al: Which risk factors are associated with (v2.0 Final). Available from www.sedentexct.eu/files/guidelines_final.
neurosensory deficits of inferior alveolar nerve after mandibular third pdf. Accessed July 26, 2013.
molar extraction? J Oral Maxillofac Surg 70(11):2508-2514, 2012. Tyndall D, Price JB, Tetradis S, et al: Position statement of the American
Lagerwerf MJ, Pelt DM, Palenstijn WJ, et al: A computationally efficient Academy of Oral and Maxillofacial Radiology on selection criteria for
reconstruction algorithm for circular cone-beam computed tomogra- the use of radiology in dental implantology with emphasis on cone
phy using shallow neural networks, J Imaging 6(12):135, 2020. beam computed tomography, Oral Surg Oral Med Oral Pathol Oral
Lee C, Elmore J: Radiation related risks of imaging studies. Available Radiol 113:817-826, 2012.
from Wolters Kluwer Health at www.uptodate.com. Accessed January Tyndall D, Rathore S: Cone-beam CT diagnostic applications: caries,
15, 2013. periodontal bone assessment and endodontic applications, Dent Clin
Ludlow JB, Davies-Ludlow LE, White SC: Patient risk related to com- North Am 52:825-841, 2008.
mon dental radiographic examinations: the impact of 2007 Interna- Walter C, Schmidt JC, Rinne CA, et al: Cone beam computed tomogra-
tional Commission on Radiological Protection recommendations re- phy (CBCT) for diagnosis and treatment planning in periodontology:
garding dose calculation, JADA 139(9):1237, 2008. systematic review update, Clin Oral Invest 24(9):2943-2958, 2020.
Meara DJ: Evaluation of third molars: clinical examination and imaging Weber W, Zanzonico P: The controversial linear no-threshold model,
techniques, Atlas Oral Maxillofacial Surg Clin North Am 20:163-168, J Nucl Med 58(1):7-8, 2017.
2012. Weiss R, Read-Fuller A: Cone beam computed tomography in oral and
Oberoi S, Knueppel S: Three-dimensional assessment of impacted ca- maxillofacial surgery: an evidence-based review, Dent J 7(2):52, 2019.
nines and root resorption using cone beam computed tomography, White S, Pharoah MJ: The evolution and application of dental maxillo-
Oral Surg Oral Med Oral Pathol Oral Radiol 113(2):260, 2012. facial imaging modalities, Dent Clin North Am 52:689-705, 2008.
Okano T, Sur J: Radiation dose and protection in dentistry, Jpn Dent Sci White SC, Pharoah MJ: Oral radiology: principles and interpretation,
Rev 6:112-121, 2010. Amsterdam, 2013, Elsevier.

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7
Penicillin Allergy and Anaphylaxis
C L A IR E M I L L S , PI YU SH K U M A R P. PAT E L , a n d S H A H R O K H C . B AG H ER I

CC Examination
A 21-year-old female admitted for treatment of an open man- General. The patient is a well-developed, well-nourished female in
dibular body fracture complains of the sudden appearance of a moderate distress who is sitting up and leaning forward in bed.
rash and shortness of breath after receiving her intravenous (IV) Vital signs. Her blood pressure is 98/60 mm Hg (hypoten-
antibiotics (anaphylaxis is more common with parenteral admin- sion), heart rate is 128 bpm (tachycardia), respirations are
istration of medications). 28 breaths per minute (tachypnea), temperature is 36.7°C,
and Sao2 is 100% on 2 L per nasal cannula.
HPI Neurologic. The patient’s Glasgow Coma Scale score is 15; she
is alert and oriented 33 (place, time, and person).
The patient was admitted that day with a diagnosis of an open Maxillofacial. Examination is consistent with a mandibular
right mandibular body fracture secondary to assault. The patient body fracture.
did not report any known drug allergies (most frequently, Cardiovascular. She is tachycardic at 128 bpm. Her heart rate
patients do not have a previous history), and the admitting and rhythm are regular, with no murmurs, gallops, or rubs.
surgeon ordered IV penicillin G, morphine sulfate, and nothing- Cardiovascular symptoms and signs occur in up to 45% of
by-mouth status in preparation for surgical treatment in the op- anaphylactic episodes; they include hypotonia (collapse),
erating room. Upon arrival of the patient on the hospital ward, syncope, dizziness, tachycardia, and hypotension.
the nursing staff administered the first dose of IV aqueous peni- Pulmonary. The patient has bilateral wheezing. Respiratory
cillin G. Approximately 5 to 10 minutes later, the patient devel- symptoms and signs occur in up to 70% of anaphylactic
oped multiple circumscribed, erythematous, and raised pruritic episodes; they include nasal congestion and discharge, a
wheals on her skin. (Symptoms generally develop within change in voice quality, a sensation of throat closure or
5–60 minutes after exposure; earlier onset is seen with parenteral choking, stridor, shortness of breath, wheezing, and cough.
introduction of the allergen.) The patient also reported feeling Abdominal. The abdomen is soft, tender to palpation (sec-
short of breath and the onset of wheezing (secondary to broncho- ondary to spasm of intestinal smooth muscles), and nondis-
spasm), nausea, and cramping abdominal pain. tended with no rebound tenderness and normal bowel
sound. Gastrointestinal (GI) symptoms and signs occur in
PMHX/PDHX/Medications/Allergies/SH/FH up to 46% of anaphylactic episodes; they include nausea,
vomiting, diarrhea, and crampy abdominal pain.
The patient reports no known drug allergies. She has no history Skin. The patient has urticaria. (Commonly known as “hives,”
of food, environmental, or seasonal allergies. She has no family urticaria consists of circumscribed areas of raised erythema
history of drug allergies. (Multiple drug allergy syndrome is a term and edema of the superficial dermis.) Skin symptoms and
that may be applied to individuals who have experienced allergic signs occur in up to 80% to 90% of anaphylactic episodes;
reactions to two or more non–cross-reacting medications. People they include generalized hives; itching or flushing; swollen
who are allergic to another drug are likely at increased risk of re- lips, tongue, and uvula; periorbital edema; and conjunctival
acting to penicillin. The reasons are not clear, but genetics may swelling.
play a role. Genetics may also play a role in the expression of The clinical presentation of anaphylaxis is variable and may
penicillin allergy between family members; however, currently, include any combination of common signs and symptoms. Ana-
the studies are limited.) phylaxis is underrecognized and undertreated; the goal is early
Anaphylaxis is a serious allergic reaction that is rapid in onset recognition and treatment with epinephrine. Diagnostic criteria
and may cause death. Allergic anaphylaxis involves the produc- were updated by an expert panel in 2020 with the intention of
tion of symptoms via an immunologic mechanism. Nonallergic helping clinicians recognize anaphylaxis.
anaphylaxis (previously known as an anaphylactoid reaction) The World Allergy Organization (WAO) has developed a
produces a very similar clinical syndrome but is not immune poster that presents the key clinical criteria for both the diagnosis
mediated (direct activation of mast cell). Treatment for the two and initial treatment of patients with anaphylaxis (Fig. 7.1). These
conditions is similar. criteria reflect the different clinical presentations; anaphylaxis is

31
t.me/Dr_Mouayyad_AlbtousH
32 S E C TI O N Pharmacology

highly likely when any one of the criteria is met. It was acknowl- previous criteria is the presence of “severe” rather than “persistent”
edged that no single set of criteria can provide 100% sensitivity GI symptoms including abdominal cramping, pain, and repetitive
and specificity, but it is believed that the WAO’s proposed criteria vomiting.
are likely to capture more than 95% of cases of anaphylaxis. The
majority of anaphylactic reactions include skin symptoms, which Imaging
are noted in more than 80% of cases. Thus at least 80% of
anaphylactic reactions should be identified by criterion 1, even In the acute phase of anaphylaxis, no imaging studies are indi-
when the allergic status of the patient and the potential cause of cated. (Any unnecessary delay may compromise other lifesaving
the reaction might be unknown. One significant change to the interventions.)

Anaphylaxis is highly likely when any one of the following three criteria is fulfilled:

Sudden onset of an illness (minutes to several hours), with involvement of the skin, mucosal tissue,
1 or both (e.g. generalized hives, itching or flushing, swollen lips-tongue-uvula)

And at least one

of the following:

Sudden respiratory symptoms Sudden reduced BP or

and signs symptoms of end-organ
(e.g. shortness of breath, wheeze, dysfunction (e.g. hypotonia
cough, stridor, hypoxemia) [collapse], incontinence)

OR 2 Two or more of the following that occur suddenly after exposure to a likely allergen or other trigger* for that
patient (minutes to several hours):

Sudden skin or mucosal Sudden respiratory symptoms Sudden reduced BP or Sudden gastrointestinal
symptoms and signs and signs symptoms of end-organ symptoms (e.g. crampy
(e.g. generalized hives, itch-flush, (e.g. shortness of breath, wheeze, dysfunction (e.g. hypotonia abdominal pain, vomiting)
swollen lips-tongue-uvula) cough, stridor, hypoxemia) [collapse], incontinence)

Reduced blood pressure (BP) after exposure to a known allergen** for that patient
OR 3
(minutes to several hours):

Infants and children: Low systolic BP (age-specific) Adults: Systolic BP of less than 90 mm Hg or greater
or greater than 30% decrease in systolic BP*** than 30% decrease from that person’s baseline

* For example, immunologic but IgE-independent, or non-immunologic (direct mast cell activation)

** For example, after an insect sting, reduced blood pressure might be the only manifestation of anaphylaxis; or,
after allergen immunotherapy, generalized hives might be the only initial manifestation of anaphylaxis.

*** Low systolic blood pressure for children is defined as less than 70 mm Hg from 1 month to 1 year, less than (70 mm Hg 1
[2 3 age]) from 1 to 10 years, and less than 90 mm Hg from 11 to 17 years. Normal heart rate ranges from
80–140 beats/minute at age 1–2 years; from 80–120 beats/minute at age 3 years; and from 70–115 beats/minute after age
3 years. In infants and children, respiratory compromise is more likely than hypotension or shock, and shock is more likely to
be manifest initially by tachycardia than by hypotension.

• Fig. 7.1 A, Clinical criteria for the diagnosis of anaphylaxis.

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 CHAPTER 7 Penicillin Allergy and Anaphylaxis 33

1
Have a written emergency protocol for recognition and treatment of anaphylaxis and rehearse it regularly.

2 Remove exposure to the trigger if possible, e.g. discontinue an intravenous diagnostic or therapeutic agent that
seems to be triggering symptoms.
3
Assess the patient’s circulation, airway, breathing,
mental status, skin, and body weight (mass).

Promptly and simultaneously, perform steps 4, 5 and 6.

4
Call for help: Resuscitation team (hospital) or emergency
medical services (community) if available.
5 Inject epinephrine (adrenaline) intramuscularly in the mid-
anterolateral aspect of the thigh, 0.01 mg/kg of a 1:1,000
(1 mg/mL) solution, maximum of 0.5 mg (adult) or 0.3 mg
(child); record the time of the dose and repeat it in 5–15
minutes, if needed. Most patients respond to 1 or 2 doses.
6
Place patient on the back or in a position of comfort it
there is respiratory distress and/or vomiting; elevate the
lower extremities; fatality can occur within seconds if
patient stands or sits suddenly.

7
02
When indicated, give high-flow supplemental oxygen
(6–8 L/minute), by face mask or oropharyngeal airway.

8
Establish intravenous access using needles or catheters
0.9% with wide-bore cannulae (14–16 gauge). When indicated,
NaCl give 1–2 litres of 0.9% (isotonic) saline rapidly
(e.g. 5–10 mL/kg in the first 5–10 minutes to an adult,
10 mL/kg to a child).

9
When indicated at any time, perform cardiopulmonary
resuscitation with continuous chest compressions.

In addition,
10

At frequent, regular intervals, monitor patient’s blood

pressure, cardiac rate and function, respiratory status,
and oxygenation (monitor continuously, if possible).

• Figure 7.1,cont’d B, Initial treatment of anaphylaxis. (From Cardona, V., Ansotegui, I. J., Ebisawa, M.,
et al. (2020). World Allergy Organization anaphylaxis guidance 2020. The World Allergy Organization
Journal, 13(10), 100472–100472).

Labs Serum tryptase. This peaks 60 to 90 minutes after the onset of ana-
phylaxis and remains elevated for up to 5 hours. Tryptase is a
During an acute anaphylactic episode, no laboratory tests are in- protease specific to mast cell activation. It is the only protein that
dicated. However, after the patient’s condition has been stabilized is concentrated selectively in the secretory granules of human mast
(or if the diagnosis is in question), in addition to a complete cells. Normal levels of either tryptase or histamine do not rule out
blood cell count and comprehensive metabolic panel, the follow- the clinical diagnosis of anaphylaxis. It is recommended to evalu-
ing tests can be obtained: ate serum tryptase at least 24 hours after resolution of symptoms
Plasma histamine level. This is elevated within 5 to 10 minutes from anaphylaxis even if levels did not increase during the episode.
after the onset but remains elevated for only 30 to 60 minutes
because of rapid metabolism. (Histamine is released secondary Assessment
to IgE-mediated mast cell degranulation.)
Urinary N-methyl histamine. A metabolite of histamine, Immediate allergic anaphylactic reaction induced by intravenously
N-methyl histamine remains elevated for several hours. administered penicillin G.
A 24-hour urine sample for N-methyl histamine may be useful. Box 7.1 outlines the differential diagnosis of anaphylactic shock.

t.me/Dr_Mouayyad_AlbtousH
34 S E C TI O N Pharmacology

• BOX 7.1 Differential Diagnosis of Anaphylactic receive 0.05 to 1 mg of 0.1 mg/mL epinephrine solution (further
Shock diluted in 10 mL of normal saline) intravenously over the course
of 1 to 10 minutes. Alternatively, a continuous infusion of 0.1 to
• Anaphylaxis 0.2 mg/kg/minute (8–16 mg/min for an 80-kg patient) of epineph-
A. Anaphylaxis from foods, drugs, insect stings rine (titrated to effect) may be administered. (This is preferred over
B. Anaphylaxis from physical factors (exercise, cold, heat) bolus dosing of epinephrine because bolus dosing is associated
C. Idiopathic (cause undetermined) anaphylaxis with more adverse effects including cardiac arrhythmias). Patients
• Vasodepressor reactions (vasovagal reactions) receiving IV epinephrine require continuous cardiac monitoring
Flushing syndromes
because of the potential for arrhythmias and ischemia, which occur
A. Carcinoid
B. Vasointestinal polypeptide tumors
most commonly with this route of administration. If IV access
C. Mastocytosis and mast cell activating syndrome cannot be established, epinephrine can be administered via an
D. Medullary carcinoma of the thyroid endotracheal tube (3–5 mL of 1:10,000 epinephrine).
Restaurant syndromes It has been recommended that the epinephrine be administered
A. Monosodium glutamate early because this can prevent progression to severe symptoms.
B. Scombroidosis Delayed administration has been implicated in contributing to
• Nonorganic disease fatalities.
A. Panic attacks Nebulized albuterol (b2 agonist) for respiratory symptoms may
B. Munchausen stridor (factitious anaphylaxis) be administered, and IV aminophylline (bronchodilator) can be
C. Vocal cord dysfunction syndrome
considered, although its effectiveness for anaphylaxis is question-
D. Undifferentiated somatoform anaphylaxis
E. Prevarication anaphylaxis able. These are adjunctive treatments to epinephrine. Large vol-
• Miscellaneous umes of fluids may be required to treat hypotension caused by
A. Hereditary angioedema accompanied by rash increased vascular permeability and vasodilatation. Patients with
B. Paradoxical pheochromocytoma evidence of intravascular volume depletion (e.g., hypotension,
C. Red man syndrome (vancomycin) low urine output, low or no response to injected epinephrine)
D. Capillary leak syndrome should receive volume replacement. Normal saline is preferred
Adapted from Lieberman, Phillip, et al. “Anaphylaxis—a practice parameter update 2015.” Annals of initially. Additional pressors, such as dopamine (5–20 mg/kg/
Allergy, Asthma, & Immunology, vol. 115, no. 5, 2015, pp. 341–384. min), norepinephrine (0.05–0.4 mg/kg/min), or phenylephrine
(100–200 mg/min), may be required.
Antihistamines also are considered adjunctive to epinephrine.
The purpose of using antihistamines is to relive itch and hives. A
Treatment combination of H1 and H2 blockers may be superior to either
agent alone. Thus, diphenhydramine (H1-receptor blocker) 25 to
The initial management of anaphylaxis is to perform a focused ex- 50 mg intravenously or intramuscularly every 4 to 6 hours can be
amination, discontinue the suspected medication, call emergency used with famotidine (H2-receptor antagonist) 20 mg intrave-
services, administer intramuscular (IM) injection of epinephrine, nously given over 2 minutes.
place the patient in a supine position unless there is respiratory Most authorities also advocate the administration of cortico-
distress (then sitting is indicated) or a semi-recumbent position on steroids (methylprednisolone 1–2 mg/kg/day); their benefit is not
the left side if the patient is pregnant (the benefit of elevation of the realized for 6 to 12 hours after administration, but they may be
lower extremities or the Trendelenburg position is controversial and helpful in the prevention of biphasic reactions. They can be
no longer recommended by the American Heart Association), ad- stopped after 72 hours, because all biphasic reactions reported to
minister supplemental high flow oxygen (preferably 100% using a date have occurred within 72 hours.
nonrebreather facemask), establish a stable airway (with intubation Glucocorticosteroids are often used in the management of
if necessary), obtain venous access (preferably with two large-bore anaphylaxis to prevent protracted symptoms. However, evidence
[16-gauge] peripheral IV catheters) for volume resuscitation, and is increasingly showing that they may be of no benefit in the acute
continuously monitor the vital signs and level of consciousness. management of anaphylaxis. In fact, they may be harmful. Thus,
Immediately upon diagnosis, 0.3 to 0.5 mL of 1:1000 (1 mg/mL) routine use is controversial.
epinephrine (up to 0.5 mg in adults, 0.15–0.3 mg in children, and Patients currently taking b-blockers pose a challenge because
0.01 mg/kg in infants) should be injected intramuscularly into the these drugs may limit the effectiveness of epinephrine. These pa-
anterolateral thigh. (Injection at this site has been shown to be more tients may develop resistant hypotension, bradycardia, and a
effective than subcutaneous or upper arm [deltoid] injection.) The site prolonged course. Atropine (anticholinergic) may be given for
can be massaged to facilitate absorption. This dose may be repeated bradycardia. Some clinicians recommend administering glucagon.
every 5 to 15 minutes, up to a total of three doses. The therapeutic Glucagon exerts a positive inotropic and chronotropic effect on
effects of epinephrine include: the heart independent of catecholamines. A 1 to 5 mg slow IV
• a1-Adrenergic agonist: increased vasoconstriction, increased bolus followed by an infusion of 5 to 15 mg/minute titrated to
peripheral vascular resistance, and decreased mucosal edema effect may improve hypotension in 1 to 5 minutes, with maximal
(in the upper airway) benefit at 5 to 15 minutes. All patients with anaphylaxis should
• b1-Adrenergic agonist: increased inotropy and chronotropy be monitored for the possibility of recurrent symptoms after ini-
• b2-Adrenergic agonist: increased bronchodilation and de- tial resolution.
creased release of mediators from mast cells and basophils In the current patient, penicillin was immediately discontinued,
Patients with severe upper airway edema, bronchospasm, or and 0.3 mg of 1:1000 epinephrine was injected intramuscularly into
significant hypotension or who do not respond to IM injection the right anterolateral thigh. Synchronously, a code was called, the
(may not be perfusing muscle tissue) and fluid resuscitation should patient was placed in a supine position, and supplemental oxygen at

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 7 Penicillin Allergy and Anaphylaxis 35

10 L/minute was administered via a nonrebreather mask. Two from anaphylaxis. Also, detecting cutaneous changes in draped
16-gauge peripheral IV lines were started at each antecubital fossa, patients is very challenging. Anaphylaxis can occur at any time
and a bolus of normal saline was given. The patient also received IV during anesthesia but is most common at induction. The clinical
medications (i.e., 50 mg diphenhydramine, 20 mg famotidine, features of perioperative anaphylaxis are the same in the nonanes-
100 mg methylprednisone) and nebulized albuterol. The vital signs thetic setting. Severe hypotension is widely observed because the
were continuously monitored. An additional 0.3 mg of 1:1000 epi- trigger is most often administered intravenously.
nephrine was given intramuscularly after 12 minutes. The patient
remained stable, and marked improvement was noted. She was sub- Discussion
sequently transferred to the intensive care unit (ICU) for observation.
After an uneventful overnight stay in the ICU, the patient was Penicillin allergy is reported by up to 10% of all patients and 15%
taken to the operating room the next day, where she underwent of hospitalized patients in the United States. Penicillin-induced
open reduction with internal fixation of the mandibular fracture. anaphylaxis occurs at an incidence between 0.02% to 0.04%. In
The anesthesia team was informed of her hospital course (in case the large-scale studies of penicillin allergy skin testing, it has also been
patient experienced a biphasic recurrence, with the signs and symp- observed that more than 90% of patients who report a penicillin
toms of anaphylaxis occurring during anesthesia). Approximately allergy are not truly allergic to the drug. Of significance is that
50% of biphasic reactions occur within the first 6 to 12 hours after many people are falsely labeled as being penicillin allergic.
the initial reaction. All early symptoms of anaphylaxis usually ob- Clinicians often prescribe different treatments for patients
served in the awake patient (e.g., malaise, pruritus, dizziness, and with a history of penicillin allergy, including broad-spectrum an-
dyspnea) are absent in the anesthetized patient. The most commonly tibiotics and clindamycin, which carry many side effects and risk
reported initial features are pulselessness, difficulty in ventilating, of antimicrobial resistance. A recent study by Roistacher et al.
desaturation, and decreased end-tidal CO2. Also, cutaneous signs found that penicillin allergy was significantly associated with sur-
may be difficult to notice in a completely draped patient. gical site infection after oral and maxillofacial surgical procedures.
Upon discharge, the patient was thoroughly informed of her They identified that this was specifically because these patients
allergy. She was provided with a medical alert bracelet, and fol- received non–b-lactam antibiotics during the perioperative pe-
low-up was arranged with allergy care specialists. riod. The authors of the study thus recommended that patients
with a history of penicillin allergy who have not had a recent
Complications anaphylaxis episode should be referred for definitive allergy test-
ing to reduce their risk of postoperative complications.
Complications of anaphylaxis range from full recovery to anoxic An additional study from Chadha et al. found that while patients
brain injury and death despite adequate response and treatment. with a reported penicillin allergy did not have significantly different
The factors that determine the course of anaphylaxis are not un- outcomes following odontogenic infections compared to non-
derstood. At the onset of an episode, it is not possible to predict allergic patients, they did have a much higher risk for antibiotic
how severe it will become, how rapidly it will progress, or whether resistance, namely clindamycin resistance. In addition, a 2023 sys-
it will resolve spontaneously (as a result of endogenous produc- tematic review from Edibam et al. found that self-reported penicillin
tion of compensatory mediators, such as epinephrine) or become allergy paired with administration of clindamycin are over three
biphasic or protracted. The rapidity of onset of symptoms makes times more likely to undergo implant failure. Patients who were
this uncommon condition difficult to treat. Early recognition and administered clindamycin had an average failure rate of 11% com-
treatment are essential. It is estimated that anaphylaxis causes ap- pared to 3.8% in patients administered amoxicillin. The authors
proximately 1400 to 1500 fatalities per year in the United States. emphasize the importance of allergy testing as up to 10% of patients
Between 5% and 20% of patients experience biphasic anaphy- may report a penicillin allergy, only 0.01% of patients will experi-
laxis, with a recurrence of symptoms after apparent initial resolu- ence a life-threatening adverse event from administration. In addi-
tion (typically 1–10 hours after initial resolution). Some cases of tion, the authors note that it is unclear whether penicillin allergy or
recurrence have been reported up to 72 hours later. Protracted the addition of clindamycin is the cause of this higher failure rate.
anaphylaxis also has been reported, with persistence of symptoms Quantities of Prevotella bacterial species in saliva may rise as a result
for hours, days, or even weeks despite therapy. of clindamycin administration and have been identified in implants
Anaphylaxis is known to be difficult to recognize clinically for with peri-implantitis. However, additional studies are needed to
several reasons, including the broad differential that needs to be con- determine if clindamycin is directly damaging to implant health.
sidered. Concurrent use of central nervous system–active medications, Each of these studies emphasizes the importance of allergy testing
such as sedatives, hypnotics, antidepressants, and first-generation for patients with a history of penicillin allergy as the true incidence
sedating H1 antihistamines, can interfere with recognition of anaphy- of a penicillin allergy is quite low while the risk of complications due
laxis triggers and symptoms and with the ability to describe symp- to alternative antibiotic prescriptions can be high.
toms. In patients with concomitant medical conditions, such as Most clinicians simply accept a diagnosis of penicillin allergy
asthma, chronic obstructive pulmonary disease, or congestive heart without obtaining a detailed history of the reaction. In their review,
failure, symptoms and signs of these diseases can also cause confusion Salkind and colleagues stressed the importance of a thorough history
in the differential diagnosis of anaphylaxis. Death most commonly when faced with a penicillin-allergic patient (Box 7.2). However, it
results from intractable bronchospasm, asphyxiation from upper air- has been shown that patients with a vague history have also been
way edema, or cardiovascular collapse. found to have an IgE-mediated allergy. The time elapsed since
Perioperative anaphylaxis is a serious and unpredictable ad- the last reaction is important because penicillin-specific IgE
verse event with an estimated incidence of 1 in 10,000. Many antibodies decrease with time. (Approximately 80% of patients with
challenges exist to recognizing anaphylaxis in an anesthetic setting IgE-mediated penicillin allergy have lost sensitivity after 10 years.)
because of the variety of drugs administered intravenously and Nonetheless, it is prudent to refer any patient with a history of
difficulty distinguishing anesthetic drug hemodynamic effects IgE-mediated penicillin allergy for testing. Penicillin is the most

t.me/Dr_Mouayyad_AlbtousH
36 S E C TI O N Pharmacology

• BOX 7.2 Taking a Detailed History From a the number and density of cardiac mast cells are increased in these
Penicillin-Allergic Patient areas, and mast cells also are present in the atherosclerotic plaques.
During anaphylaxis, the mediators released from cardiac mast
Important Questions cells contribute to vasoconstriction and coronary artery spasm.
What was the patient’s age at the time of the reaction? Foods are the most common trigger for anaphylaxis in children,
Does the patient recall the reaction? If not, who informed him or her of it? teens, and young adults. (Food triggers differ according to local
How long after beginning penicillin did the reaction start? dietary habits.) Insect stings and medications (e.g., penicillin, ra-
What were the characteristics of the reaction? diocontrast media) are relatively common triggers in middle-aged
What was the route of administration? and older adults. Natural rubber latex (NRL) may trigger anaphy-
Why was the patient taking penicillin?
What other medications was the patient taking? Why and when were they
laxis in health care settings, where it is found in equipment such
prescribed? as airway masks, endotracheal tubes, blood pressure cuffs, and
What happened when the penicillin was discontinued? stethoscope tubing and also in supplies such as disposable gloves,
Had the patient taken antibiotics similar to penicillin (e.g., amoxicillin, ampicillin, catheters, adhesive tape, tourniquets, and vials with NRL closures.
cephalosporins) before or after the reaction? Since 2010, health care institutions have dramatically reduced the
If yes, what was the result? purchase and use of latex gloves, and labeling medical devices with
the latex content became mandatory in many countries. A compre-
hensive occupational health program to aid individuals who de-
velop latex allergies and reactions became the standard. Prompt
common cause of drug-induced anaphylaxis. It causes an estimated recognition and treatment are critical in anaphylaxis.
40% to 50% of all anaphylactic deaths in the United States. For patients whose history appears to indicate an IgE-mediated
Allergic drug reactions are one type of adverse drug reaction response, skin testing to confirm allergy is useful if there is a com-
(ADR). An ADR has been defined by the World Health Organiza- pelling reason to use penicillin. Penicillin skin testing is per-
tion as any noxious, unintended, and undesired effect of a drug that formed by three classic methods: prick, intradermal, and patch.
occurs at doses used for prevention, diagnosis, or treatment. ADRs Skin testing itself carries a risk of fatal anaphylaxis, and the facility
can be categorized into two types: type A reactions, which account must be prepared to respond if a reaction occurs. Studies have
for 85% to 90% of all ADRs and can affect any individual (e.g., shown that among patients who test positive on a penicillin skin
diarrhea in response to antibiotics), and type B reactions, which are test, approximately 2% will react to a cephalosporin.
hypersensitivity reactions that occur in susceptible patients. If patients test negative to skin testing or show tolerance after a
Although it has been difficult to determine the frequency of drug- one- or two-dose ingestion challenge, delabeling their penicillin
induced allergic reactions specifically, it is known that they account allergy can become a challenge. A multidisciplinary group in
for only a small proportion of ADRs, approximately 6% to 10%. Australia was able to remove a penicillin allergy label in 83% of
An allergic drug reaction can be classified as immediate (reac- patients and as a result increase appropriate antibiotic usage to
tion occurs within 1 hour of administration and is usually IgE improve patient care. However, effectively removing the penicillin
mediated) or delayed (reaction occurs after 1 hour, at times days allergy from all of the patient’s records is often a difficult and
or weeks after treatment, and is not IgE mediated). Anaphylaxis time-consuming process and cannot guarantee that the patient will
is an example of an immediate reaction. Late reactions can range not be mischaracterized in the future. Also, the burden of proof to
from a rash that develops during treatment with amoxicillin to convince patients that their previous allergy label is no longer nec-
life-threatening conditions, such as Stevens-Johnson syndrome essary can be challenging, and many patients may choose to still
and toxic epidermal necrolysis. In rare cases, certain b-lactams can avoid the medication despite its potential benefits.
cause interstitial nephritis, hepatitis, or a vasculitis with or with- Patients who have a hypersensitivity reaction to penicillin and in
out signs of serum sickness. whom the administration of a penicillin antibiotic is very desirable
Allergic reactions can also be classified by the immune mecha- or even essential can be managed by desensitizing the patient to
nism involved, as described by Gell and Coombs. In this classifi- penicillin. Desensitization is accomplished by administering in-
cation, type I represents an IgE-mediated response, whereas types creasing doses of penicillin over a period of 3 to 5 hours. The
II, III, and IV are non–IgE dependent. Type II, III, and IV reac- mechanism whereby clinical tolerance is achieved is not entirely
tions are classified as delayed reactions because they generally clear. Recent rapid desensitization in vitro and in vivo models have
occur more than 1 hour after drug administration. shown inhibition of all the hallmarks of mast cell and basophil ac-
The clinical syndrome of anaphylaxis results from activation tivation, including impaired receptor internalization, calcium flux,
and release of mediators from mast cells and basophils (e.g., his- degranulation, early synthesis of lipid mediators, and late cytokine
tamine). The cross-linking of mast cell–bound IgE with antigens production. The desensitization procedure should be undertaken in
causes the release of these mediators, with manifestations that an ICU setting, where continual monitoring is available. Also, the
include increases in vascular permeability (causing edema), vaso- clinician must be at the bedside or readily available.
dilatation (causing hypotension), respiratory smooth muscle con- It has been shown that desensitization is an acceptable, safe
traction (causing bronchospasm), stimulation of the autonomic approach to therapy in patients who are penicillin allergic but
nervous system (causing tachycardia), mucus secretion, platelet require b-lactams for treatment. Oral desensitization is safer than
aggregation, and recruitment of inflammatory cells. parenteral desensitization. There are no specific contraindications
Middle-aged and older adult patients are at increased risk of to desensitization. However, patients who are unable to withstand
severe or fatal anaphylaxis because of known or subclinical cardio- the consequences of an acute allergic reaction and its management
vascular diseases and the medications used to treat them. In the are poor candidates.
healthy human heart, mast cells are present around the coronary
arteries and the intramural vessels, between the myocardial fibers, ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
and in the arterial intima. In patients with ischemic heart disease, complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 36.e1

Bibliography Misbah SA, Krishna MT: Peri-operative anaphylaxis—an investigational

challenge, Front Immunol 10:1117, 2019.
Parisi CAS, Kelly KJ, Ansotegui IJ, et al: Update on latex allergy: new in-
Campbell Ronna, Kelso John: Anaphylaxis: Emergency treatment, 2023. sights into an old problem, World Allergy Organ J 14(8):100569, 2021.
https://www.uptodate.com/contents/anaphylaxis-emergency-treatment. Park MA, Li JT: Diagnosis and management of penicillin allergy, Mayo
(Accessed 5 January 2024). Clin Proc 80:405, 2005.
Cardona V, Ansotegui IJ, Ebisawa M, et al: World Allergy Organization
Patterson RA, Stankewicz HA: Penicillin allergy. In Dulebohn, editor:
Anaphylaxis Guidance 2020, World Allergy Organ J 13(10):100472,
StatPearls [Internet], Treasure Island (FL), 2023, StatPearls Publishing.
2020.
Riedl M, Casalias A: Adverse drug reactions: types and treatment op-
de Las Vecillas Sánchez L, Alenazy LA, Garcia-Neuer M, et al: Drug
hypersensitivity and desensitizations: mechanisms and new approaches, tions, Am Fam Physician 68:1781, 2003.
Int J Mol Sci 18(6):1316, 2017. Roistacher DM, Heller JA, Ferraro NF, et al: Is penicillin allergy a risk
Chadha S, Troost J, Shivers P: Does the penicillin allergy label affect factor for surgical site infection after oral and maxillofacial surgery?,
outcomes of complicated odontogenic infections?, J Oral Maxillofac J Oral Maxillofac Surg 80(1):93-100, 2022.
Surg 81(10):1301–1310, 2023. Romano A, Blanca M, Torres MJ, et al: Diagnosis of nonimmediate reac-
Edibam N, Lorenz-Pouso A, Caponio V: Self-reported allergy to penicil- tions to b-lactam antibiotics, Allergy 59:1153, 2004.
lin and clindamycin administration may be risk factors for dental Salkind AR, Cuddy PG, Foxworth JW: The rational clinical examination—
implant failure: A systematic review, meta-analysis and delabeling is this patient allergic to penicillin? An evidence-based analysis of the
protocol, Clin Oral Implants Res 34(7):651–661, 2023. likelihood of penicillin allergy, JAMA 285:2498, 2001.
Gell POH, Coombe RRA: The classification of allergic mediated under- Sampson H, Muñoz-Furlong A, Campbell RL, et al: Second symposium
lying disease. In Coombe RRA, Gell POH (eds): Clinical Aspects of on the definition and management of anaphylaxis: summary report:
Immunology, ed 2, Oxford, 1968, Blackwell Science. second National Institute of Allergy and Infectious Disease/Food
Gomez MB, Torres MJ, Mayorga C, et al: Immediate allergic reactions to Allergy and Anaphylaxis Network Symposium, J Allergy Clin Immunol
beta lactams: facts and controversies, Curr Opin Allergy Clin Immunol 117(2):391, 2006.
4:261, 2004. Simons F, Estelle R, Ardusso Ledit RF, et al: World Allergy Organization
Gruchalla R: Drug allergy, J Allergy Clin Immunol 111:548, 2003. guidelines for the assessment and management of anaphylaxis, World
Macy E, Contreras R: Health care use and serious infection prevalence Allergy Organ J 4(2):13-37, 2011.
associated with penicillin “allergy” in hospitalized patients: a cohort Stone CA Jr, Trubiano J, Coleman DT, et al: The challenge of de-labeling
study, J Allergy Clin Immunol 133(3):790-796, 2013. penicillin allergy, Allergy 75(2):273-288, 2020.
Mertes PM, Tajima K, Regnier-Kimmoun MA, et al: Perioperative ana- Tang AW: A practical guide to anaphylaxis, Am Fam Physician 68:1325,
phylaxis, Med Clin North Am 94:761, 2010. 2003.
Metcalfe D, Nowak-Wegrzyn A, Sicherer S, et al: Anaphylaxis—a practice Torres MJ, Blanca M, Fernandez J, et al: Diagnosis of immediate allergic
parameter update 2015, Ann Allergy Asthma Immunol 115(5): reactions to beta-lactam antibiotics, Allergy 58:961, 2003.
341-384, 2015. Wendel GD, Stark BJ, Jamison RB, et al: Penicillin allergy and desensi-
Miller EL: The penicillins: a review and update, J Midwifery Womens tization in serious infections during pregnancy, N Engl J Med 312:
Health 47:426, 2002. 1229, 1985.

t.me/Dr_Mouayyad_AlbtousH
8
Antibiotic-Associated Colitis
C L A IR E M I L L S , PI YU SH K U M A R P. PAT E L , a n d S H A H R O K H C . B AG H ER I

CC Abdominal. The abdomen is soft, nontender, and nondis-

tended, with hyperactive bowel sounds in all four quadrants.
A 65-year-old male, status post incision and drainage (I&D) of a There is no guarding or rebound tenderness (these would be in-
severe facial infection, who was previously admitted to the hospi- dicative of peritonitis).
tal for treatment of an odontogenic infection, complains of the
new onset of severe “watery diarrhea.” Imaging
HPI Plain radiographic imaging studies of the abdomen (e.g., kidney–
ureter–bladder) can be used to assist in the diagnosis of Clostridioi-
The patient was admitted 6 days earlier and was taken to the op- des difficile–associated diarrhea. (Clostridium difficle was reclassified
erating room on that day, where I&D of the right submandibu- in 2016 to Clostridioides difficle, this necessary change allowed the
lar–medial masticator and submental spaces, with extraction of a continued use of the familiar abbreviation C. difficle or C. diff).
grossly carious right mandibular first molar, was performed. He Plain radiographs may reveal a dilated colon suggestive of ileus.
remained intubated for 3 days and was maintained on intrave- (Patients with severe disease may develop colonic ileus or toxic dila-
nous (IV) clindamycin (900 mg every 8 hours). A previously tation with abdominal pain and distension with minimal or no
placed nasogastric tube was also removed. The patient continued diarrhea.) A diffusely thickened or edematous colonic mucosa is
to do well and was transferred to the ward from the intensive care often better visualized on an abdominal computed tomography
unit on the fourth postoperative day, with continuation of the IV scan. Thickening can sometimes be seen on abdominal plain films.
clindamycin therapy. Colonoscopy or sigmoidoscopy is a more invasive diagnostic
On hospital day 6, the patient reported lower abdominal modality that is reserved for cases in which rapid diagnosis is nec-
pain and cramping of over 12 hours’ duration. He also reported essary or stool samples cannot be obtained secondary to ileus. The
experiencing nausea, malaise, fever, and chills. He had several finding of pseudomembranes is pathognomonic for C. difficile
episodes of profuse, watery diarrhea, which were documented colitis. Because of the increased risk for intestinal perforation,
by the nursing staff. There was no evidence of blood in his endoscopy should be used sparingly in patients with suspected
stool, but he has had minimal oral intake since the symptoms C. difficile–associated diarrhea.
began. Because this patient is relatively stable, abdominal imaging and
endoscopy are not indicated.
PMHX/PDHX/Medications/Allergies/SH/FH
Labs
Allergies. The patient has a penicillin allergy (history of rash).
Current medications. He is receiving clindamycin 900 mg A basic metabolic panel demonstrated an elevated sodium level
intravenously every 8 hours and morphine sulfate 2 mg every (148 mEq/L) and elevated blood urea nitrogen and creatinine
4 hours as needed for pain. (secondary to dehydration). Serial complete blood counts demon-
strated elevation of the white blood cell (WBC) count, from
Examination 12,000 to 20,000 cells/mL, with bandemia.
The result of the patient’s stool guaiac test was negative for
General. The patient is an obese male in mild distress who is rest- blood. The enzyme-linked immunosorbent assay (ELISA) result
ing in bed. for C. difficile toxin was positive.
Vital signs. His blood pressure is 110/68 mm Hg, heart rate The current Infectious Diseases Society of America (IDSA) guide-
is 118 bpm (tachycardia secondary to elevated temperature and lines for testing for C. difficile infection (CDI) outline limiting testing
gastrointestinal [GI] fluid losses), respirations are 18 breaths per to patients (who are not taking laxatives) with an unexplained onset
minute, and temperature is 38.8°C (fever secondary to release of of three or more unformed stools in 24 hours. There is a high preva-
inflammatory mediators in the GI tract). lence of asymptomatic C. difficile colonization in infants, and it is not
Maxillofacial. With decreasing facial edema, drains in the recommended to test children younger than 1 year of age. Repeat
submandibular and submental spaces are nonproductive; removal testing within 7 days of onset of diarrhea is not recommended
is pending. because there is a high rate of false-positive results.

37
t.me/Dr_Mouayyad_AlbtousH
38 S E C TI O N Pharmacology

The reference tests for diagnosis of C. difficile–mediated disease Response to therapy can be assessed by the resolution of fever,
is a cytotoxin assay. Although this test is highly sensitive and spe- usually within the first 2 days. Diarrhea should resolve within 2
cific, it is difficult to perform, and the results are not available for to 4 days; however, treatment is continued for 10 to 14 days.
24 to 48 hours. In addition, the testing facility must be equipped Therapeutic failure is not determined until treatment has been
with tissue culture capabilities. Instead, it is recommended to use given for at least 5 days.
enzyme ELISA can be used to detect C. difficile toxin (A and/or The best treatment is prevention. This includes the judicious
B) in stool. This test has a sensitivity of 63% to 99% and a speci- use of antibiotics; hand washing between patient contacts (hand
ficity of 93% to 100%. ELISA can be quickly performed (2– washing with soap and water may be more effective than the use
6 hours) and is the laboratory test most frequently used to diag- of alcohol-based hand sanitizers because C. difficile spores are re-
nose CDI. Bacterial culture, nucleic acid amplification testing, and sistant to killing by alcohol), rapid detection of C. difficile by
antigen glutamate dehydrogenase detection methods have high immunoassays for toxins A and B, and isolation of patients who
sensitivity but low specificity for accurately detecting C. difficile. have C. difficile–associated diarrhea.
The average range for peripheral WBCs in patients with C. In the current case, the patient was placed on contact precau-
difficile–associated diarrhea is 12,000 to 20,000 cells/mL, but tions. Current guidelines from the Centers for Disease Control
occasionally, the count is higher. An important indicator of im- and Prevention indicate that patients should be placed under
pending fulminant colitis is a sudden rise in peripheral WBCs to contact precautions and in isolation until the diarrhea has re-
30,000 to 50,000 cells/mL. Because progression to shock can solved. This patient was given a bolus of normal saline (NS) and
occur even in patients who have had benign symptoms for weeks, started on maintenance fluids of dextrose 5% in 1/2 NS at
early warning signs, such as leukocytosis, can be invaluable. 110 mL/hr. Clindamycin was discontinued, and the patient was
started on fidaxomicin 200 mg orally twice daily for 10 days. His
Assessment diarrhea resolved in 2 days, and he was subsequently discharged.
He was given a non-opiate pain medication during his hospital
Resolving odontogenic infection now complicated by C. difficile– stay and upon discharge. The patient was educated about his di-
associated diarrhea. agnosis, and it was recommended that he inform other practitio-
ners of it before initiation of antibiotic therapy.
Treatment
Complications
In otherwise healthy adults, the first steps are to discontinue the
precipitating antibiotic and to administer fluids and electrolytes Recurrence can develop and is usually caused by the germination
to maintain hydration. For many patients, antibiotic-associated of persistent C. difficile spores in the colon after treatment or
diarrhea is a mild and self-limited illness that responds to the secondary to reinfection by the pathogen. Relapse is reported to
discontinuation of antibiotics, supportive care, and fluid and occur in 15% to 20% of cases regardless of the initial treatment
electrolyte replacement. Specific pharmacotherapy for C. difficile– used. Some conditions identified as potential markers for relapse
associated diarrhea should be initiated after the diagnosis of C. include previous relapses, chronic renal failure, marked leuko-
difficile has been confirmed or in highly suggestive cases of se- cytes, and continued antibiotic use. In patients who have had
verely ill patients. more than one relapse, the recurrence rate can be as high as 65%;
The IDSA recently updated its guidelines for the management in such cases, avoidance of unnecessary antibiotics is strongly
of CDI in 2021, which are outlined in Table 8.1. Fidaxomicin, a advised. Different agents, regimens, doses, and even unusual
macrocyclic antibiotic and the newest US Food and Drug Admin- forms of therapy, such as fecal enemas, have been tried in these
istration–approved treatment for CDI, is the recommended first- cases, with varying success.
line treatment for initial and recurrent CDI. Fidaxomicin is orally Approximately 3% of patients develop severe C. difficile–
delivered, similar to vancomycin, with minimal systemic absorp- associated diarrhea. The mortality rate in these patients ranges
tion, targeted activity against C. difficile, and a low risk of resistance. from 30% to 85%. Treatment of severe cases must be aggressive,
Four randomized clinical trials have shown that patients treated with IV metronidazole and oral vancomycin used in combination.
with 200 mg of fidaxomicin given twice daily for 10 days have a If ileus occurs, vancomycin can be administered by nasogastric
lower risk of CDI recurrence than those treated with vancomycin. tube with intermittent clamping, retention enemas, or both. If
However, vancomycin is more widely available and remains an medical therapy fails or perforation or toxic megacolon develops,
effective treatment for managing initial and recurrent CDI. Van- surgical intervention with colectomy and ileostomy is indicated
comycin 500 mg four times daily is the recommended treatment but carries a high mortality rate.
for fulminant CDI in which patients show signs of hypotension Of concern is the fact that recent studies indicate the emergence
or shock, ileus, or megacolon. of a new, more virulent strain of C. difficile that is associated with
Metronidazole is an acceptable alternative to fidaxomicin and more severe disease (higher rates of toxic megacolon, leukemoid
vancomycin for initial treatment of nonsevere CDI (WBC count reaction, shock, need for colectomy, and death). This new strain is
#15,000 cells/mL, serum creatinine level ,1.5 mg/dL) but commonly designated as NAP1/BI/027. (The designation denotes
should be avoided in pregnant patients. the following: NAP1—a North American Pulse Field type 1 pat-
The use of opiates and antidiarrheal medications has previ- tern on gel electrophoresis; BI—a BI pattern on restriction endo-
ously been discouraged; however, some studies have shown that nuclease analysis; 027—type 27 on ribotyping.) Deletion of a gene
evidence supporting this hypothesis is lacking. Additionally, in this new strain may be responsible for its greater pathogenicity.
antimotility agents may be beneficial in providing symptomatic This deletion is thought to be responsible for production of 16 to
relief and reducing environmental contamination with infec- 23 times more toxin A and B. In addition, it produces an additional
tious stool. toxin called CD196 ADP-ribosyltransferase (CDT) or binary

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 8 Antibiotic-Associated Colitis 39

TABLE
8.1 Recommendations for the Treatment of Clostridioides difficile Infection in Adultsa

Clinical Presentation Recommended and Alternative Treatments Comments

Initial CDI episode Preferred: fidaxomicin 200 mg given twice daily for 10 days Implementation depends on available resources
Alternative: vancomycin 125 mg given four times daily PO for Vancomycin remains an acceptable alternative
10 days
Alternative for nonsevere CDI, if above agents are unavailable: Definition of nonsevere CDI is supported by the following labo-
metronidazole, 500 mg three times daily PO for 10–14 days ratory parameters: WBC count of #15,000 cells/mL and a
serum creatinine level ,1.5 mg/dL
First CDI recurrence Preferred: fidaxomicin 200 mg given twice daily for 10 days —
OR twice daily for 5 days followed by once every other day
for 20 days
Alternative: vancomycin PO in a tapered and pulsed regimen Tapered or pulsed vancomycin regimen example: 125 mg four
times daily for 10–14 days, two times daily for 7 days, once
daily for 7 days, and then every 2–3 days for 2–8 weeks
Alternative: vancomycin 125 mg given four times daily PO for Consider a standard course of vancomycin if metronidazole was
10 days used for treatment of the first episode
Adjunctive treatment: bezlotoxumab 10 mg/kg given intrave- Data when combined with fidaxomicin are limited; caution for
nously once during administration of SOC antibioticsb use in patients with CHFc
Second or subsequent Fidaxomicin 200 mg given twice daily for 10 days OR twice —
CDI recurrence daily for 5 days followed by once every other day for 20 days
Vancomycin PO in a tapered and pulsed regimen …
Vancomycin 125 mg four times daily PO for 10 days followed …
by rifaximin 400 mg three times daily for 20 days
Fecal microbiota transplantation The opinion of the panel is that appropriate antibiotic treatments
for at least two recurrences (i.e., three CDI episodes) should
be tried before offering fecal microbiota transplantation
Adjunctive treatment: bezlotoxumab 10 mg/kg given intrave- Data when combined with fidaxomicin are limited; caution for
nously once during administration of SOC antibioticsb use in patients with CHFb
Fulminant CDI Vancomycin 500 mg four times daily PO or by nasogastric tube Definition of fulminant CDI is supported by hypotension or
If the patient has ileus, consider adding rectal instillation of shock, ileus, and megacolon
vancomycin
Intravenously administered metronidazole (500 mg every
8 hours) should be administered together with oral or
rectal vancomycin, particularly if ileus is present
a
The recommendations are based on the 2017 guidelines and these current focused guidelines (2021).
b
Bezlotoxumab may also be considered for patients with other risks for Clostridioides difficile infection (CDI) recurrence, but implementation depends on available resources and logistics for intravenous
administration, particularly for those with an initial CDI episode. Additional risk factors for CDI recurrence include age older than 65 years, immunocompromised host (per history or use of immunosup-
pressive therapy), and severe CDI on presentation.
cThe Food and Drug Administration warns that “in patients with a history of congestive heart failure (CHF), bezlotoxumab should be reserved for use when the benefit outweighs the risk.”

PO, By mouth; SOC, standard of care; WBC, white blood cell.

From Johnson, S., et al. Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines
on Management of Clostridioides difficile Infection in Adults, Clinical Infectious Diseases, Volume 73, Issue 5, 1 September 2021, Pages e1029–e1044

toxin. CDT toxin production increases bacterial adherence to the Discussion

gut and promotes increased uptake of toxins A and B. The emer-
gence of this virulent strain underscores the importance of judicious C. difficile is a gram-positive, spore-forming rod that is responsible
use of antibiotics (especially cephalosporins, clindamycin, and fluo- for 20% to 30% of antibiotic-related cases of diarrhea. In 2016,
roquinolones). Strict infection control measures, including contact CDIs accounted for 28% of all registered outbreaks of hospital-
isolation and enhanced environmental cleaning, are mandatory. acquired infections, of which 6.2% were fatal. CDI results in
Recent outbreaks of the more virulent strain in hospitals in the more than 300,000 cases of diarrhea in the United States and is
United States and Canada, which have been reported in the popular the most common cause of nosocomial diarrhea. The case mortal-
media, have increased public awareness of this disease process. ity rate is approximately 1% to 2.5%.

t.me/Dr_Mouayyad_AlbtousH
40 S E C TI O N Pharmacology

• BOX 8.1 Risk Factors for Clostridioides difficile– damage, though the mechanisms for this damage are still being
Associated Diarrhea investigated.
The diagnosis of C. difficile colitis requires a detailed history,
Antibiotic therapy including use of any antibiotics over the past 3 months. A detailed
Age older than 65 years description of the type, frequency, and consistency of diarrhea is
Hospitalization $4 weeks or stay in long-term medical care facility important. The enzyme immunoassay that detects toxins A and B
Disease associated with immunosuppression or chemotherapy is the laboratory test most commonly used to diagnose C. difficile–
Use of proton pump inhibitors mediated disease.
Chronic diseases, including:
Probiotics, a group of agents designed to resist colonization
• Chronic kidney disease
• Diabetes requiring dialysis and restore normal flora, have been tried in antibiotic-associated
• Cystic fibrosis diarrhea. Probiotics are live organisms that can improve the
• Stroke balance of gut microbiota by counteracting antibiotic-induced
• Malnutrition disturbances in intestinal flora and thus reduce the risk of op-
• Alcoholism portunistic colonization from pathogenic bacteria. Probiotics
• Chronic heart disease have been shown, in some cases, to reduce the risk of antibiotic-
• Chronic lung disease associated diarrhea when administered during antibiotic therapy.
• Human immunodeficiency virus infection A large-scale systematic review of 31 randomized controlled trials
• Inflammatory bowel disease that included 8672 patients found that probiotics given with
• Cancer
antibiotics reduce the risk of C. difficile–associated diarrhea by
60%. However, the studies included in the review varied signifi-
cantly in the probiotic formula used and duration of probiotic
administration, which makes it hard to draw conclusions or
Acquisition of C. difficile occurs primarily in the hospital set- recommend specific probioitic regimes.
ting or long-term care facilities through fecal–oral spread or direct The most promising probiotic agent is Saccharomyces boulardii,
contact with a contaminated environment, including bed rails, a live, nonpathogenic yeast. Some studies have shown that when S.
floors, windowsills, and toilets, in addition to the hands of hospi- boulardii was given prophylactically to patients receiving antibiot-
tal workers who provide care for patients with CDI. The rate of ics, it was safe and beneficial in reducing the incidence of C. difficile
C. difficile acquisition is estimated to be 13% to 20% in patients colitis. In addition, S. boulardii was shown to reduce infection re-
with hospital stays up to 2 weeks and 50% in those with hospital currence in patients with severe or recurring antibiotic-associated
stays longer than 4 weeks. diarrhea. S. boulardii provides an anti-inflammatory effect by re-
The risk factors for the development of symptomatic C. difficile– ducing nuclear transcription factor kB and interleukin-8 produc-
associated diarrhea are summarized in Box 8.1. The most important tion, which mediate the inflammatory response in C. difficile colitis.
modifiable risk factor for the development of CDI is exposure to Lactobacillus GG, another popular probiotic, has been shown
antimicrobial agents. to improve intestinal immunity by increasing IgG and IgA levels
The commonly prescribed antibiotics by risk of CDI can be at the intestinal mucosal level. However, despite some positive
divided into high, medium, and low risk. The high risk antibiotics findings, conclusive studies are still lacking to recommend the use
include the fluoroquinolones, second and third cephalosporins, of probiotics for routine prevention of antibiotic-associated diar-
clindamycin, Ampicillin, broad-spectrum and penicillins with rhea. Although usually considered harmless, both S. boulardii and
inhibitors. Lactobacillus therapy are capable of inducing fungemia and bacte-
Even very limited exposure, such as single-dose surgical anti- remia, respectively. At this time, there are no recommendations
biotic prophylaxis, increases a patient’s risk of both C. difficile for probiotic administration in managing or preventing antibi-
colonization and symptomatic disease. The initiating event for otic-associated diarrhea.
C. difficile colitis is disruption of colonic flora, with subsequent It should be noted that despite the potential benefits of pro-
colonization. Depending on host factors, a carrier state or dis- biotic use concurrent with antibiotics for treatment of CDI,
ease results. The disruption is usually caused by broad-spectrum there is also a risk of side effects to probiotic use. Namely, pro-
antibiotics. Clindamycin and broad-spectrum penicillins and biotics may hinder the recovery of normal gut flora and can
cephalosporins are most commonly implicated. C. difficile colitis increase the risk of bacteremia or fungal infection in immuno-
can occur up to 8 weeks after discontinuation of antibiotics. compromised patients. At this time, the IDSA does not recom-
C. difficile produces two exotoxins that are responsible for its mend the administration of probiotics with antibiotics because
pathogenesis, toxins A and B. Both toxins play a role in the of insufficient evidence that probiotics are a beneficial measure
pathogenesis of C. difficile–associated diarrhea. Toxin B is ap- to prevent colitis.
proximately 10 times more potent than toxin A. The toxins bind Other types of diarrhea should be considered and ruled out
to intestinal receptors, leading to disruption of the cellular skel- based on the history and physical examination. These include in-
eton and intracellular junctions. Protein synthesis and cell divi- fectious enteritis or colitis, bacterial gastroenteritis, viral gastroen-
sion are inhibited. Inflammatory mediators attract neutrophils teritis, amebic dysentery, inflammatory bowel disease (e.g., Crohn
and monocytes, increasing capillary permeability, tissue necrosis, disease), ulcerative colitis, and ischemic colitis. Antibiotic intoler-
hemorrhage, and edema. As colitis worsens, focal ulcerations oc- ance manifested as diarrhea in which there is no evidence of
cur, and the accumulation of purulent and necrotic debris forms colitis usually resolves upon antibiotic withdrawal.
the typical pseudomembranes. C. difficile toxins can cause sys-
temic complications as well, including cardiopulmonary arrest, ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
acute respiratory distress syndrome, renal failure, and liver complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 40.e1

Bibliography Koo HL, Koo DC, Musher DM, et al: Antimotility agents for the treat-
ment of Clostridium difficile diarrhea and colitis, Clin Infect Dis
48(5):598, 2009.
Bartlett JG, Perl TM: The new Clostridium difficile: what does it mean?, Kukla M, Adrych K, Dobrowolska A, et al: Guidelines for Clostridium
N Engl J Med 353:2503-2505, 2005. difficile infection in adults, Gastroenterology Rev 15(1):1-21, 2020.
Bartlett JG: Antibiotic-associated diarrhea, N Engl J Med 346:334, 2002. Loo VG, Poirier L, Miller MA, et al: A predominantly clonal multi-insti-
C. difficile - a rose by any other name, The Lancet Infectious Disease, 2019, tutional outbreak of Clostridium difficile–associated diarrhea with high
https://doi.org/10.1016/S1473-3099(19)30177-X. morbidity and mortality, N Engl J Med 353(23):2442-2449, 2005.
Cohen S, Gerding DN, Johnson S, et al: Clinical practice guidelines for Louie TJ, Miller MA, Mullane KM, et al: Fidaxomicin versus vancomy-
Clostridium difficile infection in adults—2010: update by the Society cin for Clostridium difficile toxins, N Engl J Med 364:422, 2011.
for Healthcare Epidemiology of America (SHEA) and the Infectious McDonald LC, Killgore GE, Thompson A, et al: An epidemic, toxin
Diseases Society of America (IDSA), Infect Control Hosp Epidemiol gene-variant strain of Clostridium difficile, N Engl J Med 353(23):
31(5):431-455, 2010. 2433-2441, 2005.
Di Bella S, Ascenzi P, Siarakas S, et al: Clostridium difficile toxins A and Mounsey A, Smith KL, Reddy VC, et al: Clostridioides difficile infection:
B: insights into pathogenic properties and extraintestinal effects, Tox- update on management, Am Fam Physician 101(3):168-175, 2020.
ins 8(5):134, 2016. Mylonakis E, Ryan E, Calderwood S: Clostridium difficile–associated di-
Efron P, Mazuski J: Clostridium difficile colitis, Surg Clin North Am 89(2): arrhea: a review, Arch Intern Med 161:525, 2001.
483-500, 2009. Pimental R, Choure A: Antibiotic associated diarrhea and Clostridium
Fatima R, Aziz M: The hypervirulent strain of Clostridium difficile: difficile. In Carey WD (ed): Cleveland Clinic: Current Clinical Medicine:
NAP1/B1/027—a brief overview, Cureus 11(1):e3977, 2019. Expert Consult Premium Edition, ed 2, St Louis, 2010, Saunders.
Goldenberge JZ, Yap C, Lytvyn L, et al: Probiotics for the prevention of Savola KL, Baron EJ, Tompkins LS, et al: Fecal leukocyte stain has diag-
Clostridium difficile–associated diarrhea in adults and children, nostic value for outpatients but not inpatients, J Clin Microbiol
Cochrane Database Syst Rev 2017(2):CD006095, 2017. 39:266, 2001.
Johnson S, Lavergne V, Skinner AM, et al: Clinical practice guideline by Schroeder M: Clostridium difficile–associated diarrhea, Am Fam Physician
the Infectious Diseases Society of America (IDSA) and Society for 71(5):921, 2005.
Healthcare Epidemiology of America (SHEA): 2021 focused update Thomas RV: Nosocomial diarrhea due to Clostridium difficile, Curr Opin
guidelines on management of Clostridioides difficile infection in Infect Dis 17:323, 2004.
adults, Clin Infect Dis 73(5):e1029-e1044, 2021.

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9
Opioid Side Effects
C L A IR E M I L L S , PI YU SH K U M A R P. PAT E L , a n d S H A H R O K H C . B AG H ER I

CC TABLE Risk Factors for Postoperative Nausea and

9.1 Vomiting (PONV)and Postdischarge Nausea
A 30-year-old female presents to the office complaining that “the
pain medication is making me feel nauseous.” (Nausea is one of and Vomiting (PDNV)
the most commonly seen adverse effect of orally administered Anesthetic
opioids. In a large retrospective review, it was found that female Patient Factors Factors Surgical Factors
adults have a 60% higher risk of nausea and vomiting than male Female Use of periopera- Duration of surgery
adults when administered opioids.) tive opioids Type of surgery
Nonsmoker Use of volatile Ear, nose, and throat
HPI anesthetics
The patient had several mandibular teeth extracted with no intra- History of motion sick- Nitrous oxide Gynecologic
operative complications 2 days before presentation. She was given ness or PONV Laparoscopic
a 3-day prescription for a combination analgesic containing hydro- Family history of motion Ophthalmologic
codone (an opioid) and acetaminophen. She reports poor oral in- sickness or PONV Orthopedic
take since her procedure and has been feeling nauseated, with one (pediatric) Age 3 yr or Plastic
episode of vomiting since taking the medication. (Opioids have a older (pediatric) Strabismus (pediatric)
greater tendency to cause nausea and vomiting when taken on an
empty stomach.) She has not had any relief from pain and explains
that she is now worse because she has both pain and nausea.
A detailed history of symptoms can provide clues to rule out PMHX/PDHX/Medications/Allergies/SH/FH
other causes for this acute nausea episode. Abrupt onset of nausea
and vomiting is suggestive of cholecystitis, food poisoning, gastro- The patient has no known history of narcotic abuse (a risk factor
enteritis, pancreatitis, or drug-related etiologies. If a patient has for drug-seeking behavior). Current medications include hydro-
pain, obstructive etiologies must be considered. codone/acetaminophen (5/325 mg tablets). She admits to having
Postoperative nausea and vomiting (PONV), defined as nausea ingested four tablets in the past 6 hours, with minimal oral intake.
and vomiting occurring in the 0- to 24-hour postoperative period,
is one of the most common complaints after surgery. It has a mul- Examination
tifactorial etiology, and risk factors for the development of PONV
have been identified (Table 9.1). A simplified scoring system by General. The patient is a well-developed and well-nourished fe-
Apfel and colleagues (1999) is one of the most popular and widely male who appears her stated age and is in mild discomfort sec-
used scoring systems. They identified four highly predictive risk ondary to nausea. (The physical examination of this patient
factors for PONV: Female gender, history of motion sickness or should focus initially on signs of dehydration, evaluating skin
PONV, nonsmoker, and use of perioperative opioids. The presence turgor and mucous membranes and observing for hypotension or
of 0, 1, 2, 3, or 4 of these factors corresponded to a PONV inci- orthostatic changes.) She is alert and oriented to time, place, and
dence of 10%, 21%, 39%, 61%, and 79%, respectively. person. (It is important to assess mental status in cases of acute
Risk factors for postdischarge nausea and vomiting, in which opioid toxicity.)
symptoms occur late (24–72 hours) appear to be similar to the Vital signs. Her vital signs are stable, and she is afebrile (AF),
typical risk factors for PONV and are also likely related to, among except for slight tachycardia at 110 bpm (caused by dehydration
other factors, emetic symptoms before discharge, increased pain at secondary to decreased oral intake).
home, and the use of postoperative opioids. Maxillofacial. Pupils are 3 mm, equal, round, and bilaterally
The term opioid is used to refer to all the agonists and antago- reactive. (Pupillary constriction, or miosis, would be a sign of ex-
nists of the morphine-like family of compounds. This term is cessive opioid intake and is not affected by tolerance.)
preferred to older terms, such as opiate or narcotic. Narcotic refers Intraoral. The examination is consistent with healing extrac-
to any drug that can cause dependence; the term is not specific for tion sockets with no evidence of alveolar osteitis or acute infec-
opioids (i.e., not all narcotics are opioids). tion. Mucous membranes are moist and within normal limits.

41
t.me/Dr_Mouayyad_AlbtousH
42 S E C TI O N Pharmacology

Abdominal. The abdomen is soft, nontender, and nondis- Opioid rotation (also called opioid switching or substitution)
tended; bowel sounds are present but hypoactive in all four quad- requires familiarity with a range of opioid agonists and with the
rants. (Abdominal examination may not be routine in this situa- use of opioid dose conversion tables to find equianalgesic dosages.
tion, but it may demonstrate decreased bowel sounds secondary The objective of switching one opioid with another is to reduce
to the effect of opioids on gastrointestinal [GI] motility or disten- the adverse effects. Alternatively, switching the route of systemic
sion with tenderness suggestive of a bowel obstruction. Pain in the administration, such as changing from the intravenous to the oral
right upper quadrant is more consistent with cholecystitis or bili- route, has been shown to ameliorate symptoms of nausea, consti-
ary tract disease.) pation, and drowsiness. In many acute situations, nonsteroidal
antiinflammatory drugs (NSAIDs) provide analgesia equal to the
Imaging starting doses of opioids. However, unlike opioids that lack a ceil-
ing dose, NSAIDs have a maximum dose above which no addi-
No imaging studies are indicated unless the situation is com- tional analgesic effect is obtained.
pounded by other medical conditions. For patients with a suspi- The current patient was treated with a single dose of oral pro-
cion of aspiration, such as those with concomitant alcohol con- methazine (Phenergan) 12.5 mg. (Studies have shown that
sumption or decreased mental status secondary to excessive opioid 12.5 mg of oral Phenergan is as effective in reducing symptoms of
intake, chest radiography may be indicated. nausea as 25 mg of oral Phenergan and may result in fewer ad-
verse effects.) The patient's medication was switched to a nonopi-
Labs oid analgesic (ibuprofen 400 mg orally every 6 hours). She was
also instructed to increase her oral intake, preferably with isotonic
No laboratory studies are indicated unless dictated by preexisting drinks. She responded well to this regimen, with resolution of her
medical conditions, such as uncontrolled diabetes. In patients nausea and reduction of pain to an acceptable level. If the initial
with prolonged vomiting, metabolic alkalosis and other electro- antiemetic agent fails, a rescue antiemetic from a different treat-
lyte abnormalities may ensue. Appropriate laboratory studies ment class can be considered.
should be ordered as needed.
Complications
Assessment
Although opioids are well recognized as being effective for moder-
Acute nausea and vomiting associated with postoperative opioid an- ate to severe pain, they are frequently associated with an array of
algesia, status post dentoalveolar surgery; subjective report of moderate troublesome side effects (Table 9.2). Genuine allergy to opioids is
pain that is nonresponsive to the current pharmacologic regimen. rare. In most cases, patients report having an opioid allergy when
It is important to distinguish acute pain, which is of recent they actually have had an opioid-related adverse effect.
onset and limited duration, from chronic pain, which is described The following are some of the complications that can arise
as lasting for an undefined period, beyond that expected for the with opioid therapy.
injury to heal. This distinction has both diagnostic and treatment Nausea and vomiting. Approximately 40% of patients using
implications. Caution should be exercised when treating chronic opioids report experiencing nausea and 15% to 25% of patients
pain with opioids because of the development of dependence. may experience vomiting after opioid administration. It is a com-
mon and unpleasant adverse effect of opioids. However, fewer
Treatment than 20% of patients experiencing these side effects reported this
to their health care providers. Opioid receptors play an important
Several different approaches can be used, either alone or in com- role in the control of emesis (vomiting). They directly stimulate
bination, for the management of the adverse effects of opioids.
These include:
• Dose reduction of the systemic opioid TABLE
• Symptomatic management of the adverse effect 9.2 Common Opiate-Induced Adverse Effects
• Opioid rotation (or switching)
• Alternate routes of systemic administration Body System Adverse Effects
Reducing the dose of the administered opioid can result in a Gastrointestinal Nausea Vomiting
reduction of dose-related adverse effects. To compensate for the Autonomic Constipation
loss of pain control, adjunctive strategies can be used to maintain Central nervous system Xerostomia
control while reducing the dose or eliminating the opioid. Com- Cutaneous Urinary retention
mon strategies include addition of a nonopioid coanalgesic or an Postural hypotension
adjuvant analgesic that is appropriate to the pain syndrome and Drowsiness
mechanism (e.g., addition of gabapentin (Neurontin) for the Cognitive impairment
Hallucinations
treatment of neuropathic pain). In addition, therapy targeting the
Delirium
cause of the pain (e.g., placement of packing material into a dry Respiratory depression
socket wound), application of a regional anesthetic, or a neuroab- Myoclonus
lative intervention may be used. Seizure disorder
Symptomatic management of the adverse effect is usually Hyperalgesia
based on cumulative anecdotal experiences. In general, this in- Itch
volves the addition of one or more new medications. However, Sweating
polypharmacy adds to medication burden, and the possibility of
drug interactions needs to be considered.

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 CHAPTER 9 Opioid Side Effects 43

TABLE Nausea or vomiting has been shown to occur despite the use of
9.3 Antiemetic Drugs preemptive antiemetics. Switching to an alternative opioid can
reduce the severity of nausea and vomiting. In addition, it has
Pharmacologic Common Generic Common Trade been shown that patients who receive opioids intravenously
Group Name Names (primarily through patient-controlled analgesia pumps) exhibit
Anticholinergic Scopolamine Scopace, Transderm more nausea and vomiting. It should also be remembered that
Antihistamine Cyclizine Marezine, Migril independent of other factors, pain could be the cause of nausea or
Antiserotonins Dimenhydrinate Dramamine, vomiting.
Benzamides Diphenhydramine Dimentabs Constipation. This is another common adverse effect of opi-
Butyrophenones Promethazine Benadryl oids, one that is more problematic for patients on chronic opioid
Phenothiazines Dolasetron Phenergan therapy. Constipation may also contribute to nausea and vomit-
Steroids Granisetron Anzemet ing. It is defined by the four “too’s”: stools that are too hard, too
Ondansetron Kytril
small, too difficult to expel, or too infrequent. Opioids cause
Metoclopramide Zofran
Droperidol Reglan, Octamide
constipation by binding to receptors in the GI tract, thereby slow-
Haloperidol Droleptan ing peristalsis and increasing transit time. Consequently, sodium
Chlorpromazine Haldol and water are reabsorbed, resulting in dry, hardened stools. Pa-
Betamethasone Thorazine tients on long-term therapy seldom develop tolerance to this side
Dexamethasone Celestone effect and should be advised to increase their fluid intake and di-
Decadron etary fiber to compensate for the constipation. It has been sug-
gested that a stool softener and a large bowel stimulant (e.g.,
docusate sodium) be used for chronic opioid therapy. A stool
softener alone should not be prescribed because opioids slow nor-
the chemoreceptor trigger zone (CTZ), depressing the vomiting mal peristalsis and may result in an uncomfortable patient who is
center and slowing GI motility. Signaling between the CTZ and unable to evacuate his or her bowel. Thus, a stimulant laxative
the vomiting center is mediated through a variety of neurotrans- may also be prescribed. In the absence of a bowel movement for
mitter receptor systems, including the serotonergic, dopaminer- 3 to 4 days, more invasive measures may be necessary, such as
gic, histaminergic, cholinergic, and neurokininergic receptors. stool disimpaction or rectally administered bowel evacuants (e.g.,
The available antiemetics block one or more of the associated re- Fleet enema). A single dose of an opioid can affect GI tract motil-
ceptors (Table 9.3). The 2014 Consensus Guidelines for the ity. In addition, opioids are thought to have a role in the develop-
Management of Postoperative Nausea and Vomiting now recom- ment of postoperative ileus (a multifactorial phenomenon).
mend prophylactic antiemetics in moderate- to high-risk patients Respiratory depression. This is the most serious and most
to reduce the risk of nausea and vomiting. There is no “universal” feared adverse effect of opioid therapy. Respiratory depression to
antiemetic, and no current single antiemetic is 100% effective for the point of apnea is dose dependent and caused by opioids act-
all patients. ing directly on respiratory centers within the brainstem. This is
A commonly prescribed class of drugs are the serotonin characterized by a reduction in tidal volume, minute volume,
(5-HT3) receptor antagonists, which reduce the risk of nausea and respiratory rate, and the response to hypoxia and hypercapnia.
vomiting by approximately 26%. These include ondansetron Careful monitoring of the patient can prevent this adverse out-
(Zofran), granisetron droxytr (Kytril), dolasetron (Anzemet), and come. Equianalgesic dosages of other opioids produce the same
palonosetron (Aloxi), which act by inhibiting the action of sero- degree of respiratory depression. A review conducted in 2018
tonin in 5-HT3 receptor–rich areas of the brain and GI tract. found that the major risk factors for opioid-induced respiratory
These agents have been shown to be effective antiemetic agents; depression include age 65 years of age or older, female sex, ob-
their differing chemical structures may explain slight differences structive sleep apnea, chronic obstructive lung disease, cardiac
in receptor binding affinity, dose response, and duration of action. disease, neurologic disease, diabetes mellitus, hypertension, and
Ondansetron is one of the most commonly prescribed drugs in use of additional opioids (multiple prescriptions, analgesia pump,
this class but should be used cautiously because it can cause pro- etc.). In addition, patients with impaired respiratory function or
longed QT intervals and cardiac complications. Palonosetron has bronchial asthma are at greater risk of experiencing clinically
a longer duration of action and may be beneficial in preventing significant respiratory depression in response to the usual doses
nausea for up to 72 hours after discharge. In addition, palonose- of these drugs. If respiratory depression does occur, it is often in
tron was shown to have a significantly lower incidence of nausea an opioid-naïve patient; other signs and symptoms, such as seda-
and vomiting and severity of nausea than ondansetron. tion and mental clouding, can also be seen. Tolerance to this
The phenothiazines, including promethazine, are some of the effect occurs with repeated use of opioids, allowing the manage-
most commonly used antiemetics in the world, which act by an- ment of chronic pain without significant risk of respiratory
tagonizing histamine (H1) receptors in the vomiting center and depression. Naloxone (Narcan) can be used to reverse opioid-
vestibular apparatus. However, their use has fallen out of favor induced respiratory depression. To avoid an abrupt reversal of
because of their high incidence of adverse effects, such as sedation, analgesia (which may produce a catecholamine surge, resulting in
restlessness, diarrhea, agitation, central nervous system (CNS) tachycardia, hypertension, pulmonary edema, and arrhythmias),
depression and, more rarely, extrapyramidal effects, hypotension, naloxone is administered in doses of 40 mg repeated every few
neuroleptic syndrome, and supraventricular tachycardia. In 2009, minutes as necessary.
the US Food and Drug Administration issued a black box warn- Sedation. Opioid analgesics produce sedation and drowsiness.
ing for promethazine, advising practitioners of possible severe These properties are useful in certain situations (e.g., preopera-
tissue injury, including gangrene, from injection into an artery, tively), but they are not desirable in ambulatory patients.
under the skin, or even after intravenous administration. The CNS-depressant actions, in addition to respiratory depressant

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44 S E C TI O N Pharmacology

effects, are synergistic with alcohol, barbiturates, and benzodiaz- Tolerance. Tolerance is a physiologic adaptation to a drug. As
epines. Concurrent administration of dextromethamphetamine a person becomes tolerant to the pharmacologic effects, increasing
(2.5–5 mg orally twice daily) has been reported to reduce the doses are required to produce the same effect. Patients may de-
sedative effects of opioids. However, it has also been reported that velop tolerance to some but not all the effects of the opioid. In
using dextromethamphetamine and similar agents can, in certain general, tolerance develops rapidly to the sedative, analgesic, and
individuals, produce adverse effects such as hallucinations, delir- respiratory effects but is not commonly seen with the constipating
ium, psychosis, decreased appetite, tremor, and tachycardia; there- effects or the development of miosis. The hallmark of the develop-
fore, these drugs are contraindicated in those with psychiatric ment of tolerance is a decrease in the duration of effective analge-
disorders and are relatively contraindicated in those with a history sia. The rate of development of tolerance varies greatly among
of paroxysmal tachyarrhythmia. Opioid rotation or switching the individuals. However, a sudden increase in opioid requirement
route of administration can reduce the severity of opioid sedation. may also represent progression of the disease. Opioid rotation
Tolerance to sedative effects of opioids develops within the first may be of value for patients requiring long-term treatment.
several days of long-term administration. Mild cognitive impair- In addition, combining the opioid with a nonopioid not only
ment, delirium, and agitated confusion have also been reported in provides additive analgesia but also delays the development of
patients taking opioids. CNS effects appear to be idiosyncratic, tolerance.
not dose related. Meperidine is the opioid most commonly associ- Dependence. An individual is physically dependent on a drug
ated with adverse CNS events. (Meperidine is currently consid- when cessation of the drug or a rapid dose reduction initiates
ered for brief use as a second-line agent for the treatment of pa- symptoms of withdrawal. This generally includes autonomic
tients with acute pain.) After GI effects (nausea, vomiting, and signs, including diarrhea, rhinorrhea, piloerection, sweating, and
constipation), the combined CNS effects account for the second indicators of central arousal (e.g., sleeplessness, irritability, psy-
highest percentage of adverse drug events. chomotor agitation). Dependence is an expected physiologic
Pruritus. Pruritus is most often seen in neuraxial opioids (epi- phenomenon when certain drugs are used for sufficiently long
dural or spinal administration) but is occasionally observed with periods; it is neither a necessary nor a defining characteristic
parenteral opioid use. The mechanism by which opioids cause of addiction. Withdrawal can be avoided by slowly tapering the
itching is not fully known, although opioid-mediated direct re- dosage.
lease of histamine from mast cells is thought to contribute to this Addiction. According to the American Society of Addiction
effect (most notably with meperidine). Some opioids, such as Medicine, addiction is a primary chronic neurobiologic disease
fentanyl and alfentanil, do not cause histamine release but can that is influenced by genetic, psychosocial, and environmental
cause mild pruritus; the mechanism of this is not clear. (Mor- factors. Characteristics of addiction include impaired control over
phine, codeine, and meperidine stimulate histamine release; fen- drug use or continued use despite harm and cravings. It has been
tanyl, sufentanil, and alfentanil do not.) If pruritus is accompa- shown that among persons without a history of substance abuse
nied by a rash, allergic reactions cannot be ruled out. In such who are being treated for acute pain, the risk of true iatrogenic
patients, an opioid from a different chemical class may be used. addiction is relatively low and strongly related to the strength and
Options for managing itching include the use of histamine- duration of the medication prescribed. A 2021 cohort study pub-
blocking agents (e.g., diphenhydramine), administration of nal- lished in JAMA of addiction from first opioid prescriptions found
oxone, or changing the opioid. that there were two distinct trajectories of opioid use. The high-
Urinary retention. Although urinary retention is a known risk for addiction group was characterized by greater than
side effect of opioid administration, it is uncommon when the 10 milligram morphine equivalents (MME) per day, prescriptions
drug is administered for a short period. Opioids increase smooth intended for coverage 5 days or more, and multiple opioid pre-
muscle tone, cause bladder spasm, and increase sphincter tone, scriptions within the first month of opioid exposure. The low-risk
resulting in urinary retention, which occurs more frequently in group was characterized by lower MMEs per day at 4.7 MME,
the elderly. Catheterization may be required. supply for coverage for 4 days, and single opioid prescriptions.
Cough suppression. Suppression of the cough reflex is a well- Note that 5-mg hydrocodone taken twice per day would equal
known effect of opioids. In particular, codeine and derivatives are 10 MMEs. Patients in the high-risk group were three times more
extensively used in antitussive preparations. Dextromethorphan is likely to be diagnosed with opioid use disorder. Dental providers
an over-the-counter antitussive agent that acts centrally at thera- made up 37.7% of the prescribers included in the study. Being
peutic doses by binding to opioid receptors. The drug is about aware of the risk of addiction when prescribing opioids is espe-
equal to codeine in depressing the cough reflex. cially important in the field of dentistry.
Miosis. Constriction of the pupils is seen with all opioids. It is Pseudoaddiction. Pseudoaddiction is an iatrogenic syndrome
an action to which little or no tolerance develops even in chronic that mimics substance abuse. It resembles addiction but is a direct
users. This is a valuable sign in the diagnosis of opioid overdose result of inadequate treatment of pain. In the treatment of acute
and toxicity (and one commonly used by law enforcement pain (e.g., postsurgical pain), clinicians should attempt to provide
agents). an adequate regimen of analgesics to prevent this phenomenon.
Truncal rigidity. An increase in the tone of large trunk mus-
cles (stiff chest) has been seen with administration of large doses Discussion
of primarily highly lipophilic opioids (e.g., fentanyl, sufentanil,
alfentanil) that are administered rapidly (bolus administration). There are three major classes of opioid receptors in the CNS,
In the setting of acute respiratory distress, a rapidly acting neuro- designated by the Greek letters mu (m), kappa (k), and delta (d)
muscular agent, such as succinylcholine, can be administered to (Table 9.4). Most of the opioids used work clinically by binding
paralyze the muscles and allow ventilation. Alternatively, an opi- with relative selectivity to the mu receptors. Peripheral opioid re-
oid antagonist can be used, but this will also antagonize the anal- ceptors also exist and are thought to be responsible for some of the
gesic effects. adverse events. Mu receptor agonists have no therapeutic ceiling

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 9 Opioid Side Effects 45

TABLE hydromorphone and oxymorphone, respectively. Approximately

9.4 Major Opioid Receptors 7% to 10% of the White population metabolizes codeine, oxy-
codone, and hydrocodone poorly because of inherited deficien-
Receptor Effects cies of CYP2D6; therefore, analgesia from these drugs will be
Mu (m) Analgesia less than expected.
Mu 1 Respiratory depression, bradycardia, physical dependence, Preemptive analgesia, the administration of analgesics before
Mu 2 euphoria, ileus the onset of a noxious stimuli, has been shown to reduce postop-
Delta (d) Analgesia; modulates activity at the mu receptor. It is erative opioid use and thus opioid side effects. Preemptive analge-
Kappa (k) thought that mu and delta receptors coexist sia can be achieved with the use of agents to modify both periph-
Analgesia, sedation, dysphoria, psychomimetic effects eral CNS processing of noxious stimuli (e.g., use of a long-acting
local anesthetic) and central CNS processing of these stimuli (e.g.,
preoperative ibuprofen 800 mg orally or ketorolac 30 mg intrave-
nously). A randomized controlled study published in 2020 evalu-
effect. Therefore, unlike nonopioid analgesics, the dose of these ated the relationship between administering preemptive medica-
drugs can be adjusted until satisfactory pain control is achieved. tions (200 mg of celecoxib vs 500 mg of acetaminophen) before
Most members of the opioid family are chemically similar to third molar extraction and postoperative pain and pain medica-
morphine, with minor chemical modifications that change the tions taken. The researchers found that patients given oral cele-
pharmacokinetics and pharmacodynamics. Pharmacodynamics coxib 30 minutes before surgery (compared with acetaminophen)
refers to the biochemical effects of drugs and their mechanism had significantly lower postoperative pain and took fewer pain
of action. Pharmacokinetics refers to the factors (absorption, medications in the 24 hours after surgery. These results are sup-
distribution, biotransformation, and excretion) that determine ported by findings from studies of patients undergoing hysterecto-
the concentration of a drug at its sites of action. Pharmacody- mies in whom fewer opioids were needed in the days after surgery.
namics can be thought of as “what the drug does to the body,” A large number of analgesics have both nonopioid and opioid
and pharmacokinetics can be thought of as “what the body does ingredients. Combinations allow a lower dosage of the opioid be-
to the drug.” ing used (an “opioid-sparing effect”) with a decrease in opioid-
Individual patients could also be genetically predisposed to related adverse effects. When prescribing these agents, clinicians
poor analgesia. Codeine has very little affinity for the mu recep- must be sure to be aware of the toxic dose of the nonopioid agent.
tor and may be considered a prodrug because 10% of the parent
drug is converted to morphine by cytochrome P450 (CYP) ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
2D6. Hydrocodone and oxycodone require demethylation to complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 45.e1

Bibliography Phero JC, Becker DE, Dionne RA, et al: Contemporary trends in acute
pain management, Curr Opin Otolaryngol Head Neck Surg 12:209-
216, 2004.
Abdelal R, Banerjee AR, Carlberg-Racich S, et al: The need for multiple Plaisance L: Opioid induced constipation, Am J Nurs 102:72, 2002.
naloxone administrations for opioid overdose reversals: a review of the Sachs CJ: Oral analgesics for acute nonspecific pain, Am Fam Physician
literature, Subst Abus 43(1):774–784, 2022. 71:913-918, 2005.
Apfel CC, Laara E, Koivuranta M, et al: A simplified risk score for Scorza K: Evaluation of nausea and vomiting, Am Fam Physician
predicting postoperative nausea and vomiting: conclusions from 76(1):76-84, 2007.
cross-validations between two centers, Anesthesiolog y 91(3): Scuderi PE: Pharmacology of antiemetics, Int Anesthesiol Clin 41:41-66,
693-700, 1999. 2003.
Barrett TW, DiPersio DM, Jenkins CA, et al: A randomized placebo Sharbaf Shoar N, Marwaha R, Molla M: Dextroamphetamine-Amphet-
controlled trial of ondansetron, metoclopramide and promethazine in amine. [Updated 2023 May 23]. In StatPearls [Internet], Treasure
adults, Am J Emerg Med 29:3, 2011. Island, FL, 2023, StatPearls Publishing. https://www.ncbi.nlm.nih.
Bates JJ, Foss JF, Murphy DB, et al: Are peripheral opioid antagonists the gov/books/NBK507808/.
solution to opioid side effects? Anesth Analg 98:116-122, 2004. Silva PUJ, Meneses-Santos D, Vieira WA, et al: Preemptive use of intra-
Cepeda MS: Side effects of opioids during short term administration: venous ibuprofen to reduce postoperative pain after lower third molar
effect of age, gender, and race, Clin Pharmacol Ther 74:102-112, 2003. surgery: a systematic review of randomized controlled trials, Clinics
Cherny N, Ripamonti C, Pereira J, et al: Strategies to manage the adverse (São Paulo) 76:e2780–e2780, 2021.
effects of oral morphine: an evidence based report, J Clin Oncol Strassels SA: Postoperative pain management: a practical review. Part 1,
19:2542-2554, 2001. Am J Health Syst Pharm 62:1904-1916, 2005.
Fletcher M, Spera J: Management of acute postoperative pain after oral Strassels SA: Postoperative pain management: a practical review. Part 2,
surgery, Dent Clin North Am 56:95-111, 2012. Am J Health Syst Pharm 62:2019-2025, 2005.
Gupta K, Prasad A, Nagappa M, et al: Risk factors for opioid-induced Swegle JM, Logemann C: Management of common opioid-induced ad-
respiratory depression and failure to rescue: a review, Curr Opin An- verse effects, Am Fam Physician 74(8):1347–1354, 2006.
aesthesiol 31(1):110-119, 2018. Swift JQ: Nonsteroidal anti-inflammatory drugs and opioids: safety and
Inturrisi CE: Clinical pharmacology of opioids for pain, Clin J Pain usage concerns in the differential treatment of postoperative orofacial
18:S3-S13, 2002. pain, J Oral Maxillofac Surg 58:8-11, 2000.
Katzung BG (ed): Basic and clinical pharmacology, ed 9, New York, 2004, Tirupathi S, Rajasekhar S, Maloth SS, et al: Pre-emptive analgesic effi-
Lang/McGraw-Hill. cacy of injected ketorolac in comparison to other agents for third
Le T, Gan T: Update on the management of postoperative nausea and molar surgical removal: a systematic review, J Dent Anesth Pain Med
vomiting and post discharge nausea and vomiting in ambulatory 21(1):1–14, 2021.
surgery, Anesthesiol Clin 28:225-249, 2010. Wheeler M, Oderda GM, Ashburn MA, et al: Adverse events associated
Longstreth GF, Hesketh PJ: Characteristics of antiemetic drugs. In Post with postoperative opioid analgesia: a systematic review, J Pain 3:159-
TW, editor: UpToDate, Waltham, MA, 2023, UpToDate Inc. http:// 180, 2002.
www.uptodate.com. Wilson JD, Abebe KZ, Kraemer K, et al: Trajectories of opioid use fol-
Mallick-Searle T, Fillman M: The pathophysiology, incidence, impact, lowing first opioid prescription in opioid-naive youths and young
and treatment of opioid-induced nausea and vomiting, J Am Assoc adults, JAMA Netw Open 4(4):e214552, 2021.
Nurse Pract 29(11):704-710, 2017. Xie L, Yang RT, Lv K, et al: Comparison of low pre-emptive oral doses
Nguyen E, Lim G, Ross SE: Evaluation of therapies for peripheral and of celecoxib versus acetaminophen for postoperative pain manage-
neuraxial opioid-induced pruritus based on molecular and cellular ment after third molar surgery: a randomized controlled study, J Oral
discoveries, Anesthesiology 135(2):350-365, 2021. Maxillofac Surg 78(1):75.e1-75.e6, 2020.

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10
The Opioid Epidemic
E L I S E L . E HL A N D, S H AE BR YA N T, a n d C H A D LOW E L L WAG N E R

CC Imaging
A 16-year-old female is referred for consultation regarding her A panoramic radiograph reveals a minimally restored dentition
third molars. and no pathology of the bones, joints, or sinuses in the field of
view. Bonded retainer is present. All third molars are vertically
HPI impacted at the level of the adjacent teeth cementoenamel junc-
tion. There are greater than 50% root development and a lack of
The patient desires extraction of her third molars before initiating space to accommodate eruption. There is no interruption of the
orthodontic therapy, and she presents with her mother to her ap- inferior alveolar canal.
pointment. She is currently asymptomatic and denies any fever,
swelling, or pain. She reports being very nervous, she is afraid of Labs
needles, and she does not want to feel any pain.
No routine laboratory tests are indicated for the evaluation of im-
PMHX/PDHX/Medications/Allergies/SH/FH pacted third molars unless dictated by underlying medical conditions.

The patient has uncontrolled depression and anxiety. She reports Assessment
fear of the dentist with a low pain tolerance. She denies past sur-
geries and medications. She denies a history of alcohol, tobacco, 16-year-old ASA (American Society of Anesthesiologists physical status
or illicit drug use. She has no known drug allergies or family his- classification system) I female with a history of depression and anxiety
tory of anesthesia complications. with impacted third molar teeth. The patient and her mother elect
for extraction of her asymptomatic maxillary and mandibular
impacted third molars with local anesthesia and intravenous (IV)
Examination sedation.
General
Treatment
The patient is a well-developed and well-nourished teenager in no
acute distress. Intravenous sedation is indicated to reduce fear and anxiety dur-
ing surgical removal of impacted third molars and to attempt to
Maxillofacial eliminate recall of the procedure. A combination of drugs is
There are no soft tissue abnormalities or cervical lymphadenopa- typically used to achieve a proper balance of sedative, amnestic,
thy. There are no clicks or pain to palpation of the temporoman- and analgesic effects with appropriate durations of action. The
dibular joints bilaterally. The muscles of mastication are nontender perioperative medications delivered have been shown to have an
to palpation. Maximum interincisal opening is 4–5 mm with no effect on the amount of postoperative pain the patient will expe-
lateral deviation upon open or close. rience and subsequently the amount of opioids prescribed.
Counterintuitively, reducing the use of intraoperative opioids (in
Intraoral an effort to combat the epidemic) may actually result in a greater
need for postoperative opioids. There is no significant evidence
Examination of the oropharynx is without tonsillar hypertrophy, correlating the use of intraoperative opioids with addiction.
the uvula is midline, and the patient has a Mallampati score of 1. Therefore, clinicians should not shy away from intraoperative
There are no visible lesions or pathology of the soft tissues. The opioid use when indicated. Opioid-sparing multimodal analgesia
patient has minimally restored dentition, stable occlusion, and has been shown to augment and maximize pain control while
fair oral hygiene; a bonded mandibular lingual retainer is present. combating the negative side effects of opioids (see Complica-
All third molars are not visible intraorally. Probing depths are tions). This technique may include the perioperative use of non-
6 mm distal to the mandibular second molars with no bleeding steroidal anti-inflammatory drugs (NSAIDs), acetaminophen,
on probing. There is no tenderness to palpation, no erythema, corticosteroids, long-acting local anesthetics, and other adjuncts
and no signs of infection in the third molar regions. such as ketamine.

46
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 10 The Opioid Epidemic 47

The patient arrived at the clinic and was visibly nervous. A monotherapy, suggesting opioids are less effective than nonopioid
preoperative discussion was held with the patient and her mother alternatives in this setting. Low-dose opioids do provide some
to address their concerns, calm her fears, and answer all questions. benefit as a rescue medication for severe breakthrough pain, but
They both expressed understanding that postoperative pain would this situation can usually be avoided with proper patient educa-
be appropriately managed but not entirely eliminated. The mother tion and compliance.
was escorted back to the waiting room while monitors and oxygen
were placed. IV access was obtained using distraction techniques. Complications
(Assistants discussed her pet animals at home while she looked
away with consent.) Prescription opioids carry the potential to be both beneficial and
Midazolam was administered immediately for its amnestic and harmful. The benefits may lead clinicians to overprescribe, whereas
anxiolytic effects followed by slow titration of fentanyl to a com- the risks may lead them to underprescribe. Both of these scenarios
fortable state of conscious sedation. Dexamethasone was adminis- result in complications. Therefore, prescribing opioids is a balanc-
tered slowly to address postoperative inflammation and swelling ing act that requires careful consideration of the risks, benefits,
and therefore indirectly reducing postoperative pain. Dexametha- and alternatives.
sone also carries the added benefit of preventing postoperative The primary risk of underprescribing opioids is uncontrolled
nausea and vomiting (PONV), which is a known side effect of breakthrough pain after failed management with first-line agents.
opioids. At this point, ketamine may sometimes be considered for Common sequelae of untreated pain include functional impair-
deeper sedation and adjunctive analgesia. However, there is no evi- ment, increased morbidity, delayed healing and recovery time, in-
dence to show IV ketamine for third molar surgery reduces postop- creased health care costs, and undue emotional stress. The primary
erative pain or opioid consumption, particularly in patients who goal after surgery is pain modulation rather than pain elimination.
received intraoperative opioids. In this case, the patient was man- Patients should be educated beforehand that some postoperative
aged without ketamine. A throat pack and bite block were placed pain is acceptable as long as it does not affect their ability to per-
followed by administration of local anesthesia with adequate time form daily activities such as eating, talking, or sleeping.
allowed for profound effect. Specifically, lidocaine with epinephrine Alternatively, overprescribing opioids may lead to misuse, di-
was injected in all four quadrants, in addition to longer-acting bu- version, dependence, addiction, overdose, and death. Opioid use
pivacaine with epinephrine for the mandibular nerve blocks. disorder, rather than opioid abuse, is the correct term used to rec-
Surgery was completed routinely in 30 minutes with care to ognize the condition as a medical diagnosis and not a moral fail-
prevent iatrogenic injury and tissue trauma. There were no peri- ing. Risk factors for this include past or current substance use
operative surgical or anesthetic complications. Surgical variables disorder, untreated psychiatric disorders, younger age, and social
that have been shown to affect postoperative pain include dura- or family environments that encourage misuse. For chronic users,
tion of surgery, surgeon experience and technique, degree of dif- withdrawal from opioids may include nausea, diarrhea, muscle
ficulty of the extractions, and amount of hard and soft tissue aches, insomnia, agitation, and depression. Long-term use may
damage. Despite attempts to limit surgical variables that cause also lead to tolerance, thus requiring increased doses to achieve
postoperative pain, pain is not the same as nociception. Pain is a the same desired effect. Older adult patients, on the other hand,
subjective experience that is highly variable from patient to patient usually require lower doses because of altered metabolism.
based on biopsychosocial factors. The management of postopera- Even for those without opioid use disorder or substance use dis-
tive pain should therefore be individualized according to each order, opioids are not a benign substance. Common side effects of
patient and each surgery. opioids include sedation, respiratory depression, PONV, urinary
In this case, the patient’s young age and history of mental ill- retention, and constipation. Opioid-induced respiratory depression
ness place her at a higher risk of the negative consequences of may be exacerbated when combined with benzodiazepines or alco-
prescription opioids. Her quick and routine surgery, on the other hol. In the event of an emergency, naloxone is a rapid opioid reversal
hand, places her at a lower chance of prescription opioid require- that is essential for every surgical setting. It is imperative that clini-
ment for adequate analgesia. A recent study in the Journal of Oral cians routinely check expiration dates and know where their nalox-
and Maxillofacial Surgery (JOMS) showed 93% of patients did not one is located in the facility before administration of any opioids.
use any of their prescribed oxycodone after extraction of asymp-
tomatic third molars. Among the small percentage who did, an Discussion
average of 3.3 tablets were used, with the highest use on postop-
erative day 2. This patient was prescribed ibuprofen and acet- The opioid epidemic has been described as a uniquely American
aminophen as first-line analgesics to be taken around the clock on problem, though it may soon be considered a global pandemic if
an alternating schedule. After a thorough discussion of the risks we are not vigilant. It started in the mid-1990s when big pharma-
versus benefits of opioids, the patient and her mother declined an ceutical companies promoted OxyContin and exploited “pain as
opioid prescription for breakthrough pain. This discussion was the fifth vital sign” to sell their products, triggering the first wave
documented, and verbal and written postoperative instructions of overdose deaths. A second wave of deaths came around 2010
were provided along with an emergency contact number to call when people with existing addictions to opioids transitioned to
for the unlikely event of debilitating pain. The patient and her the cheaper and more abundant drug heroin. More recently, a
mother were reminded of the preoperative education regarding third wave of deaths has been driven primarily by stronger illicit
pain management expectations. A cross-sectional study in JOMS synthetic opioids such as fentanyl, despite ongoing efforts from
shows nearly half of parents do not feel comfortable with their doctors to reduce unnecessary opioid prescriptions (Fig. 10.1).
children being prescribed opioids after third molar extractions. In According to the American Medical Association, the number of
addition, several reviews by the Cochrane Collaboration indicate opioids prescribed has decreased by nearly 50% from their peak
the number needed to treat acute postoperative pain is actually in 2011 until 2021. Doctors should not be discouraged, however,
lower for NSAIDs and acetaminophen compared with opioid because the rise in deaths is more significantly correlated with

t.me/Dr_Mouayyad_AlbtousH
48 S E C TI O N Pharmacology

Three waves of opioid overdose deaths

24
22
Any opioid
20
18
Deaths per 100,000
Other synthetic opioids (e.g.,
16 Tramadol or fentanyl, prescribed or
14 illicitly manufactured)
12
10
Commonly prescribed opioids
8
(natural and semisynthetic opioids
6 and methadone)
4 Heroin
2
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Wave 1: Rise in Wave 2: Rise in heroin Wave 3: Rise in synthetic
prescription opioid overdose deaths opioid overdose deaths
overdose deaths started in 2010 started in 2013
Source: National vital statistics system mortality file.

• Fig. 10.1 Three waves of the rise in opioid overdose deaths. From Centers for Disease Control and
Prevention, National Center for Health Statistics: Understanding the Opioid Overdose Epidemic; 2021.
https://www.cdc.gov/opioids/basics/epidemic.html.

dangerous illicit fentanyl as opposed to prescription overdoses. In by a dental clinician, and there was an increased risk of prolonged
fact, the onslaught of heroin and fentanyl catastrophes only un- opioid use in opioid-exposed patients (6.9%) compared with opi-
derscores the importance of practicing safe stewardship over pre- oid-nonexposed patients (0.1%).
scription opioids. Among heroin users in the United States, about Despite all the evidence, much of the discussion surrounding
four in five reported misusing prescription opioids before starting pain management continues to be rooted in dogma and provider
heroin, suggesting exposure to prescription opioids might be a opinion. Fortunately for our specialty, the American Association
gateway to cheaper and stronger alternatives. of Oral and Maxillofacial Surgery released a white paper in 2020
Although we may not be able to solve this crisis alone, we can with guidelines for prescribing opioids in the setting of acute and
certainly play a role in preventing exacerbation of the crisis. A postoperative pain. It clearly states pain management should be
systematic review in 2017 showed between 42% and 71% of pre- individualized to each patient. NSAIDs should be prescribed as
scribed opioids went unused among patients undergoing a variety first-line agents unless contraindicated, followed by acetamino-
of different types of surgeries, suggesting a large reservoir of opi- phen, while carefully considering maximum dosages. When used
oids contributing to the nonmedical use and diversion of these together, they rival opioids in their analgesic effect. Opioids may
products. This is consistent with a 2017 study in JOMS that evalu- be considered for acute breakthrough pain, but providers should
ated the percentage of opioid pills used after all third molar extrac- prescribe the lowest effective dose and shortest duration possible.
tions with IV sedation (symptomatic and asymptomatic cases). Other adjuncts such as corticosteroids, long-acting local anesthet-
The same study showed six or seven tablets of a low-dose opioid ics, and nonopioid alternatives should be strongly considered
may be sufficient for third molar extractions during the first according to provider discretion. See Table 10.1 for drugs com-
3 postoperative days. With the convenience of electronic prescrip- monly used for multimodal analgesia by the oral and maxillofacial
tions, patients can contact their provider if this is insufficient. surgeon. Chronic pain has been shown to be ineffectively man-
The quantity of pills prescribed is arguably less remarkable than aged with opioids, and it is generally not within our specialty’s
to whom they are being prescribed. A one-time prescription for scope of practice to do so. If there is suspicion of opioid misuse,
seven tablets of oxycodone after surgery is unlikely to stock an prescribers should access their state prescription drug monitoring
entire medicine cabinet, but it may be the first exposure of opioids program. Patients should be instructed on the proper storage and
to a teenager or young adult. Even appropriate use of opioid anal- disposal of any prescribed opioids, and all instructions for pain
gesia in teenagers with no history of drug abuse has been associated management should be carefully documented.
with a 33% increase in the risk of opioid abuse after high school.
A large retrospective study in 2019 found nearly one-third of opi- ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
oids prescribed to patients aged 16 to 25 years old were prescribed complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 10 The Opioid Epidemic 49

TABLE
10.1 Drugs Commonly Used in Multimodal Analgesia by the Oral and Maxillofacial Surgeon

Class Drug Typical Adult Dosing Important Considerations

NSAIDs Ibuprofen PO: 400–600 mg q4–6h • Dose-dependent relief up to maximum dosages
• Caution with pregnancy, asthma, cardiovascular dis-
Naproxen (sodium) PO: 220–440 mg q8–12h ease, renal insufficiency, GI bleeding concerns
Celecoxib PO: 100–200 mg BID • Drug interactions

Meloxicam PO: 7.5–15 mg daily

Ketorolac IV: 15–30 mg q6h
Analgesic, Acetaminophen PO: 325–650 mg q4–6h • Do not exceed 4 g/day (all sources)
nonopioid IV: 1000 mg q6h • Caution with liver impairment, hepatotoxicity
• Potentiates warfarin anticoagulation
Opioids and Fentanyl IV: 1 mcg/kg • Variable metabolism in geriatric and ethnic popula-
combinations tions
Oxycodone PO: 5–10 mg q6–8h • Misuse, diversion
Oxycodone/acetaminophen PO: 2.5–5 mg/325 mg q6h • Addiction
• Respiratory depression
Hydrocodone/acetaminophen PO: 5 mg/325 mg q6h • Constipation
Codeine/acetaminophen PO: 30 mg/300 mg q4–6h • Urinary retention
• PONV exacerbated with benzodiazepines or alcohol
• Reversal: naloxone 0.04 mg IV q2–3min up to 2 mg
NMDA antagonist Ketamine IV: 0.3–0.5 mg/kg • Sympathomimetic
IM: 3–5 mg/kg • Increases ICP
• Emergence delirium (limited with benzodiazepines)
• Increased secretions (limited with glycopyrrolate)
Long-acting local Bupivacaine 0.5% 1 1:200,000 Nerve block: 2 mg/kg up to 90 mg • Local anesthetic systemic toxicity
anesthetics epinephrine • Cardiotoxic effects
Liposomal bupivacaine Local injection: 133 mg (10 mL)
Steroids Dexamethasone IV: 4–10 mg • Antiinflammatory, antiemetic
• Immunosuppression
Methylprednisolone PO: 24 mg on day 1; taper down 4 • Hyperglycemia
mg per day • Multiple side effects
Gabapentinoids Gabapentin PO: 300–1200 mg TID • Anticonvulsant, often used for neuropathic pain
• Caution with pregnancy
• Avoid abrupt withdrawal after long-term use

BID, Twice a day; GI, gastrointestinal; ICP, intracranial pressure; IV, intravenous; NSAID, nonsteroidal antiinflammatory drug; PO, by mouth; PONV, postoperative nausea and vomiting; TID, three times a day.

t.me/Dr_Mouayyad_AlbtousH
 49.e1

Bibliography Oral Maxillofac Surg 75(10), 2017. Available from https://doi.

org/10.1016/j.joms.2017.07.060.
Miech R, Johnston L, O’Malley PM, et al: Prescription opioids in ado-
AMA overdose epidemic report - American Medical Association, 2021. Available lescence and future opioid misuse, Pediatrics 136(5), 2015. Available
from https://www.ama-assn.org/system/files/ama-overdose-epidemic- from https://doi.org/10.1542/peds.2015-1364.
report.pdf. Opioid prescribing: acute and postoperative pain management – AAOMS,
Bicket MC, Long JJ, Pronovost PJ, et al: Prescription opioid analgesics 2020. Available from https://www.aaoms.org/docs/govt_affairs/advo-
commonly unused after surgery, JAMA Surg 152(11):1066, 2017. cacy_white_papers/opioid_prescribing.pdf.
Available from https://doi.org/10.1001/jamasurg.2017.0831. Resnick CM, Calabrese CE, Afshar S, et al: Do oral and maxillofacial
Caroline JP, Caughey J, Wang S, et al: Parents’ perception of opioid prescrip- surgeons over-prescribe opioids after extraction of asymptomatic third
tion patterns following third molar extraction, J Oral Maxillofac Surg molars?, J Oral Maxillofac Surg 77(7):1332-1336, 2019. Available
76(10), 2018. Available from https://doi.org/10.1016/j.joms.2018.06.125. from https://doi.org/10.1016/j.joms.2019.02.011.
Cheung J, Alashi A, Koto P, et al: Does sub-anesthetic ketamine provide Schroeder AR, Dehghan M, Newman TB, et al: Association of opioid
postoperative analgesia for third molar surgery?, J Oral Maxillofac prescriptions from dental clinicians for us adolescents and young
Surg 77(12):2452-2464, 2019. Available from https://doi. adults with subsequent opioid use and abuse, JAMA Intern Med
org/10.1016/j.joms.2019.05.009. 179(2):145, 2019. Available from https://doi.org/10.1001/jamain-
Jones CM: Heroin use and heroin use risk behaviors among nonmedical ternmed.2018.5419.
users of prescription opioid pain relievers – United States, 2002–2004 Teater D: Evidence for the efficacy of pain medications, n.d. Available from
and 2008–2010, Drug Alcohol Depend 132(1-2):95-100, 2013. Avail- https://www.floridahealth.gov/statistics-and-data/e-forcse/news-re-
able from https://doi.org/10.1016/j.drugalcdep.2013.01.007. ports/_documents/evidence-efficacy-pain-medications.pdf.
Lahey ET, Ji YD, Charest K, et al: How many opioid pills do patients re-
quire following third molar extraction with intravenous sedation?, J

t.me/Dr_Mouayyad_AlbtousH
11
Oral Drug–Induced Osteonecrosis
of the Jaws
R O B E R T E. MA R X

CC manifested as a rash. She is currently taking clindamycin 300 mg

three times daily for her facial swelling and pain.
A 65-year-old female is referred for evaluation because “the right
side of my face aches, and I feel it is swollen.” Examination
The right side of the patient’s face is mildly edematous and tender
Oral Drug–Induced Osteonecrosis to the touch. Vital signs indicate that the patient’s hypertension is
of the Jaws under control (126/76 mm Hg). She has a heart rate of 80 bpm
and respirations of 14 per minute.
Patients who take oral bisphosphonates must be treated differ- Oral and Maxillofacial. The oral examination identified ex-
ently from other patients and must also be treated differently from posed necrotic bone and loss of gingiva and oral mucosa on the
patients receiving intravenous (IV) bisphosphonates. Although facial aspect of the bicuspid and molar teeth in the right side of
drug-induced osteonecrosis of the jaws (DIONJ) caused by oral the maxilla (Fig. 11.1). There is a slight suppurative exudate,
bisphosphonates can result in a severe and extensive exposure of and the edge of the retracted mucosa is mildly inflamed. The roots
bone and may also require extensive surgery, it generally is less of the teeth within the exposed bone are discolored, and the teeth
common, less severe, and more amenable to office-based debride- have 11 to 21 mobility.
ment surgeries than IV DIONJ.
Imaging
HPI
Cone-beam computed tomography scan shows a disrupted and
The patient is a 65-year-old female who was referred by her perio- irregular trabecular bone pattern in the alveolar bone in the right
dontist after she developed exposed bone as a complication of side of the maxilla. The right maxillary sinus has a complete
periodontal surgery to graft vertical defects in the #3 and #4 areas. opacification with what appears to be a swollen sinus mucous
The referring periodontist did not realize that this female patient membrane (Fig. 11.2).
had been taking alendronate (Fosamax) 70 mg/week for the past
7 years. The bone exposure apparently developed soon after the
surgery, about 10 months ago. The patient states that the initial
area of exposed bone has increased in size since that time despite
attempts to advance local tissue to cover the bone, various courses
of antibiotics, and even hyperbaric oxygen treatment. She reports
episodes of increased pain accompanied by swelling of her cheek
and some drainage. She also complains that her nose “feels stuffy.”

PMHX/PDHX/Medications/Allergies/SH/FH
This patient has a history of hypertension and age-related hypo-
thyroidism, in addition to the osteopenia, for which she was
started on Fosamax to “prevent osteoporosis.” However, she re-
lates that her dual x-ray absorptiometry scan–generated T scores
last year went beyond the 2.5 benchmark for osteoporosis. She
currently takes Norvasc and hydrochlorothiazide for her hyper-
tension and Synthroid for her hypothyroidism. She stopped tak-
ing Fosamax 6 months ago. She relates an allergy to penicillin, • Fig. 11.1 Exposed bone and tooth roots in the right maxillary alveolus.

50
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 11 Oral Drug–Induced Osteonecrosis of the Jaws 51

doxycycline and reduce its absorption. Doxycycline is the best

choice after phenoxymethyl penicillin or amoxicillin for long-
term use in patients with DIONJ. Clindamycin, which this pa-
tient was taking at the time of presentation, is not a good choice.
In DIONJ, most exposed bone is colonized by Actinomyces spe-
cies, which are not very sensitive to clindamycin. The patient was
also placed on a drug holiday, with the approval of her prescribing
physician. In addition, the prescribing physician was advised to
obtain radiographs of the patient’s femur and was informed of the
increased reports of spontaneous subtrochanteric femur fractures
in women taking alendronate for 6 years or longer.
After an additional 3-month drug holiday, for a total drug
holiday of 9 months, a repeat morning fasting serum CTX test
was obtained, and its result was 180 pg/mL. This value was 30 pg/
mL above the benchmark at which debridement surgery can be
accomplished in an otherwise normal postmenopausal female
patient without cancer so that normal healing can be anticipated.
In such uncomplicated postmenopausal women who took a
bisphosphonate, it was found that after a 9-month drug holiday,
• Fig. 11.2 Cone-beam computed tomography scan shows complete all morning fasting serum CTX values were about 150 pg/mL.
opacification of the right maxillary sinus, indicative of secondary sinus in- Therefore, the CTX test is no longer used, and an arbitrary
flammation from the necrotic bony sinus floor. 9-month drug holiday before an alveolar bone procedure followed
by a 3-month drug holiday after the procedure is used.
The patient was subsequently treated in the operating room,
where the necrotic bone was removed; this amounted to the entire
Labs floor of the right maxillary sinus and the teeth within the alveolar
bone (Fig. 11.3A). The sinus was entered, and multiple mucoceles
The routine laboratory studies of a complete blood count and (often also called sinus polyps) and the entire edematous sinus
basic metabolic panel were within normal ranges. In particular, membrane were removed with vigorous curettage (Fig. 11.3B).
the white blood cell count was normal at 5000/mL with a normal An incision was then made through the periosteum in the poste-
differential. A morning fasting C-terminal telopeptide (CTX) test rior superior area of the vestibule to expose the buccal fat pad. A
was returned as 101 pg/mL. pericapsular dissection around the buccal fat pad and gentle trac-
tion were used to bring the vascular buccal fat pad forward to
Assessment completely fill the floor of the sinus (Fig. 11.3C). The fat pad was
sutured to bur holes placed into the buccal cortex of the remain-
Stage III drug-induced osteonecrosis of the maxilla secondary to alen- ing sinus wall and to the periosteum of the palatal soft tissue
dronate therapy. (Fig. 11.3D). The buccal mucosa was then undermined so as to
What was once referred to as bisphosphonate-induced, related, advance it sufficiently to gain a primary closure by suturing it to
or associated osteonecrosis of the jaws (ONJ) has now been clearly the palatal soft tissue (Fig. 11.3E).
defined as DIONJ. This is because denosumab, which also works by
an antiresorptive effect via osteoclast impairment and death but is Outcome
not a bisphosphonate, also causes ONJ. The misleading and ill-
defined terms “associated” and “related” have been dropped by the The closure healed and matured without further exposure of bone
American Medical Association; this was originally reflected in ver- (Fig. 11.4). The patient’s physician discontinued the alendronate.
sion of the International Classification of Diseases, Ninth Revision After 3 years, her osteoporosis-related T scores have not changed,
coding manual and has persisted since, which lists DIONJ, M87.10. and no osteoporosis-related fractures have occurred.
In the current patient, the stage III designation follows the
simplified staging system by Marx. That is, extension into the Discussion
maxillary sinus indicates an advanced presentation and therefore
stage III disease. The failure of other staging systems is their reli- Any drug that impairs or eliminates the normal function of an
ance on pain. Because the dead bone is not painful by itself and osteoclast or kills it has the potential to cause DIONJ or subtro-
only becomes painful if colonized or infected by microorganisms, chanteric fractures of the femur. Alendronate (Fosamax) has
pain does not relate to the extensiveness or severity of the disease. caused more than 96% of all cases of oral bisphosphonate–
Additionally, the use of antibiotics or analgesics changes the pain induced osteonecrosis, simply because it is marketed at twice the
(but not the severity or extension of the disease) and therefore also dose of its competitors, even though all these drugs have the same
changes the stage. mechanism of action, are equally potent, are absorbed in the same
amount, and have the same 11-year half-life in bone. Deno-
Treatment sumab, a newer and different type of drug, recently has become
available. Denosumab is a RANK (reactor activator of nuclear
This patient was placed on doxycycline 100 mg/day to palliate the kB) ligand inhibitor and currently is marketed as Prolia (60 mg
secondary infection and pain. She was told to take the doxycy- given by injection every 6 months) and as Xgeva (120 mg given
cline without milk products or yogurt, which are known to bind by injection every month). Denosumab, in both forms, already

t.me/Dr_Mouayyad_AlbtousH
52 S E C TI O N Pharmacology

A B

C D

E
• Fig. 11.3 A, Debridement of bone and teeth from the maxillary sinus floor. B, Multiple mucoceles (sinus
polyps) and inflamed sinus membrane are removed from the sinus. C, The buccal fat pad is advanced
forward after a pericapsular dissection. D, The buccal fat pad is sutured to the lateral sinus wall and
palatal mucosa to stabilize it in the sinus. E, Primary mucosal closure over the buccal fat pad is achieved
after extensive undermining.

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 11 Oral Drug–Induced Osteonecrosis of the Jaws 53

in turn, is due to the wide occlusal table of molar teeth and its
closer proximity to the hinge effect of the temporomandibular
joint. This greater force on the molar teeth is transmitted to the
underlying bone which, if sufficiently loaded with a bisphospho-
nate, cannot remodel to adjust and compensate for this loading
and becomes necrotic and exposed (Fig. 11.5B). It is further seen
that the axial loading on molar teeth is not on the inferior border,
as it is in other mandibular teeth, but on the lingual cortex instead
(Fig. 11.5C). The clinical importance of this is that a balanced
occlusion reduces the risk of developing DIONJ as much as any-
thing else, and the judicious use of night guards becomes a con-
sideration in many patients.
The remaining 70% of DIONJ cases caused by an oral
bisphosphonate are initiated by a surgical procedure on the alveo-
lar bone, mostly tooth extractions. All surgical procedures on the
alveolar bone require bone remodeling and renewal to heal.
Again, if the alveolar bone is sufficiently loaded with a bisphos-
• Fig. 11.4 Healed oral mucosa and resolved osteonecrosis of the jaws. phonate, it cannot meet this enhanced healing requirement and
may become necrotic. The clinical importance of this is that by
preventing the need to extract teeth by quality restorations or by
reducing periodontal inflammation by dental prophylaxis and
has produced cases of ONJ. Hence, the name was change from periodontal, both of which increase the requirement for bone re-
bisphosphonate-induced ONJ to DIONJ. modeling, the risk of developing DIONJ can be reduced.
Although alendronate caused ONJ as early as 1999, the focus Today, many clinicians are faced with the need to perform
of ONJ publications centered on the more common and more some invasive surgery on patients taking oral bisphosphonates.
severe cases attributed to pamidronate (Aredia, Novartis Pharma- Because of the minimal absorption of oral bisphosphonates, their
ceutical) and zoledronate (Zometa, Novartis Pharmaceutical). It accumulation in bone is delayed compared with IV forms, and
was not until Marx published the original article in 2003; the their impact on the bone marrow precursors of osteoclasts is less
textbook, Oral and Intravenous Bisphosphonate-Induced Osteone- and also delayed. Therefore, the risk of developing DIONJ after
crosis of the Jaws, in 2005; and another publication in 2007 that an oral surgical procedure begins at around 2 years of steady
the profession was alerted to the fact that oral bisphosphonates weekly or monthly dosing and first becomes significant at 3 years.
can cause ONJ and to the management of this problem. Since During this time and later, the author uses and recommends a
then, numerous publications, most identifying alendronate 9-month drug holiday before a procedure followed by a 3-month
(Fosamax) as the cause of ONJ, have left little doubt that oral drug holiday after a procedure.
bisphosphonates can and do cause ONJ. However, by 2008, sev-
eral publications had identified an unusual location of fractures in
the femur unassociated with trauma. These were linked to alen- Treatment of Oral Bisphosphonate Drug–
dronate taken as the commercial drug Fosamax and became Induced Osteonecrosis of the Jaws
known as subtrochanteric fractures of the femur. The number of
publications on these fractures and on ONJ has increased yearly The general principles of treating patients with oral bisphospho-
as cases of both have mounted. nate–induced ONJ were illustrated in this current patient’s case.
Prevention and treatment guidelines for patients taking oral After the exposed bone develops, it is best to consult the pre-
bisphosphonates have been published by several associations, in scribing physician to confirm the dose and the length of time
addition to several publications and textbooks. Although they the patient has been taking the drug. The higher the dose
may differ slightly, there is a consistency between them. (Fosamax is prescribed at 70 mg/week; Actonel at 35 mg/week;
For restorative dentists, it is well to remember that the teeth and Boniva at 150 mg/month, averaging 35 mg/week) and the
themselves do not take up bisphosphonates but that the alveolar greater the number of doses, the greater the severity of the ONJ.
bone does and is the target and initiation point for ONJ. There- The clinician should request a drug holiday from the bisphos-
fore, before, during, and after treatment with any bisphosphonate phonate for 9 months to 1 year. If the prescribing physician is
or denosumab, dentistry that does not invade the alveolar bone is reluctant to discontinue the oral bisphosphonate, they should be
safe. Restorative dentistry, crown and bridge work, dentures, root encouraged to read the JAMA article by Black et al. (2000) and
canals, and even scaling of the teeth that do not contact alveolar the US Food and Drug Administration 2011 publication on
bone are safe. In fact, many cases of DIONJ caused by oral drug safety (see the Bibliography for information on both cita-
bisphosphonates can be prevented by restoring teeth and by tions). Both of these publications concluded that the therapeu-
eradicating periodontal inflammation before or in the early time tic benefit of alendronate (Fosamax) does not extend beyond
course of treatment. 3 years of taking the drug and that the risk of complications
About 30% of cases of DIONJ caused by an oral bisphospho- overtakes the benefit at 5 years. Most prescribing physicians are
nate occur because of traumatic or heavy occlusion. However, very compliant with drug holidays and often use no alternative
most others are initiated by the traumatic injury of tooth removal therapy or use only calcium and vitamin D, raloxifene (Evista),
or other dentoalveolar surgery. This is particularly noted in spon- recombinant human parathyroid hormone 1-34 (Forteo), or
taneous cases in which the lingual cortex in the mandibular molar recombinant human parathyroid hormone 1-80 (Tymlos) as an
region is the first area to exhibit exposed bone (Fig. 11.5A). This, alternative treatment.

t.me/Dr_Mouayyad_AlbtousH
54 S E C TI O N Pharmacology

C
• Fig. 11.5 A, The mandibular lingual cortex is a site of predilection for spontaneous oral bisphosphonate–
induced osteonecrosis. B, Osteolysis of drug-induced osteonecrosis of the jaws caused by an oral
bisphosphonate but initiated by hyperocclusion. C, Cone-beam computed tomography scan identifies the
lingual cortex of the mandible as the point of axial loading of its molar teeth.

The author has observed that 50% of cases will have sloughed the taken a bisphosphonate—as long as a bisphosphonate or deno-
exposed bone and healed over the area with normal-appearing mu- sumab has not been reinitiated.
cosa with a 9-month drug holiday. The remaining 50% at that time, Although hyperbaric oxygen is the standard of care for treating
the patient can undergo debridement with the expectation of normal osteoradionecrosis, it is of no use in patients with DIONJ. This is
bone and wound healing. Only 15% of oral bisphosphonate DIONJ because radiation injury creates an oxygen gradient deficit, which
cases are sufficiently severe to need a mandibular continuity resection hyperbaric oxygen corrects; in DIONJ, however, there is no oxy-
or a radical sinusotomy (as was required in the current patient’s case). gen gradient deficit but rather a direct chemical toxicity to bone,
In patients whose oral bisphosphonate DIONJ has resolved, re- which hyperbaric oxygen does not affect.
construction of the alveolar bone with the clinician’s preferred bone
grafting materials or dental implant placements can be accomplished ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
with the same success rate as that for any similar patient who has not complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 54.e1

Bibliography Lasseter KC, Porras AG, Denker A, et al: Pharmacokinetic considerations

in determining the terminal elimination half-lives of bisphospho-
nates, Clin Drug Invest 25:107-114, 2005.
Advisory Task Force on Bisphosphonate-Related Osteonecrosis of the Marx RE (ed): Oral and Intravenous Bisphosphonate-Induced Osteonecrosis
Jaws: American Association of Oral and Maxillofacial Surgeons posi- of the Jaws: History, Etiology, Prevention, and Treatment, ed 2, Hanover
tion paper on bisphosphonate-related osteonecrosis of the jaws, J Oral Park, IL, 2010, Quintessence.
Maxillofac Surg 65:369-376, 2007. Marx RE, Cillo JE Jr, Ulloa JJ: Oral bisphosphonate–induced osteonecro-
Aghaloo TL, Felsenfeld AL, Etradis S: Osteonecrosis of the jaw in a pa- sis: risk factors, prediction of risk using serum CTX testing, preven-
tient on denosumab, J Oral Maxillofac Surg 68(5):959-963, 2010. tion, and treatment, J Oral Maxillofac Surg 65(12):2397-2410, 2007.
Black DM, Schwartz AV, Ensrud KE, et al: Effects of continuing or stop- Neviaser AS, Lane JM, Lenart BA, et al: Low energy femoral shaft frac-
ping alendronate after five years of treatment: the Fracture Interven- tures associated with alendronate use, J Orthop Trauma 22:346-350,
tion Trial Long-Term Extension (FLEX)—a randomized trial, JAMA 2008.
296:2927-2938, 2006. Park-Wyllie LY, Mamdani MM, Juirlink DN, et al: Bisphosphonate use
Black DM, Thompson DE, Bauer DC, et al: Fracture risk reduction with and atypical fractures of the femoral shaft, N Engl J Med 36:
alendronate in women with osteoporosis: the Fracture Intervention 1728-1737, 2011.
Trial, J Clin Endocrinol Metab 85:4118-4124, 2000. Marx RE: Pamidronate (Aredia) and zoledronate (Zometa) induced avas-
Das De S, Setiobudi T, Shen L, et al: A rationale approach to manage- cular necrosis of the jaws: a growing epidemic, J Oral Maxillofac Surg
ment of alendronate-related subtrochanteric fractures, J Bone Joint 61(9):1115-1117, 2003.
Surg 92(5):679-686, 2010. Rosen HN, Moses AC, Garber J, et al: Serum CTX: a new marker of
Edwards NH, McCrae FC, Young-Min SA: Alendronate-related femoral bone resorption that shows treatment effect more often than other
diaphysis fracture: what should be done to predict and prevent subse- markers because of low coefficient of variability and large changes
quent fracture of the contralateral side? Osteoporosis Int 4:701-703, 2010. with bisphosphonate therapy, Calcif Tissue Int 66:100-103, 2000.
Ingenix: ICD-9-CM for physicians, vol 1, Eden Prairie, MN, 2012, Taylor KH, Middlefell LS, Mizen KD: Osteonecrosis of the jaws induced
Ingenix, Inc. by anti-RANK Ligand therapy, Br J Oral Maxillofac Surg 48:221-223,
Kunchur R, Need A, Hughes T, et al: Clinical investigation of C-terminal 2010.
cross linking telopeptide test in prevention and management of US Food and Drug Administration: Background document for meeting of
bisphosphonate-associated osteonecrosis of the jaws, J Oral Maxillofac Advisory Committee for Reproductive Health Drugs and Drug Safety
Surg 67:1167-1173, 2009. and Risk Management Advisory Committee. September 9, 2011.
Kwon YD, Ohe JY, Lim DY, et al: Retrospective study of two biochemi-
cal markers for the risk assessment of oral bisphosphonate related
osteonecrosis of the jaws: can they be utilized as risk markers? Clin
Oral Implants Res 22:100-105, 2011.

t.me/Dr_Mouayyad_AlbtousH
12
Intravenous Drug–Induced
Osteonecrosis of the Jaws
R O B E R T E. MA R X

CC arthritis (8 years ago) and placement of a coronary artery stent

(6 years ago). She is a past smoker of one pack per day but quit
A 71-year-old female with a history of multiple myeloma of the 10 years ago. She takes no medications other than Zometa and
past 5 years is referred by her oncologist because of “exposed Revlimid.
bone” and a draining fistula (Fig. 12.1).
Examination
Intravenous Drug–Induced Osteonecrosis of Exposed bone is noted in the lingual alveolar bone in the right
the Jaws mandibular molar area (see Fig. 12.1A). There is a draining fistula
at the level of the inferior border of the mandible (see Fig. 12.1B).
Two classes of drugs have been directly linked to osteonecrosis of Although there is no exposed bone seen on the buccal, there is
the jaws: bisphosphonates and reactor activator of nuclear kB prominent exposed bone seen on the lingual, which is jagged.
(RANK) ligand inhibitors. Therefore, what was once referred to There are also several fistulas arising from the adjacent lingual
as bisphosphonate-induced osteonecrosis of the jaws (BIONJ) mucosa, which suggests that the nonvital bone extends beyond
now is best called drug-induced osteonecrosis of the jaws (DIONJ). the clinically exposed bone.
The clinically important distinction is the route of administra-
tion, intravenous (IV) versus oral, versus subcutaneous across Imaging
both classes of drugs. Therefore, a sample case of an oral bisphos-
phonate ONJ is presented in a different chapter. A sample case of A cone-beam computed tomography (CBCT) scan shows signifi-
an IV bisphosphonate ONJ is presented here, and sample cases of cant osteolysis in the right midbody area of the mandible and a
subcutaneous injections of denosumab (a RANK ligand inhibi- diffuse surrounding sclerosis (Fig. 12.2). Compared with a CBCT
tor) are presented as different cases in the chapters that follow. scan taken 6 months earlier, a greater amount of osteolysis and
osteosclerosis is noted.
HPI
Labs
The current patient’s multiple myeloma is stated to be in remis-
sion as a result of stem cell transplantation and Velcade treatment Routine laboratory testing is required to particularly assess for
in the past. She now takes only Revlimid, but she took zoledronic anemia and blood chemistry changes. This patient shows a clini-
acid (Zometa) in the recent past. She took Zometa 4 mg monthly cally insignificant anemia, with hemoglobin of 11.3 g/dL and
for 2 years; this treatment was discontinued 9 months ago when hematocrit of 34%. She also exhibits slightly elevated myeloma
exposed bone and pain developed spontaneously. Since then, the proteins (immunoglobulin G [IgG], 160.8 mg/mL; normal range,
exposed bone has failed to heal. The patient was initially treated 3–19.4 mg/mL). This IgG value is still not a contraindication to
with clindamycin 300 mg three times daily but without relief of nonsurgical or even surgical management of the exposed bone.
pain. Pain relief was obtained when she was placed on phenoxy-
methyl penicillin (penicillin VK) 500 mg four times daily along Assessment
with 0.12% chlorhexidine oral rinses three times daily. Despite
initial pain control, the area of exposed bone increased, and two Stage III DIONJ by virtue of its osteolysis to the inferior border
draining cutaneous fistulas developed along with a return of pain. threatening a pathologic fracture.

PMHX/PDHX/Medications/Allergies/SH/FH Treatment
In addition to multiple myeloma and its related treatments, the The treatment choices discussed with the patient included palliative
patient has had a left total knee replacement for degenerative nonsurgical management using intermittent or ongoing antibiotic

55
t.me/Dr_Mouayyad_AlbtousH
56 S E C TI O N Pharmacology

Surgical resection was performed after consultation with and

clearance from her medical oncologist and her internist. The sur-
gical access was made through a convenient neck crease to expose
the right hemimandible (Fig. 12.3A). A 2.9-mm titanium recon-
struction plate (the strongest made) then was placed and fixated
onto the intact mandible with locking screws so as to index the
position of the condyle and the remaining occlusion (Fig. 12.3B).
The plate was subsequently removed, with each screw marked to
correlate with the appropriate screw hole. The mandible was then
resected from the right canine area to the right midramus, with
the surgeon observing for residual viable marrow space as the best
assessment for an adequate resection margin (Fig. 12.3C and D).
The titanium plate was replaced and fixated in its preoperative
position after the resection edges were rounded off (Fig. 12.3E).
The mucosa and skin were closed primarily over the reconstruc-
tion plate.

A Outcome
The patient has been followed for the past 3 years. Her multiple
myeloma remains under control, and her DIONJ remains re-
solved, with no further exposed bone; the secondary infection,
foul order, and taste also have resolved, and there are no fistulas
(Fig. 12.4). The patient eats in a near-normal fashion with her
residual dentition in the anterior region and left side. She has not
been restarted on zoledronic acid but continues to be on mainte-
nance chemotherapy.

Pathology
The specimen microscopically showed the features characteristic
of DIONJ. Specifically, one section showed nonvital bone with
scalloped edges representing empty resorption pits (Fig. 12.5A).
B These were generated by osteoclasts that began resorbing the dead
• Fig. 12.1 A, Exposed bone with ragged edges on the lingual mandibular bone but died as they ingested the metabolic poison of the
cortex in the molar region. B, Draining cutaneous fistula. bisphosphonate, leaving an incompletely resorbed portion of dead
bone with scalloped edges. Between the necrotic bone trabeculae
were dense colonies of Actinomyces organisms, the most common
microorganisms to colonize DIONJ-exposed bone (see Fig. 12.5A).
Another section at the resection edge showed surface inflammation
but normal marrow spaces without inflammation, which distin-
guished the condition from a primary osteomyelitis. A thick, bony
trabecular network also was noted, which is the result of the anti-
resorptive effect of bisphosphonates and is related to the osteoscle-
rosis seen on imaging (Fig. 12.5B).

Discussion
Drug-induced osteonecrosis of the jaws was first recognized in
2003 as bisphosphonate-induced osteonecrosis of the jaws. Since
then, researchers have noted that denosumab, a RANK ligand
inhibitor (marketed as Prolia, given orally, and Xgeva, given by
• Fig. 12.2 Osteolysis extending into the inferior border. Note the surround- injection), causes the same type of osteonecrosis of the jaws. For
ing sclerotic bone and the beginning sequestra with the radiolucency. this reason, the American Medical Association has settled on
DIONJ as the correct term. In just under 2 decades, more than
2400 scientific articles, reporting more than 25,000 cases, have
therapy, along with oral rinses of 0.12% chlorhexidine three times underscored the clinical epidemic predicted by the first article.
daily, and adaptation to long-term and probably permanent ex- The takeaway lessons from the case presented here are many.
posed bone or surgical resection to achieve resolution and a cure. One is that about 30% of cases occur spontaneously because of
Because this patient had endured the pain, odor, and foul taste of the dose, potency of the drug, and duration of drug exposure
the exposed bone for 9 months already and because the bone dete- often promoted by heavy or traumatic occlusion. The current
rioration was advancing, she chose to undergo surgical resection. patient took zoledronic acid, the most potent bisphosphonate, for

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 CHAPTER 12 Intravenous Drug–Induced Osteonecrosis of the Jaws 57

A B

C D

E
• Fig. 12.3 A, Outline of the mandible and area of necrotic bone with planned incision placement for
maximum cosmetic outcome. B, A 2.9-mm titanium reconstruction plate fixated to the intact mandible
with intended resection margins. C, Defect of the mandible after resection of necrotic bone. Note the
bleeding marrow space and residual cancellous marrow at the distal resection margin. This is currently
the best indicator of an adequate margin. D, Resection specimen with discolored necrotic bone.
E, Reconstruction plate returned after the resection, positioning the occlusion and the condyle in their
preresection positions.

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58 S E C TI O N Pharmacology

A
A

B
• Fig. 12.5 A, Resection specimen showed necrotic bone with scalloped
B edges representing empty resorption lacunae for osteoblastic death. Colonies
of Actinomyces organisms also are seen, but no residual bone marrow cells
• Fig. 12.4 A, Healed mucosa and resolution of drug-induced osteonecro- are seen. B, Surface inflammation with no marrow inflammation ruled out a
sis of the jaws after resection surgery. B, Profile facial view identifies resolu-
primary osteomyelitis in this case. Note the thick trabecular bone, which ac-
tion of the cutaneous fistula and a well-hidden incision scar in the neck.
counts for the sclerosis seen on the cone-beam computed tomography scan.

approximately 24 doses, which was the cause of her DIONJ. The as part of these staging systems; however, pain is unrelated to the
fact that she persisted with exposed bone for longer than extent or the severity of DIONJ. Pain is related only to secondary
9 months and actually experienced a worsening of her DIONJ is infection, and it changes with the use of antibiotics; therefore, a
due to the 11-year half-life of these drugs. Although a drug holi- patient’s disease may jump from stage Ia to stage Ib or to stage IIb
day of 9 months is effective in cases of oral bisphosphonate or back and forth as a function of secondary infection or of the
DIONJ, drug holidays are not effective with IV bisphosphonate patient’s use of analgesics. The following is a more straightforward
DIONJ, even if they last several years. This is due to the IV route staging system:
itself, which loads the bone 140 times faster and more completely • Stage 0: radiographic evidence of the toxic effect of bisphos-
than an oral bisphosphonate, which is poorly absorbed into the phonates or RANK-L inhibitors on bone (i.e., sclerosis of the
systemic circulation (0.64% of an oral bisphosphonate is ab- lamina dura, diffuse marrow hypermineralization, deep bone
sorbed into the systemic circulation). It is also caused by this pain not caused by endodontic or periodontic etiologies)
greater drug load on the bone marrow osteoclast precursors, • Stage I: exposed bone limited to one quadrant
which do not quickly recover to replenish functioning osteoclasts • Stage II: exposed bone involving two quadrants
when an IV bisphosphonate is discontinued. The clinical value of • Stage III: exposed bone involving three or four quadrants, os-
discontinuing Zometa in this case, and in others like it, is more to teolysis to the inferior border, a pathologic fracture, or exten-
reduce the probability of DIONJ from developing in other sites sion into the maxillary sinus if in the maxilla
in the jaws. The importance of a stage III presentation is that it brings
As a result of the influence of the drug companies, the medical surgery to the forefront, as it did in this case. The value of non-
and dental associations have each put forth a confusing and over- surgical management is that it avoids the risks of general anes-
complicated staging system. This is because pain is incorporated thesia and surgery. In some patients with metastatic cancer,

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 CHAPTER 12 Intravenous Drug–Induced Osteonecrosis of the Jaws 59

debilitation and systemic compromise may not allow for safe

anesthesia or surgery. These patients and patients who decide
against surgery must accept the continuation of exposed bone,
the expectation of episodes of pain, and ongoing courses of an-
tibiotics. In such cases, penicillin VK 500 mg four times daily
or amoxicillin 500 mg three times daily are the drugs of choice.
As an alternative in refractory cases or in a patient who is allergic
to penicillin, doxycycline 100 mg/day is a good choice. In pa-
tients whose DIONJ is refractory to either of those drugs, the
addition of metronidazole 500 mg three times daily for a 10-day
course is usually effective. Patients whose condition remains re-
fractory despite all these medications usually choose the surgical
option. In accepting a palliative course, with continued exposed
bone with colonization and episodes of bacterial infection, the • Fig. 12.6 The continuity defect of the mandible was reconstructed with
clinician should take into account the potential for bacterial only the titanium plate and has been stable for 2 years.
seeding on implanted devices, such as prosthetic heart valves,
knee or hip replacements, and cardiac stents.
The surgical option is mostly a continuity resection of the man- rhBMP-2/ACS (recombinant human bone morphogenetic pro-
dible or, if the disease is in the maxilla, local resection of the maxilla tein-2/acellular collagen sponge) is contraindicated in patients with
with sinus debridement. Limited office-based debridements can be active cancers. Therefore, a titanium plate, used as an “artificial jaw”
successful if the exposed bone shows an involucrum or becomes to establish and maintain continuity, often becomes the permanent
clinically mobile. However, with a resection (such as was performed reconstruction in the mandible (Fig. 12.6), and a closed mucosa
with the patient in the example case), bony reconstruction of with no underlying bone is the permanent outcome in the maxilla.
the defect is problematic and usually is not accomplished. This is
because disease-free donor bone is not predictably available because ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
of the presence of malignant cells in the donor bone, and complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 59.e1

Bibliography prevention, and treatment, J Oral Maxillofac Surg 63:1567-1575,

2005.
Marx RE: Pamidronate (Aredia) and zoledronate (Zometa) induced avas-
Aghaloo TL, Felsenfeld AL, Tetradis S: Osteonecrosis, J Oral Maxillofac cular necrosis of the jaws: a growing epidemic, J Oral Maxillofac Surg
Surg 68(5):959-963, 2010. 61:1115-1157, 2003.
Buck CJ: American Medical Association ICD-9-CM for physicians, St Merck & Co: Fosamax (alendronate sodium) tablets and oral solution.
Louis, 2011, Saunders, p 962. Product information sheet, 2012. Available at www.merck.com/prod-
Khosla S, Burr D, Cauley J, et al: Bisphosphonate-associated osteonecro- uct/usa/pi_circulars/f/fosamax/fosamax_pi.pdf. Accessed April 2, 2013.
sis of the jaw: report of a task force of the American Society for Bone Ruggiero SL, Dodson TB, Assael LA, et al: American Association of Oral
and Mineral Research, J Bone Miner Res 22(10):1479-1491, 2007. and Maxillofacial Surgeons position paper on bisphosphonate-related
Lasseter KC, Porros AG, Denker A, et al: Pharmacokinetic considerations osteonecrosis of the jaws: 2009 update, J Oral Maxillofac Surg 67(5
in determining the terminal elimination half lives of bisphosphonates, Suppl):2-12, 2009.
Clin Drug Invest 25(2):107-114, 2005. Taylor KH, Middlefell LS, Mizen KD: Osteonecrosis of the jaws induced
Marx RE, Cillo JE Jr, Ulloa JJ: Oral bisphosphonate-induced osteonecro- by anti-RANK ligand therapy, Br J Oral Maxillofac Surg 48:221-223,
sis: risk factors, prediction of risk using serum CTX testing, preven- 2010.
tion, and treatment, J Oral Maxillofac Surg 65(12):2397-2410, 2007.
Marx RE, Sawatari Y, Fortin M, et al: Bisphosphonate induced exposed
bone (osteonecrosis/osteopetrosis) of the jaws: risk factors, recognition,

t.me/Dr_Mouayyad_AlbtousH
13
Subcutaneous Drug–Induced
Osteonecrosis of the Jaws in Patients
With Osteoporosis
R O B E R T E. MA R X

CC However, denosumab cases can be effectively managed with

the knowledge that they do not bind to bone as do the bisphos-
A 52-year-old postmenopausal female is referred for evaluation by phonates. They have a half-life of only 26 days, which lends treat-
her restorative dentist for “oral rehabilitation” using dental implants. ment protocols to a short drug holiday of 3 months before and
3 months after an alveolar bone surgery.
Subcutaneous Drug–Induced Osteonecrosis HPI
of the Jaws
The patient is a 52-year-old female who was referred by her restor-
The most commonly used subcutaneous drug approved to treat ative dentist. This patient had a neglected dentition with mobility
osteoporosis and is also known to cause osteonecrosis of the jaws is and significant periodontal bone loss about her few remaining
denosumab (Prolia). Denosumab is a monoclonal antibody, hence teeth. She now presents with an edentulous maxilla, a lone stand-
the word ending in “mab.” Denosumab inhibits RANK (reactor ing left mandibular canine (tooth #22), and exposed bone in the
activator of nuclear kB) ligand and by doing so inhibits the devel- area of the right mandibular canine (tooth #27) (Fig. 13.2). She
opment of osteoclasts in the bone marrow, as well as in the circula- relates that she took alendronate (Fosamax) 70 mg/week for
tion and tissue spaces and while resorbing bone. Therefore, it has 4 years for “severe osteoporosis” (T score 5 4.2 and one vertebral
a much greater antiosteoclastic effect than even a bisphosphonate. fracture). When her treating physician identified no improvement
Therefore, drug–induced osteonecrosis of the jaws (DIONJ) cases by her every-2-year dual x-ray absorptiometry scan (a radio-
solely caused by denosumab occur sooner and are more extensive. graphic analysis of bone density), she was switched to denosumab
Moreover, if the patient has previously taken a bisphosphonate and (Prolia) 60 mg subcutaneously every 6 months as per US Food
was switched to denosumab, the alveolar bone now loaded with and Drug Administration (FDA) approval. She has no comor-
the bisphosphonate readily becomes exposed with the switch to bidities other than Hashimoto’s thyroiditis for which she takes
denosumab. This is caused by denosumab’s targeting the osteoclast Synthroid.
precursors in the bone marrow (Fig. 13.1).

• Fig. 13.1 Pale and ballooned osteoclast precursors indicating death • Fig. 13.2 Exposed bone drug–induced osteonecrosis of the jaws
caused by denosumab. caused by denosumab preceded by alendronate.

60
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 13 Subcutaneous Drug–Induced Osteonecrosis of the Jaws in Patients With Osteoporosis 61

PMHX/PDHX/Medications/Allergies/SH/FH
Examination
The exposed bone in the mandible is nonmobile as is tooth #22.
Although there is granulation tissue present, there is no pus. Both
the maxillary and mandibular ridges are irregular because of areas
of more severe bone loss and past extractions. There is no exposed
bone, and there is no drainage.

Oral and Maxillofacial • Fig. 13.3 Involucrum separating a sequestrum of necrotic bone after a
9-month holiday.
Imaging
A cone-beam computed tomography scan shows no osteolysis but
moderate demineralization in the exposed alveolar bone. The holiday. The bone was leveled and contoured, and four im-
maxillary sinuses are appropriately pneumatized with no evidence plants were placed into the remaining mandibular bone as
of sinusitis. well as six implants into the maxilla together with bilateral
sinus lift procedures. After the drug holiday has been taken
Assessment to the appropriate time, all commonly used alveolar bone
surgeries, sinus lift procedures, and grafting procedures can
Stage I drug-induced osteonecrosis of the maxilla secondary to alen- be done with a minimal risk for exposed bone. The graft
dronate therapy. material used is the choice of the surgeon with none contra-
The exposed bone limited one quadrant represents stage I. The indicated by the history of DIONJ-causing drugs.
previous use of a bisphosphonate followed by a RANK ligand in- The patient should not wear a temporary denture for the first
hibitor is the underlying cause of this rapidly appearing exposed postoperative month. At that time, a well-cushioned temporary
bone. The treatment plan will require a drug holiday. Therefore, appliance can be made with the caution to use it only at times of
discussion must occur with her treating physician about drug necessity (i.e., social functions, eating).
holidays. Moreover, because she has severe osteoporosis, an alterna- The implants and bone grafts should be allowed 6 to 8 months
tive osteoporosis medication will be likely required during the drug for full graft maturity and osteointegration. The four implants
holiday. If she did not have a diagnosis of severe osteoporosis with were placed in the mandible using the “all of four concept,” and
a vertebral compression fracture, either no alternative osteoporosis six implants were placed in the axilla, including one in each max-
medication would have been acceptable, or vitamin D3 and cal- illary sinus.
cium or raloxifene (Evista) could be substituted. However, because
of her “severe osteoporosis,” the use of an anabolic osteoporosis Outcome
drug that adds new bone rather than retains old bone is needed.
Specific to the drug holiday, this case will require a 9-month All 10 implants fully osseointegrated to allow the referring dentist
drug holiday before the procedure rather than the 3-month drug to accomplish a removable Hader bar retained prothesis (Fig. 13.4).
holiday for a denosumab-only case followed by 3 months after the
procedure. If a bisphosphonate with its 11.2-year half-life was Discussion
used at any time in the patient’s osteoporosis treatment, then the
drug holiday must be the one appropriate for the bisphosphonate. This sample case illustrates the effective use of a drug holiday and
the team approach required to gain a successful outcome in the case
Treatment of an established DIONJ in a patient who required a coordinated

A. Osteoporosis Management and Drug Holiday

The treating physician was happy to place this patient on our
recommended drug holiday and chose to continue treating
her with rhPTH1-34 (Forteo). Recombinant human para-
thyroid hormone 1-34 (rhPTH 1-34) is an anabolic agent
that builds new bone rather than retains old bone as do
bisphosphonates and denosumab. It has no known cases of
DIONJ and has no mechanism to produce DIONJ. It is
also FDA approved specifically for “severe osteoporosis.” As
an alternative, rhPTH 1-80, Tymlos, or romosozumab
(Evenity), can be used.
B. The Dental and Oral and Maxillofacial Treatment Plan:
During the 9-month drug holiday, radiographs identified an
involucrum around a sequestrum encompassing the exposed
bone (Fig. 13.3). The office-based procedure easily removed • Fig. 13.4 All 10 dental implants placed successfully osseointegrated
the exposed bone because it became mobile during the drug because of the drug holiday.

t.me/Dr_Mouayyad_AlbtousH
62 SE C TI O N Pharmacology

and complex plan. This case also sheds light on the mechanism by
which a drug holiday allows bone healing, osseointegration, and
graft healing to return to normal. Core bone biopsies taken at the
time of dental implant placement identified return of normal osteo-
blasts remodeling bone (Fig. 13.5).
Today, physicians are well aware of DIONJ and are usually
glad to work with the dental community in avoiding DIONJ in
their patients. In our experience, such cases have ultimately be-
come a referral source and increase respect for dentists and oral
and maxillofacial surgeons among the medical community.

,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for

complete set of bibliography.

• Fig. 13.5 During a drug holiday, osteoclasts return from the recovering
bone marrow to resorb old and necrotic bone. This photomicrograph
identifies normal functioning osteoclasts in a bone core taken from this
patient after the drug holiday.

t.me/Dr_Mouayyad_AlbtousH
 62.e1

Bibliography osteonecrosis of the jaws: can they be utilized as risk markers? Clin
Oral Implants Res 22:100-105, 2011.
Lasseter KC, Porras AG, Denker A, et al: Pharmacokinetic considerations
Advisory Task Force on Bisphosphonate-Related Osteonecrosis of the in determining the terminal elimination half-lives of bisphospho-
Jaws: American Association of Oral and Maxillofacial Surgeons posi- nates, Clin Drug Invest 25:107-114, 2005.
tion paper on bisphosphonate-related osteonecrosis of the jaws, J Oral Marx RE (ed): Oral and Intravenous Bisphosphonate-Induced Osteonecrosis
Maxillofac Surg 65:369-376, 2007. of the Jaws: History, Etiology, Prevention, and Treatment, ed 2, Hanover
Aghaloo TL, Felsenfeld AL, Etradis S: Osteonecrosis of the jaw in a pa- Park, IL, 2010, Quintessence.
tient on denosumab, J Oral Maxillofac Surg 68(5):959-963, 2010. Marx RE, Cillo JE Jr, Ulloa JJ: Oral bisphosphonate–induced osteonecro-
Black DM, Schwartz AV, Ensrud KE, et al: Effects of continuing or stop- sis: risk factors, prediction of risk using serum CTX testing, preven-
ping alendronate after five years of treatment: the Fracture Interven- tion, and treatment, J Oral Maxillofac Surg 65(12):2397-2410, 2007.
tion Trial Long-Term Extension (FLEX)—a randomized trial, JAMA Neviaser AS, Lane JM, Lenart BA, et al: Low energy femoral shaft frac-
296:2927-2938, 2006. tures associated with alendronate use, J Orthop Trauma 22:346-350,
Black DM, Thompson DE, Bauer DC, et al: Fracture risk reduction with 2008.
alendronate in women with osteoporosis: the Fracture Intervention Park-Wyllie LY, Mamdani MM, Juirlink DN, et al: Bisphosphonate use
Trial, J Clin Endocrinol Metab 85:4118-4124, 2000. and atypical fractures of the femoral shaft, N Engl J Med 36:
Das De S, Setiobudi T, Shen L, et al: A rationale approach to manage- 1728-1737, 2011.
ment of alendronate-related subtrochanteric fractures, J Bone Joint Rosen HN, Moses AC, Garber J, et al: Serum CTX: a new marker of
Surg 92-b:679-686, 2010. bone resorption that shows treatment effect more often than other
Edwards NH, McCrae FC, Young-Min SA: Alendronate-related femoral markers because of low coefficient of variability and large changes
diaphysis fracture: what should be done to predict and prevent subse- with bisphosphonate therapy, Calcif Tissue Int 66:100-103, 2000.
quent fracture of the contralateral side? Osteoporosis Int 4:701-703, Taylor KH, Middlefell LS, Mizen KD: Osteonecrosis of the jaws induced
2010 (EPUB: June 27, 2009). by anti-RANK Ligand therapy, Br J Oral Maxillofac Surg 48:221-223,
Ingenix: ICD-9-CM for physicians, vol 1, Eden Prairie, MN, 2012, 2010.
Ingenix, Inc. US Food and Drug Administration: Background document for meeting
Kunchur R, Need A, Hughes T, et al: Clinical investigation of C-terminal of Advisory Committee for Reproductive Health Drugs and Drug
cross linking telopeptide test in prevention and management of Safety and Risk Management Advisory Committee. September 9,
bisphosphonate-associated osteonecrosis of the jaws, J Oral Maxillofac 2011.
Surg 67:1167-1173, 2009.
Kwon YD, Ohe JY, Lim DY, et al: Retrospective study of two biochem-
ical markers for the risk assessment of oral bisphosphonate related

t.me/Dr_Mouayyad_AlbtousH
14
Subcutaneous Drug–Induced
Osteonecrosis of the Jaws in
Patients With Cancer
R O B E R T E. MA R X

CC
A 57-year-old female is referred by her oncologist for progressively
advancing bone exposure in her mandible.

Subcutaneous Drug–Induced Osteonecrosis

of the Jaws
The subcutaneous oncology drug used to reduce cancer-stimulated
osteolysis and pathologic fractures is denosumab 120 mg sub
cutaneous every month (Xgeva). Denosumab is an inhibitor
of RANK (reactor activator of nuclear kB) ligand, which is the
ligand that activates osteoclasts in bone remodeling. However,
• Fig. 14.1 This exposed bone began 18 months before her initial
denosumab acts on the bone marrow osteoclast precursors,
presentation.
significantly reducing their numbers, and acts on the mature
circulating osteoclasts and even those actively resorbing bone.
Although this effect indeed works to reduce cancer-stimulated
bone resorption and pathologic fractures, its profound effect of
reducing the total osteoclast population and its bone marrow re-
placements has created the most severe and most extensive drug-
induced osteonecrosis of the jaws (DIONJ).
In contrast to bisphosphonates, which have a strong affinity to
bind to bone, thus exhibiting a 11.2-year half-life in bone, deno-
sumab does not bind to bone and therefore has a half-life in the
bone marrow plasma of only 26 days. The clinical importance of
this is that a 3-month drug holiday before a procedure followed
by another 3-month drug holiday after the procedure is useful in
treating almost every denosumab-exposed patient.

HPI • Fig. 14.2 The exposed bone became more extensive over the next year.
This 57-year-old female presents with several photographs taken
at the start of the exposed bone 18 months earlier (Figs. 14.1 and prednisone. Her oncologist has deferred a bone marrow trans-
14.2). An initial oral examination today indicates a loss of all the plant partially because of the exposed bone and bouts of infection
teeth present at the time of the last photograph, 6 months ago, as well as her currently active multiple myeloma.
and exposed necrotic bone of the entire alveolar process of the She related that she received zoledronate 4 mg intravenously
mandible (Fig. 14.3). monthly for 4 years. Because of two vertebral compression fractures,
This patient is currently being treated for active multiple my- her oncologist switched her to subcutaneous denosumab
eloma with lenalidomide (Revlimid), bortezomib (Velcade), and 120 mg monthly. Just after the second dose of denosumab 18 months

63
t.me/Dr_Mouayyad_AlbtousH
64 S E C TI O N Pharmacology

In the anterior area, a slight suppurative exudate came to be ex-

pressed. The maxilla is partially edentulous with moderate peri-
odontal bone loss and 11 mobility of the remaining teeth.

Oral and Maxillofacial

Imaging
A cone-beam computed tomography scan shows osteolysis mainly
focused on the intercortical bone area of the mandible (Fig. 14.5).
There is no evidence of osteolysis to the inferior border or that of
a pathologic fracture.

• Fig. 14.3 After this patient was switched from zoledronate to deno- Labs
sumab, the exposed bone rapidly became more extensive.
The accompanying laboratory results from the oncologist identi-
fies a chronic anemia with hemoglobin of 9.7 g/dL and hemato-
crit of 29%, a white blood cell count of 8000 cells/mm3, and
myeloma proteins at 2400 mg/dL.

Assessment
This is a somewhat typical example of a severe and extensive
DIONJ. The main causative agent in this case is denosumab, but
both the previous treatment with zoledronate and the multiple
myeloma itself contributed to its extensiveness.
It is now well-known that if a RANK ligand inhibitor follows
a loading period of a bisphosphonate, rapid and extensive
DIONJ results. Although denosumab is known to cause a more
extensive DIONJ by itself, the downregulation of the osteoclast
population by zoledronate contributed to the extensiveness seen
here. Additionally, multiple myeloma is a malignancy of the bone
marrow. Its very presence and pathophysiology also reduce the
• Fig. 14.4 The acceleration of drug–induced osteonecrosis of the jaws by
denosumab caused exfoliation of her remaining mandibular teeth.
number of osteoclast precursors.

Treatment
ago, exposed bone appeared in the anterior mandible (Fig. 14.1). The focus of treatment for the oral and maxillofacial surgeon is not
With continued denosumab use, the exposed bone area extended to necessarily to resolve the DIONJ but to support the oncologist’s
all of her remaining dentition (see Fig. 14.3). About 6 months ago, continuing treatment of the life-threatening malignancy. This, of
these teeth “were exfoliated,” or “fell out,” leaving her with the exten- course, requires a direct communication with the oncologists with
sive alveolar bone exposure seen today (Fig. 14.4). She reports that in
the past year, she has had several bouts of severe pain and swelling,
one requiring a hospital admission for intravenous antibiotics.

PMHX/PDHX/Medications/Allergies/SH/FH
This patient’s past medical history is significant for hypertension,
osteoporosis, and insomnia. She currently takes amlodipine–
benazepril, atenolol, and dapagliflozin for her hypertension and
uses zolpidem for sleep each night. Her vital signs are stable with a
blood pressure of 138/87 mm Hg. She is a never smoker and has a
stated allergy to penicillin that she reports as “shortness of breath.”
She is currently receiving lenalidomide, bortezomib, and pred-
nisone for her multiple myeloma IGa type, which is at 2400 mg/
dL (reference range, 60–400 mg/dL).

Examination
The oral examination today identifies exposed sockets and alveolar
bone from the left second molar area to the right second molar
area. The exposed bone is nonmobile but is tender to the touch. • Fig. 14.5 Osteolysis within the marrow space in the mandible.

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 14 Subcutaneous Drug–Induced Osteonecrosis of the Jaws in Patients With Cancer 65

the stated goals of controlling infections, controlling pain, reducing

or limiting the exposed bone, and preventing a pathologic fracture
so the oncologist does not need to stop the anticancer treatment
and the support of the patient’s overall health and infection-free
status to be eligible for a bone marrow transplant.
This patient was begun on a drug holiday from denosumab
and started on doxycycline 100 mg/day for a long-term plan to-
gether with metronidazole 500 mg three times daily limited to
14 days to control the secondary infection and pain. Because most
oral organisms known to secondarily infect exposed bone are an-
aerobes, especially actinomyces, doxycycline in penicillin-allergic
patients combined with metronidazole covers most of the known
pathogens. Although doxycycline is well tolerated in the long
term, metronidazole is limited to 14 days because of gastritis as-
sociated with long-term use.
This patient’s DIONJ-related symptoms improved as did her • Fig. 14.7 Because of a resection across the midline, a tracheostomy
diet. The oncologist added a protease inhibitor (carfilzomib) to was required to support her airway in the early postoperative phase.
her regimen, which was specially approved by the US Food and
Drug Administration for refractory multiple myeloma patients.
While taking carfilzomib for 4 months, this patient’s myeloma
proteins improved to 600 mg/dL from the original 2400 mg/dL,
and her chronic anemia improved to hemoglobin of 11.1 and
hematocrit of 31.9. The oncologist diagnosed this patient’s mul-
tiple myeloma as “in remission” and requested that the oral and
maxillofacial surgery team accomplish a debridement surgery.
After a thorough discussion with the patient, identifying risks
and informing her that the so-called debridement would need to
be an angle-to-angle resection and a short-term tracheostomy, the
patient consented.
The surgery indeed was an angle-to-angle resection (Fig. 14.6),
which included the placement of a 2.8-mm titanium reconstruc-
tion plate fixated with four screws in each ramus (Fig. 14.7) and
a tracheostomy.
The titanium plate serves as an artificial jaw, but in contrast to
similar patients with similar defects, such as patients with oral
• Fig. 14.8 Allogeneic dermis (AlloDerm) was used to reduce the potential
cancer and those with osteoradionecrosis, bone grafting to the for plate exposure over thin skin and to provide a greater chin projection.
defect and eventual dental implants are not likely. To support the
soft tissue around the plate to prevent a plate exposure later as well

as to provide some soft tissue chin contour, covering it with allo-

geneic dermis (AlloDerm) is useful (Figs. 14.8 and 14.9).

Outcome
The outcome for this patient was complete resolution of her
DIONJ with retention of speech and lip competence because of
the titanium plate. She ate with her edentulous artificial mandible
and a soft diet. She underwent a successful bone marrow trans-
plant and continued for 6 years before dying from reactivated
multiple myeloma, a total of 12 years since her first multiple
myeloma diagnosis.

Discussion
This case illustrates the complexity of treating and co-managing
DIONJ in patients treated for cancer. The goals should support
quality of life, support of the patient’s family, and support of the
oncologist. It often requires difficult decisions, the appropriate use
of antibiotics, close follow-up, and selective surgeries.

• Fig. 14.6 Resection specimen from right ramus to left midbody together ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
with the titanium reconstruction plate that acted as her “artificial jaw.” complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
66 S E C TI O N Pharmacology

• Fig. 14.9 Profile view after jaw resection and plate reconstruction.

t.me/Dr_Mouayyad_AlbtousH
 66.e1

Bibliography Lasseter KC, Porros AG, Denker A, et al: Pharmacokinetic considerations

in determining the terminal elimination half-lives of bisphospho-
nates, Clin Drug Invest 25(2):107-114, 2005.
Aghaloo TL, Felsenfeld AL, Tetradis S: Osteonecrosis, J Oral Maxillofac Marx RE, Sawatari Y, Fortin M, et al: Bisphosphonate induced exposed
Surg 68(5):959-963, 2010. bone (osteonecrosis/osteopetrosis) of the jaws: risk factors, recognition,
Assili Z, Dolivet G, Salleron J, et al: A Comparison of the clinical and prevention, and treatment, J Oral Maxillofac Surg 63:1567-1575, 2005.
radiological extent of denosumab (Xgeva®) related osteonecrosis of the Marx RE: Pamidronate (Aredia) and zoledronate (Zometa) induced avas-
jaw: a retrospective study, J Clin Med 10(11):2390, 2021. cular necrosis of the jaws: a growing epidemic, J Oral Maxillofac Surg
Buck CJ: American Medical Association ICD-9-CM for physicians, St 61:1115-1157, 2003.
Louis, 2011, Saunders, p 962. Ruggiero SL, Dodson TB, Assael LA, et al: American Association of Oral
Katzmann JA, Willrich MA, Kohlhagen MC, et al. Monitoring IgA and Maxillofacial Surgeons position paper on bisphosphonate-related
multiple myeloma: immunoglobulin heavy/light chain assays, Clin osteonecrosis of the jaws: 2009 update, J Oral Maxillofac Surg 67(5
Chem 61(2):360-367, 2015. Suppl):2-12, 2009.
Khosla S, Burr D, Cauley J, et al: Bisphosphonate-associated osteonecro- Taylor KH, Middlefell LS, Mizen KD: Osteonecrosis of the jaws induced by
sis of the jaw: report of a task force of the American Society for Bone anti-RANK ligand therapy, Br J Oral Maxillofac Surg 48:221-223, 2010.
and Mineral Research, J Bone Miner Res 22(10):1479-1491, 2007.

t.me/Dr_Mouayyad_AlbtousH
15
Laryngospasm
M I C H A E L L. B E C K L E Y a n d S H A H R O K H C . B AG H E R I

CC Neck and chest. There was evidence of tracheal tug and para-
doxical chest wall motion (despite chin-lift and jaw-thrust ma-
A 12-year-old female is scheduled for extraction of four bicuspids neuvers). This phenomenon is the result of forced inspiration
under intravenous (IV) general anesthesia. (Laryngospasm may against a closed glottis.
occur more often in children because of the frequency of upper Vital signs. The patient's heart rate was 160 bpm, blood pres-
respiratory tract infections [URIs] in this patient population.) sure was 145/78 mm Hg, Etco2 was 0, and respirations were 0
breaths per minute.
HPI Oxygen saturation. Oxygen saturation decreased from 99%
to 65% with the onset of laryngospasm. (Continued decline in
Preoperative evaluation of the patient revealed no recent URIs. The the oxygen saturation can result in respiratory acidosis.)
lungs were clear to auscultation. After electrocardiography, blood ECG. The patient was in sinus tachycardia. (This is a common
pressure, pulse oximetry, and capnography monitors were applied, finding, but hypoxia can trigger more life-threatening cardiac ar-
the patient was administered 4 L of oxygen and 2 L of nitrous oxide rhythmias. Hypoxemia in children may result in bradycardia.)
via nasal hood. Sedation was achieved using 4 mg of midazolam
and 50 mg of fentanyl titrated to effect. Before administration of Imaging
local anesthesia, 40 mg of propofol was infused. During the first
extraction, respiratory stridor (a high-pitched, inspiratory “crow- Imaging is not relevant in the acute management of laryngo-
ing” sound) was noted. A noisy, harsh sound was heard on inspira- spasm. This is an anesthetic emergency and is diagnosed based on
tion through the precordial stethoscope, and the patient’s oxygen the clinical presentation. Chest films can be ordered if there is
saturation decreased from 99% to 65%. Capnography indicated no suspicion of foreign body aspiration or to aid in the diagnosis of
ventilation. At this point, the respiratory noises ceased. Tracheal tug negative-pressure or postobstructive pulmonary edema after the
and paradoxical chest wall motion were observed (signs of upper acute management of the airway.
airway obstruction), and the patient began to appear cyanotic.
Labs
PMHX/PDHX/Medications/Allergies/SH/FH
None are indicated in the acute setting.
Noncontributory. A recent history of URI may indicate an in-
creased risk of perioperative respiratory complications, especially Assessment
laryngospasm. In the event of a recent URI, it may be prudent to
reschedule surgery after a 2-week symptom-free period. Patients Intraoperative laryngospasm during odontectomy under general
with reactive airway disease and those with exposure to passive anesthesia.
smoke may be more prone to experience laryngospasm.
Treatment
Examination
Prompt recognition and treatment of laryngospasm usually results
General. A harsh inspiratory noise, or crowing, is audible on in- in a good outcome. Upon diagnosis, the airway should be suc-
spiration, which is best heard through the precordial stethoscope. tioned clear of noxious stimuli, and the surgical site should be
The patient's skin color is assessed for signs of cyanosis, which is packed. Any foreign bodies should be removed from the oral cav-
seen with severe hypoxemia. In pediatric patients, hypoxemia is ity, and 100% oxygen is administered. Positive-pressure ventila-
often a late finding of decreased ventilation or apnea. End-tidal tion should be attempted, ideally with a two-person technique
CO2 (Etco2) monitoring and use of the precordial stethoscope in- and jaw-thrust maneuver; this often “breaks” the laryngospasm.
dicate hypoventilation or apnea before changes in pulse oximetry. (Jaw thrust and pressure at the angle of the mandible may also
Oropharynx. The throat pack was removed, and there was no assist in breaking laryngospasms.)
evidence of foreign bodies. Copious amounts of mucous secre- A technique described by Dr. N.P. Guadagni also has been
tions were observed. (Blood and mucus are common stimuli for found to be effective at “breaking” laryngospasm. This involves
airway irritation.) placing the middle finger of each hand anterior to the mastoid

68
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 15 Laryngospasm 69

and posterior to the condyle. The fingers then press inward while
at the same time positioning the mandible forward. If the patient
cannot be ventilated, the plane of anesthesia may be deepened
with a short-acting IV general anesthetic; this often obviates the
need for a skeletal muscle relaxant.
In rare situations, these methods are unsuccessful, and it is
necessary to administer succinylcholine, a short- and fast-acting
depolarizing neuromuscular blocking agent. If IV access is not
available, succinylcholine may be administered intramuscularly at
a dose of 4 mg/kg. A dose of 20 mg intravenously is usually suf-
ficient to break the spasm (pediatric dose, 0.25 mg/kg). However,
up to 60 mg can be administered if laryngospasm persists. Rapa-
curonium, rocuronium, and mivacurium can be used for patients
in whom succinylcholine is contraindicated. The longer half-life
of these nondepolarizing muscle relaxants may require continuous
bag-mask ventilation until spontaneous respiration resumes.
Bradycardia is common after administration of succinylcho-
line. This usually occurs in children and in adults after repeated
doses. Atropine may be administered in an effort to prevent this.
IV lidocaine 2 mg/kg administered before extubation was found
to be effective in preventing postextubation laryngospasm in pa-
tients undergoing tonsillectomy. Other studies have found the
prophylactic use of IV lidocaine to be ineffective.

Complications
Laryngospasm may produce partial or complete respiratory ob-
• Fig. 15.1 Tight approximation of the true vocal cords as seen during
struction. Fortunately, early recognition and management allow
laryngospasm. (From Malamed SF: Sedation: a guide to patient manage-
for rapid resolution and minimal morbidity. However, with ment, ed 5, St Louis, 2010, Mosby.)
prolonged hypoxemia, the complications can be devastating.
Laryngospasm may result in an acid–base disturbance, such as
respiratory acidosis. Rare complications of laryngospasm in- supraglottic tissues act as a ball valve and obstruct the laryngeal
clude cardiac arrhythmias, anoxic brain injury, negative-pressure inlet during inspiration. Laryngospasm has a reported occurrence
pulmonary edema, and death. of 8.7 per 1000 patients receiving general anesthesia. It is 19 times
If succinylcholine is administered, the patient may complain more frequent than bronchospasm. Children with sleep-disordered
of general postoperative myalgia secondary to the rapid muscle breathing and a body mass index at or above the 85th percentile
depolarization. Other potential complications of succinylcholine are more likely to experience laryngospasm.
include masticator muscle rigidity, malignant hyperthermia, and Laryngospasm accounts for more than 50% of the cases of
hyperkalemic cardiac arrest (secondary to the transient hyperkale- negative-pressure or postobstructive pulmonary edema. With the
mia), which can be seen in patients with undiagnosed myopathies use of general endotracheal intubation, laryngospasm classically
(e.g., Duchenne’s and Becker’s muscular dystrophies). occurs during extubation in a light plane of anesthesia (stage II).
Children and patients who have had a recent URI are predisposed
Discussion to developing laryngospasm during anesthesia.
Efforts to prevent laryngospasm include postponing surgery in
Laryngospasm results in tight approximation of the true vocal patients who have had recent upper respiratory infections, main-
cords (Fig. 15.1). It is a protective reflex that is most commonly taining a dry surgical field, and using anticholinergics and avoid-
caused by a noxious stimulus to the airway during a light plane of ing extubation during stage II of anesthesia. Laryngospasm is
anesthesia. The structural and functional bases of the laryngospasm common in outpatient and inpatient oral and maxillofacial sur-
reflex were described by Rex. Secretions, vomitus, blood, pungent gery. Recognition and early intervention are essential in prevent-
volatile anesthetics, painful stimuli, and oral and nasal airways may ing morbidity and mortality.
elicit this protective reflex. Mediated by the vagus nerve, this reflex
is designed to prevent foreign materials from entering the tracheo- ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
bronchial tree. During laryngospasm, the false vocal cords and complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 69.e1

Bibliography general anesthesia through an orotracheal tube and inhalation agents,

Korean J Anesthesiol, 65(2):136-141, 2013.
Larson CP: Laryngospasm—the best treatment, J Am Soc Anesthesiol
Baraka A: Intravenous lidocaine controls extubation laryngospasm in 89(5):1293-1294, 1998.
children, Anesth Analg 57:506-507, 1978. Leicht P, Wisborg T, Chraemmer-Joorgensen B: Does intravenous lido-
Ciavarro C, Kelly JP: Postobstructive pulmonary edema in an obese child caine prevent laryngospasm after extubation in children? Anesth Analg
after an oral surgery procedure under general anesthesia: a case report, 64:1193-1196, 1985.
J Oral Maxillofac Surg 60(12):1503-1505, 2002. Louis PJ, Fernandes R: Negative pressure pulmonary edema, Oral Surg
Collins S, Schedler P, Veasey B, Kristofy A, McDowell M. Prevention and Oral Med Oral Pathol Oral Radiol Endod 93(1):4-6, 2002.
treatment of laryngospasm in the pediatric patient: a literature review, Rex MAE: A review of the structural and functional basis of laryngo-
AANA J 87(2):145-151, 2019. spasm and a discussion of the nerve pathways involved in the reflex
Hartley M, Vaughan RS: Problems associated with tracheal extubation, and its clinical significance in man and animals, Br J Anaesth 42:
Br J Anaesth 71:561-568, 1993. 891-898, 1970.
Hurford WE, Bailin MT, Davison JK, et al: Clinical procedures of the Stoelting RK, Miller RD: Basics of anesthesia, ed 3, 161, New York, 1994,
Massachusetts General Hospital, ed 5, Philadelphia, 1998, Lippincott- Churchill Livingstone, pp 85-90.
Raven, pp 299-300, 514, 609.
Kim SY, Kim JM, Lee JH, et al: Perioperative respiratory adverse events
in children with active upper respiratory tract infection who received

t.me/Dr_Mouayyad_AlbtousH
16
Perioperative Considerations in
Pregnant Patients
SU Z AN N E B AR N E S a n d BR YAN K EN DR IC K S

CC patients, ambulation, compression devices, and subcutaneous

heparin should be considered.
A 22-year-old multiparous G3P2002 (this is the patient’s third Hypertension during pregnancy is classified as chronic hyper-
pregnancy: two children were born at term, zero children were tension, gestational hypertension, or pre-eclampsia. This is typi-
born premature, zero were abortions or miscarriages, and two liv- cally classified clinically based on the onset of hypertension.
ing children) who is currently 39 weeks and 4 days pregnant Chronic hypertension is present before 20 weeks of gestation, and
presents to the emergency department (ED) after sustaining a gestational hypertension begins after 20 weeks of gestation.
gunshot wound to the face. The oral and maxillofacial surgery Gestational hypertension is defined as a systolic blood pressure
(OMFS) team is consulted for evaluation and management of of 140 mm Hg or greater but less than 160 mm Hg or a diastolic
facial injuries. blood pressure of 90 mm Hg or greater but less than 110 mm Hg.
These pressures must also be observed on at least two occasions
HPI 4 hours apart but no more than 7 days apart. Pre-eclampsia is
gestational hypertension plus proteinuria or the presence of symp-
The 22-year-old female presents with right-sided facial pain and toms consistent with pre-eclampsia.
swelling after being shot by an unknown person. She is currently Proteinuria may be present before pregnancy or newly diag-
hemostatic and stable but reports dysphagia (difficulty swallow- nosed during pregnancy. Proteinuria is diagnosed when greater
ing) and odynophagia (painful swallowing). Her airway appears than 0.3 g is detected in a 24-hour urine collection or a P/C
patent, but she elicits difficulty breathing and appears to be strug- (protein/creatinine) ratio is greater than 0.3. If a 24-hour urine
gling with increased intraoral secretions. She is followed by her protein or P/C ratio is not possible, proteinuria can be defined as
obstetrician regularly and states that her pregnancy is progressing a dipstick measurement of at least 11 on two occasions.
without complications. Her previous two pregnancies have re-
sulted in spontaneous vaginal deliveries at full term. She currently Examination
denies any loss of fluid or vaginal bleeding (a sign that amniotic
fluid may be leaking from ruptured membrane) or pelvic cramp- Vital signs: The patient’s blood pressure was 127/80 mm Hg,
ing (cramping described by pregnant patients may actually be heart rate was 103 to 110 bpm (tachycardic), and respirations
contractions). Her current pregnancy is complicated by obesity, were 18 breaths per minute. The patient is afebrile with a tem-
gestational hypertension, and gestational thrombocytopenia. perature of 97.6°F.
General: Obese (body mass index, 34), mild distress.
PMHX/PDHX/Medications/Allergies/SH/FH Maxillofacial: The patient has right-sided facial edema and ec-
chymosis surrounding what appears to be the projectile entry site.
The patient has obesity, gestational hypertension, and gestational The entry wound is hemostatic. The patient’s intraoral examination
thrombocytopenia. is limited because of pain. The tongue is edematous with lacerations
associated with both the posterior right and left sides. The maxillary
POBHx right alveolar segment is mobile with associated edematous gingiva
tissue and multiple fractured teeth. The maxilla and mandible ap-
This is the patient’s third pregnancy. Her previous two pregnan- pear stable. The oropharynx is not clearly visible because of limited
cies resulted in spontaneous vaginal deliveries at full term. She mouth opening. The floor of mouth is soft and nonelevated (rules
currently is at high risk because of morbid obesity, gestational out floor-of-mouth expansile hematoma). The patient appears to be
hypertension, and gestational thrombocytopenia. in mild distress with minor difficulty tolerating secretions.
Maternal obesity increases the risk for gestational diabetes, pre- Cardiovascular: The patient is mildly tachycardic, which is
eclampsia, cesarean delivery, infectious morbidity, and thrombo- likely attributable to pain.
embolism, especially in the postoperative period. Because of the Abdominal: Examination reveals a gravid uterus (pregnant
increased risk of venous thromboembolism in obese pregnant uterus). The fundal height is appropriate for gestational age, and

70
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 16 Perioperative Considerations in Pregnant Patients 71

the abdomen is soft, nontender, and nondistended. Fetus presen- Thrombocytopenia is also quite common during pregnancy
tation is cephalic. Fetal heart rate (FHR) is in the 130s. and is generally not concerning until platelets drop below 100,000
Extremities: Extremities are nontender with 11 pitting edema platelets per microliter. Gestational thrombocytopenia is the most
at the ankles bilaterally (common during pregnancy) and 21 common cause of thrombocytopenia in pregnancy, which typically
equal pulses. She is negative for Homan’s sign (calf pain upon occurs in the third trimester. The platelet count usually does not
dorsiflexion of the foot, suggestive of deep vein thrombosis). drop below 70,000 platelets per microliter. These patients typically
are asymptomatic and have never had a history of thrombocytope-
Imaging nia. This patient is stable with platelets at 126,000 platelets per
microliter, making her at low risk for complications.
Despite the potential theoretical effects of radiation exposure to
the fetus, all necessary plain film and computed tomography (CT) Assessment
studies for diagnosing and managing facial trauma can be safely
performed as needed. The radiation exposure to the developing A 22-year-old G3P2002 at 39 weeks 1 4 days of gestation presents
fetus is minimal, especially when imaging the head and neck, and with a gunshot wound to the face resulting in a right-sided facial
is further reduced by using shielding devices. Nonionization tech- laceration, maxillary alveolar fracture, multiple fractured teeth, and
niques, such as ultrasound scans and magnetic resonance imaging tongue lacerations complicated by a pregnancy with gestational hyper-
(MRI) of the head and neck, are also considered safe during preg- tension, gestation thrombocytopenia, and obesity.
nancy and can aid in imaging soft tissue pathology.
Computed tomography is the initial diagnostic study of choice Treatment
for this patient because of facial trauma, the patient’s difficult in-
traoral examination, and possible airway compromise. The CT The ideal time to perform elective or semi-elective oral and maxil-
scan will help visualize facial fractures, broken teeth, foreign bod- lofacial surgical procedures is postpartum; otherwise, the early
ies, and airway deviation. The use of CT with intravenous (IV) second trimester is considered the safest period for performing
contrast material is generally considered safe during pregnancy; nonelective surgery that cannot wait until after pregnancy. Urgent
however, special attention must be paid to the gestational age of or emergent surgery should not be delayed at any gestation of
the fetus as well as the dose and type of radiation being performed. pregnancy. Local anesthesia is the preferred method for simple
The safe threshold for a fetus is 50 mGy. CT imaging of the ma- procedures that can be performed in an office setting. (There are
ternal abdomen and pelvis can potentially deliver radiation doses no contraindications to vasoconstrictors, but aspiration to avoid
that approach this safety threshold, but those of the face are well intravascular injection is important.) If the need arises, IV seda-
below the threshold. Changes in variables such as slice thickness, tion and general anesthesia (in a hospital setting, when appropri-
number of cuts, and helical movements can also affect the amount ate) can be safely performed without significant risk to the mother
of ionizing radiation used regarding IV contrast. The main concern or fetus in an uncomplicated pregnancy.
with the iodinated contrast is depression of the fetal thyroid func- There should be a low threshold for hospital admission of the
tion. After the fetus is 12 weeks old, they are producing thyroxine pregnant patient who has sustained trauma. Dehydration, bleed-
under the influence of thyroid-stimulating hormone. IV iodinated ing, inability to tolerate oral intake, and potential airway compro-
contrast can cross the placenta and depress fetal thyroid function. mise are all indications for hospital admission.
This depression in fetal thyroid function is only observed with When a pregnant patient presents to the ED with trauma,
ionic contrast agents and not nonionic contrast. evaluation should be a multidisciplinary approach. All pregnant
Regarding gadolinium contrast with MRI, the US Food and women who sustained serious injuries are first to be evaluated in
Drug Administration gives these agents a risk of “C,” which states the ED with the goal of maternal well-being. After the mother is
the “risk cannot be ruled out.” The routine use of gadolinium is stabilized, the obstetric team should provide complete physical and
not recommended because of its long half-life and its ability to obstetric assessment. This is often done simultaneously while the
accumulate in amnionic fluid. mother is being evaluated. Depending on the facility, stable
In this patient, the CT scan of the face showed multiple frac- trauma patients who are beyond 23 weeks of gestation should be
tured teeth, an alveolar fracture of the maxilla, and a foreign body admitted to labor and delivery for observation and monitoring.
within the left side floor of the mouth. Placental abruption (premature separation of the placenta before
delivery) is the most frequent cause of fetal death in trauma. Fetal
Labs and uterine contraction monitoring is considered the most sensi-
tive for detecting placental abruption. FHR is important to moni-
A basic metabolic panel and complete blood count with platelets tor in case of maternal hemorrhagic shock or hypotension. Fre-
are the baseline studies. quent uterine contractions provide the most reliable warning signs
The patient’s hemoglobin and hematocrit were 10.8 g/dL and of placental abruption or preterm labor. Uterine contractions that
32.6% on admission, respectively. Platelets were 126,000 platelets occur less frequently than every 15 minutes over a 4-hour period
per microliter. White blood cell count was 12,300 white blood of observation are an indication that placental abruption is un-
cells per microliter. likely to occur. If the fetus is beyond 23 to 24 weeks of gestation,
Anemia is common in pregnancy and is classified as a hemo- the recommended minimal time of monitoring is at least 4 hours.
globin below 11 g/dL in developed countries. This is due to the Fluid resuscitation, fetal monitoring, nutritional support, and
hemodilution from greater increases in blood volume compared pain management are important in obstetric patients. Caution
with the red blood cell mass. The circulatory volumes can increase should be exercised to avoid excessive fluid overload that can lead
by 50% during pregnancy. Other causes of anemia in pregnancy to pulmonary edema.
include iron-deficiency anemia and folate deficiency. This pa- Intravenous antibiotics should be initiated if indicated. (The
tient’s hemoglobin is 10.8 g/dL, making her slightly anemic. penicillin and cephalosporin families are considered safe first-line

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72 S E C TI O N Anesthesia

antibiotics during pregnancy.) Pain management should be initi- of the complications that increase in obstetrics patient and oral
ated as well with the goal for the patient to tolerate oral medica- and maxillofacial trauma, including intubation difficulty and in-
tions if the patient does not have NPO (nothing by mouth) sta- creased aspiration risk.
tus. Acetaminophen is the analgesic of choice during pregnancy Because of the decreased functional residual capacity in preg-
and can be used during any trimester when indicated. Aspirin or nancy, obstetric patients are more likely to become hypoxemic.
nonsteroidal antiinflammatory drugs should not be used regularly This is important to consider in this patient population with facial
as analgesic or antiinflammatory doses in the last third of preg- injuries who might develop difficulty breathing sooner than non-
nancy. When needed, orally administered hydrocodone, oxyco- pregnant patients. This makes supplemental oxygenation and pre-
done, or codeine with acetaminophen combinations are all con- oxygenation before intubation even more important. Not only does
sidered safe during pregnancy for necessary pain control as well as facial trauma increase the risk of difficulty intubation, but it is also
IV morphine and hydromorphone. Prolonged exposure may important to remember that airway patency can decrease because of
cause newborns to present with symptoms of withdrawal. edema during labor. Studies have shown a significant increase in
The current patient was admitted by the obstetric team, and Mallampati score with a decrease in oral volume and pharyngeal
OMFS was consulted for facial injuries. The patient was admitted areas when comparing prelabor and postlabor airway examinations.
with plans for primary cesarean delivery followed by management Not only are obstetric patients at risk for difficult intubation, but
of facial injuries by OMFS under general anesthesia. aspiration is also a serious possible fatal complication of general
The pelvic examination showed effacement of 50%, dilation of anesthesia after the patient is extubated. The enlarged uterus causes
1, and –3 station. There was abundant fetal movement on ultra- an increase in intraabdominal pressure, causing an increased inci-
sound examination with an estimated fetal weight of 7 lb, 1 oz. dence of esophageal reflux. Progesterone levels are also increased,
Fetal heart tracing showed heart rate in the 130s with moder- which affects smooth muscle, further delaying gastric emptying and
ate variability and positive acceleration but no decelerations. The relaxing the gastroesophageal sphincter. To help reduce the risk of
tocodynamometer monitoring showed irregular uterine irritabil- aspiration, a clear antacid should be given before surgery. If a pa-
ity with contractions every 4 to 6 minutes. tient has additional risk factors such as a difficult airway, obesity,
Because of near-term pregnancy and concern for airway com- diabetes, or recent ingestion of food, one should consider giving H2
promise, the patient was taken to the operating room for primary receptor blocking agents and metoclopramide.
cesarean delivery followed by examination under anesthesia with
washout, debridement, and closure of facial wounds by OMFS. Discussion
In the operating room, the patient was placed in the supine posi-
tion and then placed under general anesthesia, and the airway was With every trauma patient, the initial evaluation should start with
secured via a nasal endotracheal tube. She was then placed in a left airway, breathing, and circulation. For female trauma patients, one
lateral tilt (left lateral tilt of 15–30 degrees displaces the uterus off should always consider the possibility of pregnancy. The approach
the aorta and inferior vena cava [IVC] and prevents supine hypo- to a pregnant trauma patient should be a multidisciplinary ap-
tensive syndrome caused by compression of the great vessels) and proach with initial stabilization of the mother being the priority.
prepped and draped in a sterile fashion. The obstetric team com- When approaching a pregnant patient with oral and maxillo-
pleted a successful uncomplicated delivery of the infant. facial injuries, one should be aware of potential complications
After delivery of the infant, the OMFS team completed an that are increased because of the current pregnancy. Pregnant pa-
examination under anesthesia with extraction of indicated teeth, tients have a decreased ability to maintain a patent airway for
closure of intraoral lacerations, and removal of the foreign body. proper ventilation, which could lead to fetal distress. This may
The patient’s airway was deemed stable and was extubated with- result in maternal hyperventilation and alkalosis, which can re-
out difficulty. The infant was taken to the neonatal intensive care duce uterine blood, further inducing fetal distress. The anatomic
unit for observation, and the patient was discharged on postop- airway in pregnancy is more edematous and friable, which could
erative day 3 after she was tolerating oral intake, reported positive lead to a difficult intubation. One should have a lower threshold
urinary output, was ambulating, and had minimal discomfort. At for advanced airway management because of a difficult airway and
discharge, the patient was hemostatic intraorally and had signifi- lower maternal oxygen reserve. After it is decided to intubate the
cantly improved facial and intraoral edema. patient, it is important to properly position the mother in a left
lateral tilt to help displace the uterus off the IVC so one can help
Complications maintain proper vascular preload. Anesthesia is many times in-
duced with a rapid sequence intubation to help reduce aspiration.
Many things must be considered to help reduce the risk of com- To further help decrease the risk of aspiration, one should main-
plications when presented with an obstetric patient with oral and tain cricoid pressure during intubation. Even if intubation is not
maxillofacial trauma. Proper resuscitation efforts to help stabilize indicated, supplemental oxygen should be provided to the obstet-
the mother must be addressed accordingly to help reduce possible ric patient because of the reduction in oxygen reserve that can
complications in the mother and fetus. All elective surgical proce- result in inadequate respiratory compensation causing maternal
dures should be avoided during pregnancy, but necessary surgical hypoxia. After airway and breathing are stabilized, proper circula-
interventions should not be delayed. If general anesthesia is tion should be maintained with IV fluids. Lower extremity IV
needed, surgery should be performed in a setting where an obste- placement should be avoided because of vascular congestion and
trician is available for consultation and where anesthesiologists are IVC compression by the uterus. Signs of hypovolemia such as
familiar with the physiologic changes associated with pregnancy. tachycardia, hypotension, and abnormal FHC should be detected
A collaborative, multidisciplinary approach involving obstetri- early to initiate timely resuscitation.
cians, anesthesiologists, and oral and maxillofacial surgeons pro-
vides the most appropriate management and treatment plan for ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
pregnant patients. If surgery is necessary, one must consider a few complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 72.e1

Bibliography Peterson PR: Radiation in pregnancy and clinical issues of radiocontrast

agents. In Roberts JR, Hedges JR (eds): Clinical Procedures in Emer-
gency Medicine, ed 7, Philadelphia, 2019, Elsevier.
Brown HL, Small M: Trauma and related surgery in pregnancy. In Russo, RM, Jurkovich, GJ, Farmer DL: Surgery in the pregnant patient.
Landon MB, Galan HL, Jauniaux E, et al (eds): Obstetrics: Normal In Townsend CM, Beauchamp R, Evers M, et al (eds): Sabiston Text-
and Problem Pregnancies, ed 8, Philadelphia, 2021, Elsevier. book of Surgery: The Biological Basis of Modern Surgical Practice, ed 21,
Cromwell C, Paidas M: Hematology: Basic Principles and Practice. In St. Louis, 2022, Elsevier.
Hoffman R, Benz EJ, Silberstein LE, et al (eds): Hematology basic Samuels P: Hematologic complications of pregnancy. In Landon MB,
principles and practice, ed 7, Philadelphia, 2018, Elsevier. Galan HL, Jauniaux E, et al (eds): Obstetrics: Normal and Problem
Ellfolk M, Hultzsch S: Analgesics, antiphlogistics, and anesthetics. In Pregnancies, ed 8, Philadelphia, 2021, Elsevier.
Schaefer C, Peters P, Miller RK, et al (eds): Drugs During Pregnancy Schwartz N, Ludmir J: Surgery during pregnancy. In Landon MB, Galan
and Lactation Treatment Options and Risk Assessment, ed 3, London, HL, Jauniaux E, et al (eds): Obstetrics: Normal and Problem Pregnan-
2015, Elsevier. cies, ed 8, Philadelphia, 2021, Elsevier.
Hawkins JL, Bucklin BA: Obstetrical anesthesia. In Landon MB, Galan Sibal BM: Preeclampsia and hypertensive disorders. In Landon MB,
HL, Jauniaux E, et al (eds): Obstetrics: Normal and Problem Pregnan- Galan HL, Jauniaux E, et al (eds): Obstetrics: Normal and Problem
cies, ed 8, Philadelphia, 2021, Elsevier. Pregnancies, ed 8, Philadelphia, 2021, Elsevier.

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17
Effects of Marijuana and Vapinga
E L I S E L . E HL A N D a n d DAV I D S . D R A K E

CC Intraoral: The maxillary third molars are not visible intra-

orally. The mandibular third molars are partially visualized but
A 21-year-old male presents for extraction of four asymptomatic, without sufficient room for functional eruption. Bilateral man-
impacted third molars with local anesthesia and intravenous (IV) dibular second molars have probing depths greater than 4 mm on
sedation. the distal. No swelling or signs of infection are seen.
Airway: Maximum interincisal opening 31 fingerbreadths,
HPI Mallampati class I, thyromental distance 31 fingerbreadths.
Cardiovascular: Heart has a regular rate and rhythm.
The patient is a male who uses electronic cigarettes but is other- Pulmonary: Lungs are clear to auscultation bilaterally. (e-
wise healthy. Treatment was planned for extraction of all four as- Cigarette and THC users may exhibit preoperative wheezing,
ymptomatic, impacted third molars with IV sedation. The patient which increases the risk of intraoperative bronchospasm.)
arrives with nothing by mouth status for more than 8 hours with Note: It is essential to assess for signs and symptoms of acute
an escort. He states he has refrained from vaping for the past marijuana use because many of the concerning anesthetic implica-
24 hours, as requested in his preoperative instructions. tions are related to acute effects. Furthermore, there is controversy
regarding the appropriateness of obtaining informed consent
PMHX/PDHX/Medications/Allergies/SH/FH from a patient with acute cannabis intoxication.

The patient’s past medical and surgical histories are noncon- Imaging
tributory. He does not use any medications and denies any drug
allergies. He states that he vapes throughout the day and often Panoramic radiograph is the initial diagnostic study of choice.
uses vaping products infused with delta-9-tetrahydrocannabinol Additional imaging, including cone-beam computed tomogra-
(THC) and nicotine. He denies any other drug or alcohol use. phy, may be ordered as indicated. In this particular case, the
Note: Some patients who use e-cigarettes deny smoking unless panoramic radiograph showed partial bony impaction of teeth #1,
asked specifically about vaping. It is important to inquire specifically #16, #17, and #32 without any radiographic predictors of inferior
and separately regarding the use of e-cigarettes and marijuana. Ques- alveolar nerve proximity or pathology associated with the teeth to
tions should be asked regarding the most recent use as well as the be extracted. Further imaging was not indicated.
duration, route, and frequency of use. An in-depth discussion on the
perioperative evaluation and management of patients who vape and Labs
use THC is included in the discussion section of this chapter.
Routine labs are typically not indicated for healthy patients un-
Examination dergoing outpatient dentoalveolar surgery even for patients who
smoke e-cigarettes or use THC.
General: Well-developed and well-nourished male in no apparent If patients have been instructed to abstain from vaping pre-
distress. (THC use can cause anxiety, paranoia, and psychosis.) operatively, urine or blood tests for cotinine (a metabolite of
Weight: 80 kg. nicotine) can be ordered to verify patient compliance. Cotinine
Vital signs: Vital signs are normal, and the patient is afebrile. remains in the body longer than nicotine, so it is a more reliable
(Some of the most consistent effects of acute cannabis use are test to detect and measure nicotine exposure. Cotinine levels
tachycardia and orthostatic hypotension.) remain detectable in urine and blood samples for up to 7 days.
Maxillofacial: Normocephalic, atraumatic. No lymphadenopa- Cotinine test results are positive in patients using nicotine re-
thy. Examination of the temporomandibular joint reveals no click- placement therapy and smokeless tobacco as well as e-cigarettes
ing, popping, or pain to palpation. The muscles of mastication are or tobacco.
nontender to palpation. Cranial nerves are normal bilaterally. Similar toxicology screens exist for marijuana but can only
provide qualitative data regarding the use of marijuana over the
a
The views expressed in this material are those of the authors and do not re- past 30 days. These tests are unreliable in confirming patient re-
flect the official policy or position of the US Government, the Department of ports on timing of use because of nonlinear relationships between
Defense, or the Department of the Air Force. plasma cannabinoid levels and degree of intoxication.

73
t.me/Dr_Mouayyad_AlbtousH
74 S E C TI O N Anesthesia

Assessment anesthesia. A 2009 study on self-reported cannabis users showed

that they required significantly higher induction doses of propofol
A 21-year-old male with heavy use of e-cigarettes, including products to achieve loss of consciousness and a bispectral index below 60
infused with THC and nicotine, presenting for extraction of four as- compared with nonusers. A 2019 study found that cannabis users
ymptomatic, impacted third molars with local anesthesia and IV se- required 220% more propofol to complete endoscopic procedures
dation. The patient has followed preoperative instructions to refrain than nonusers. In the example patient, normal doses of propofol
from vaping for 24 hours before the procedure. resulted in a lighter sedation plane in a chronic marijuana user,
which put this patient at increased risk of bronchospasm in an
Treatment already reactive airway.
Acute cannabis intoxication can also cause anxiety, paranoia,
After standard monitors were applied, the patient was administered and psychosis in some patients, which may result in a more vio-
4 L of oxygen via nasal cannula. Sedation was initiated using 2 mg lent or agitated anesthetic emergence.
of IV midazolam, 50 mcg of IV fentanyl, and 40 mg of IV propo- Postoperatively, e-cigarettes and marijuana appear to have ef-
fol. During administration of local anesthesia, the patient began fects similar to other tobacco products related to wound healing.
moaning and attempting to reach for the anesthetic syringe. An Both are associated with an increased risk of wound dehiscence
additional 2 mg of midazolam and 40 mg of propofol were given and surgical site infections because of decreased immune defenses
to deepen the sedation. Throughout the sedation, the patient re- and the proinflammatory effects of the inhaled agents.
mained in a lighter plane of anesthesia despite repeated boluses of Other studies have also shown that cannabis users report
propofol. After extraction of the last tooth, the patient began higher pain scores, have worse sleep, and require more rescue an-
wheezing, and his oxygen saturation decreased from 100% to 85%. algesics postoperatively than nonusers.
Capnography showed a slower upslope (shark-fin appearance).
The oropharynx was suctioned, all materials were removed
from the mouth, and attempts to improve the airway were made
Discussion
by head tilt and jaw thrust. The patient’s condition continued to
decline with a progressive decrease in oxygen saturation below
Vaping Basics
85% despite increased respiratory efforts by the patient. The diag- Vaping is the inhalation of a vaporized liquid from a battery-
nosis of bronchospasm was made. An attempt to mask ventilate operated device, disposable or refillable. These devices have many
with 100% oxygen revealed airway resistance, and four puffs of names: e-cigarette, vape pen, mod, tank, and so on. The device
albuterol were given via the bag-valve-mask. Mask ventilation re- heats up the liquid, which contains (1) a carrier solvent, usually
mained difficult, and the anesthetic plane was deepened with ad- propylene glycol or glycerin; (2) various flavorings; and (3) the
ministration of 50 mg of IV ketamine. active drugs that become aerosolized upon heating, including
The patient’s airway resistance slowly decreased with continued nicotine, cannabinoids, or both.
bag-mask ventilation. Oxygen saturation returned to 100%, and The constituents of liquids and aerosols in e-cigarettes are
all other vital signs normalized. The patient was recovered and essentially toxic and have a variety of degrees of carcinogenic,
discharged to his escort after criteria were met without further cardiac, pulmonary, immunologic, and vascular toxicity. The
complication. combined effects of many of these chemicals are unpredictable.
Although e-cigarettes can reduce exposure to many of the harm-
Complications ful toxins in conventional tobacco and cigarette smoke, they intro-
duce a new array of potential toxins. Numerous toxic compounds
The long-term complications of vaping are unknown because it is have been identified in e-cigarette aerosols. With thousands of
still a relatively new trend. In the short term, however, use of e- brands available and no set Food and Drug Administration stan-
cigarettes has been shown to have significant effects on pulmonary dards, it can be difficult to determine the exact composition of a
status and wound healing. Specifically, e-cigarettes decrease airflow given e-liquid. Exposure risk certainly varies between the different
by increasing airway resistance, increase oxidative stress, impair lung manufacturers and flavors.
development, increase mucin production, and depress host defenses.
The chronic effects of marijuana smoking are better under-
stood and include cough, chronic bronchitis, and emphysema
Marijuana Basics
similar to those seen in chronic tobacco smokers. Acutely, the Marijuana is derived from plants of the genus Cannabis. The main
most consistent effects of cannabis are tachycardia and vasodila- psychoactive product of the plant is THC. Another common can-
tion, and there is evidence that this combination leads to an ele- nabinoid is cannabidiol, which lacks the psychoactive effects of
vated risk of myocardial infarction (MI) caused by an increase in THC. Many modern marijuana products have been created to
cardiac output, oxygen demand, and cardiac work. This risk of MI maximize THC content and enhance the recreational effects. Our
decreases 1 hour after use. understanding regarding the physiologic changes of marijuana on
The complications associated with surgery under IV sedation humans is limited by the variable effects of different types and
in patients who chronically vape or use marijuana are related concentrations of cannabinoids as well as research limitations in
mostly to the increase in airway inflammation and reactivity, the US because of its Schedule I status.
which places these patients at risk of perioperative respiratory
airway events such as coughing, laryngospasm, bronchospasm,
and hypoxemia.
Vaping Prevalence
Recent data also support the idea that cannabis users require A 2021 survey of high school students in America in the 2021 Na-
significantly higher doses of propofol to induce and/or maintain tional Youth Tobacco Survey found that 11.3% had used e-cigarettes

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 CHAPTER 17 Effects of Marijuana and Vaping 75

during the past 30 days with 43.6% of users using e-cigarettes on TABLE Anesthetic Considerations in Patients
more than 20 of the past 30 days. Notably, 15.6% of high school 17.1 Consuming Marijuana
users reported not knowing the e-cigarette brand they use. Among
adults, the Centers for Disease Control and Prevention (CDC) esti- Period Considerations
mates that in 2018, 3.2% of people older than 18 years of age were Preoperative • Elevated risk of MI within 1 hr after use
current e-cigarette users. Among Americans aged 18 to 24 years, • Airway hyperreactivity
7.6% were current e-cigarette users as found in the 2018 National • Anxiety, paranoia
Health Interview Survey. A premise among e-cigarette users is that it • Psychosis
is a safer form of nicotine than traditional smoking. It was also ini- • Need to assess for other drugs
tially thought to be a mechanism for smoking cessation; however, Intraoperative • Tolerance to induction agents
data are lacking to support their efficacy in this regard. There is • Elevated bispectral index
concern that the use of e-cigarettes, with higher nicotine concentra- • Unknown cross-tolerance to other anesthetic agents
tions than tobacco cigarettes, by youth may actually increase depen- • Elevated risk of MI within 1 hr after use
dence and the subsequent frequency and intensity of smoking and • Airway hyperreactivity
vaping. Postoperative • Unknown cross-tolerance to analgesics
• Possible heightened pain perception
Marijuana Prevalence • Withdrawal

Marijuana is currently designated a Schedule I drug by the US MI, Myocardial infarction.

From Alexander JC, Joshi GP: A review of the anesthetic implications of marijuana use,
Drug Enforcement Agency. This federal relegation is reserved for Proc (Bayl Univ Med Cent) 32(3):364-371, 2019.
products without any accepted medical use and a high potential
for abuse. However, 37 states currently allow medical marijuana
use, and 17 of these states allow recreational use despite federal
law. As a result, marijuana use is becoming more common in the likely be managed similar to tobacco users because of physiologic
general population. The CDC estimates 48.2 million people older similarities between the two. Ideally, patients should quit vaping
than the age of 12 years, or about 18% of Americans, used mari- 4 to 6 weeks before surgery in an effort to minimize respiratory
juana at least once in 2019. In Americans ages 18 to 25 years, and wound healing complications. This is not a realistic expecta-
more than 35% used marijuana at least once according to the tion for many patients, but even refraining from e-cigarettes for
2019 National Survey on Drug Use and Health. As these num- 24 hours before the procedure will decrease carboxyhemoglobin
bers increase, more patients who use marijuana products will be and increase oxygenation of the tissues. Cessation closer to the
presenting for oral surgical procedures. Unfortunately, marijuana’s time of surgery caries the theoretical disadvantages of increased
scheduling classification has also limited the ability of US-based airway secretions, reactivity, and increased patient anxiety.
researchers to study the effects of cannabis products. For patients who use marijuana, elective procedures should
ideally be rescheduled or delayed when there is acute intoxication
to allow for informed consent and resolution of acute cardiovas-
Evaluating Patients Who Use e-Cigarettes or cular, pulmonary, and psychologic effects. Universal guidelines do
Marijuana not exist, but delaying elective procedures for 72 hours after can-
In the preanesthetic evaluation of these patients, some specific nabis exposure will reduce incidence of perioperative tachycardia
questions to ask include: and airway hyperresponsiveness.
1. Do you use nicotine in your e-liquid? (Ninety-nine percent of
the e-cigarettes sold in the United States do contain nicotine.) Intraoperative Management
2. Do you use THC or other cannabis products in your e-liquid?
(THC is less common than nicotine but is commonly used, Before induction, the prophylactic administration of albuterol,
especially in states where it is legal.) especially in patients with a history of reactive airway disease, can
3. How much e-liquid or “vape juice” do you use in a typical be beneficial. Midazolam, fentanyl, propofol, and ketamine are
day? (E-liquid comes in different nicotine concentrations and examples of generally safe anesthetic agents for patients who use
the pods or cartridges come in different volumes; therefore, e-cigarettes or marijuana, although higher doses of propofol are
quantifying the amount an individual vapes can be difficult. often required for marijuana users. Ketamine can be particularly
For reference, the nicotine in one 5% JUUL pod [a prevalent useful because of its secondary bronchodilator effects; however, it
brand] is equivalent to about 1 pack of tobacco cigarettes.) should be used with caution in tachycardic patients acutely in-
Users should be advised to pay attention to the nicotine con- toxicated with cannabis to avoid additive sympathetic effects.
tent of their preferred e-liquid. Before anesthesia, it is also critical There is conflicting evidence regarding ketamine dosage require-
to ask about most recent use, especially as it relates to THC, be- ments in chronic cannabis users, but ketamine has been found to
cause many of the most concerning anesthetic implications are result in a satisfactory decrease in talking and agitation during the
related to its acute effects. See Table 17.1 for the perioperative procedure in this patient population. If using ketamine, con-
considerations in patients using marijuana. comitant administration of glycopyrrolate is helpful to minimize
oral and airway secretions, which may already be increased in this
population. Ultimately, providers and teams administering anes-
Preoperative Management
thesia to e-cigarette users should be prepared to manage respira-
Universal guidelines for the preoperative management of patients tory adverse events intraoperatively, including bronchospasm, la-
who use e-cigarettes do not exist. However, these patients can ryngospasm, and aspiration.

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76 S E C TI O N Anesthesia

Postoperative Management Marijuana users may exhibit a lower pain threshold and
increased tolerance to the effects of opioids prescribed for post-
Ideally, patients should refrain from vaping or marijuana use until operative pain. Rather than prescribing more opioids, a multi-
fully healed. This is not realistic for many patients. The symptoms modal analgesic regimen using acetaminophen, a nonsteroidal
of nicotine or cannabis withdrawal can develop within days of antiinflammatory drug, and a long-acting local anesthetic should
cessation and can be truly debilitating. Quitting even for only be used.
3 days can theoretically decrease the risk of alveolar osteitis, wound
dehiscence, and infection and should be discussed with patients. If ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
and when patients resume vaping in the immediate postoperative complete set of bibliography.
period, they should be instructed to avoid aggressive sucking and
exhaling actions when they vape.

t.me/Dr_Mouayyad_AlbtousH
 76.e1

Bibliography King DD, Stewart SA, Collins-Yoder A, et al: Anesthesia for patients who
self-report cannabis (marijuana) use before esophagogastroduodenos-
copy: a retrospective review, AANA J 89(3):205-212, 2021.
AAOMS, American Association of Oral and Maxillofacial Surgeons: Krishna A, Mathieu W, Mull E, et al: Perioperative implications of vap-
Implications of Cannabis Use for Patients Undergoing Office-based ing, J Med Cases 11(5):129-134, 2020.
Anesthesia and Oral and Maxillofacial Surgery, 2023. https://www. Layden JE, Ghinai I, Pray I, et al: Pulmonary illness related to e-cigarette
aaoms.org/docs/practice_resources/clinical_resources/cannabis_pa- use in Illinois and Wisconsin—final report, N Engl J Med 382(10):
tient_anesthesia_clinical_paper.pdf. 903-916, 2020.
Alexander JC, Joshi GP: A review of the anesthetic implications of mari- Lynn RSR, Galinkin JL: Cannabis, e-cigarettes and anesthesia, Curr Opin
juana use, Proc (Bayl Univ Med Cent) 32(3):364-371, 2019. Anaesthesiol 33(3):318-326, 2020.
Cutts TG, O’Donnell AM: The implications of vaping for the anaesthe- Oyston J: What do anesthesiologists need to know about vaping? Can
tist, BJA Educ 21(7):243-249, 2021. J Anaesth 67(9):1124-1129, 2020.
Echeverria-Villalobos M, Todeschini AB, Stoicea N, et al: Perioperative Park-Lee E, Ren C, Sawdey MD, et al: Notes from the field: e-cigarette
care of cannabis users: a comprehensive review of pharmacological use among middle and high school students—National Youth To-
and anesthetic considerations, J Clin Anesth 57:41-49, 2019. bacco Survey, United States, 2021, MMWR Morb Mortal Wkly Rep
Flisberg P, Paech MJ, Shah T, et al: Induction dose of propofol in patients 70(39):1387-1389, 2021.
using cannabis, Eur J Anaesthesiol 26(3):192-195, 2009. Rusy DA, Honkanen A, Landrigan-Ossar MF, et al: Vaping and e-
Harris DE, Foley EM: Anesthesia implications of patient use of elec- cigarette use in children and adolescents: implications on perioperative
tronic cigarettes, AANA J 88(2):135-140, 2020. care from the American Society of Anesthesiologists Committee on
Hobson A, Arndt K, Barenklau S: Vaping: anesthesia considerations for Pediatric Anesthesia, Society for Pediatric Anesthesia, and American
patients using electronic cigarettes, AANA J 88(1):27-34, 2020. Academy of Pediatrics Section on Anesthesiology and Pain Medicine,
Horvath C, Dalley CB, Grass N, et al: Marijuana use in the anesthetized Anesth Analg 133(3):562-568, 2021.
patient: history, pharmacology, and anesthetic considerations, AANA Villarroel MA, Cha AE, Vahratian A: Electronic cigarette use among U.S.
J 87(6):451-458, 2019. adults, 2018, NCHS Data Brief 365:1-8, 2020.
Huson HB, Granados TM, Rasko Y: Surgical considerations of mari-
juana use in elective procedures, Heliyon 4(9):e00779, 2018.

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18
ERAS (Early Recovery After Surgery)
Protocola
E L I S E L . E HL A N D

CC and posterior gingival display on animation. Lip incompetence at

rest approximately 4 to 5 mm. Long lower facial third. Mentalis
A 21-year-old female presents with complaints of “I don’t like my strain is present. Mandibular midline is on midsagittal plane.
gummy smile and weak chin.” Poor genial projection. Convex facial profile.
Intraoral. The maxillary and mandibular dental midlines are
HPI coincident with the midsagittal plane. Overbite is 60%, and over-
jet is 5 mm. Maxillary and mandibular arches are ovoid. The third
The patient has a skeletal and dental class II malocclusion with man- molars are not visible intraorally. Orthodontic brackets in place
dibular hypoplasia, maxillary vertical excess, microgenia with a with bands on all molars; surgical wire is present with surgical
convex facial profile, and a steep mandibular plane angle. She was lugs. Good oral hygiene and no periodontal disease. No soft tissue
referred by her orthodontist for maxillary and mandibular orthogna- lesions, swellings, or signs of infection.
thic surgery in conjunction with comprehensive orthodontic treat- Airway. Maximum interincisal opening 31 fingerbreadths,
ment. She has been in active orthodontic therapy for 9 months and Mallampati class I, thyromental distance 2 fingerbreadths.
is ready for the surgical phase of treatment. The patient has pre- Cardiovascular. Heart has a regular rate and rhythm.
sented to all appointments with her mother, who will be the care- Pulmonary. Lungs are clear to auscultation bilaterally.
taker after surgery. Both the patient and her mother are attentive and
interested in the surgery and ask appropriate questions. Imaging
PMHX/PDHX/Medications/Allergies/SH/FH Panoramic and lateral cephalometric radiographs were taken at
her initial evaluation. A cone-beam computed tomography scan
The patient’s past medical history is noncontributory. She has was taken for virtual surgical planning.
been wearing an orthodontic appliances for 9 months; this is her
second time to have orthodontic treatment. She had her tonsils Labs
removed at 13 years of age, after which she experienced postop-
erative nausea and vomiting (PONV). She does not use any Basic metabolic and coagulation panels were obtained preopera-
medications and denies any drug allergies. She denies tobacco use tively and were within normal limits. A quantitative human chori-
or any other drug or alcohol use. onic gonadotropin urine test was ordered for the day of her surgery.

Assessment
Examination
This is a 21-year-old female with skeletal and dental class II maloc-
General. Well-developed and well-nourished female with normal
clusion secondary to her mandibular hypoplasia, maxillary vertical
and mature affect.
excess, and with microgenia.
Weight. She weighs 65 kg.
Vital signs. Vital signs are normal and the patient is afebrile.
Maxillofacial. Normocephalic. No lymphadenopathy. Exami-
Treatment
nation of the temporomandibular joint reveals no clicking, pop- The plan for this patient is a Le Fort I single-piece maxillary oste-
ping, or pain upon palpation. The muscles of mastication are otomy, bilateral sagittal split mandibular osteotomy, and genio-
nontender to palpation. Cranial nerves are normal bilaterally. plasty with general anesthesia in a hospital operating room setting
Deficiency of infraorbital and malar regions. Excessive anterior using an early recovery after surgery (ERAS) protocol. The protocol
is implemented by a multidisciplinary team approach. In head and
a
The views expressed in this material are those of the authors and do not re- neck major surgery, this team often includes surgeon and office staff,
flect the official policy or position of the US Government, the Department of anesthesia, nursing (postanesthesia care unit [PACU], intensive care unit
Defense, or the Department of the Air Force. [ICU], or surgical ward), nutritionist, speech-language pathologist, and

77
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78 S E C TI O N Anesthesia

physical therapy. A surgical service using an ERAS protocol must have g. Encourage early oral intake of fluids
cooperation and participation by all team members for every periop- h. Encourage early ambulation
erative phase. 7. Postoperative medications
The following protocol was used for this patient: a. Acetaminophen and NSAIDs scheduled for 5 to 7 days
1. Patient and caregiver education b. Opioids: hydrocodone or oxycodone for moderate to severe
a. Patient surgical education included nutritional needs and pain
preparation, pain expectations and management, use of and c. Chlorhexidine oral rinse
directions for medications, oral care and wound care instruc- d. Nasal saline rinse, decongestant as needed
tions, activity restrictions, and expected postoperative course. 8. Discharge considerations
b. Caregiver is included in all discussions. a. Instructions for continued ambulation; oral fluid and nu-
c. Postoperative medications are ordered and dispensed before tritional intake; wound, oral, and nasal care instructions;
surgery if possible. activity limitations; deep breathing exercises; and sinus
d. Nutrition consultation is optional for management of a precautions if applicable
nonchew diet. b. Scheduled interval follow-up appointments
2. Preoperative fasting guidelines and carbohydrate loading
a. Light meal at 6 hours before surgery, clear fluids up to Complications
2 hours before surgery, avoid 81 hours of fasting
b. Complex carbohydrate clear drink with 30-g to 50-g com- The ERAS protocol was implemented by all multidiscipline team
plex carbohydrates: 1 drink the night before surgery, members, and the surgery was completed without intra- or post-
1 drink 2 hours before surgery operative complications. After her initial emergence and recovery
3. Preoperative medications period in the PACU, the patient was able to tolerate oral medica-
a. Acetaminophen 500 to 1000 mg tions and oral liquid intake. Her pain was well controlled with
b. Gabapentin 300 mg oral medications. She ambulated early with assistance, voided
c. Nonsteroidal antiinflammatory drug (NSAID) (ketorolac before discharge, and had no nausea or vomiting. She was alert
15–30 mg, ibuprofen 600–800 mg, or meloxicam 30 mg) and oriented and had a positive outlook. Her vital signs were
d. Scopolamine transdermal patch and/or aprepitant 40 mg stable, and she was on humidified room air only; there were no
4. Anesthetic management supplemental oxygen requirements. There were no bleeding or
a. Multimodal induction and maintenance, opioid sparing airway concerns at her evaluation before discharge. She was dis-
(propofol, lidocaine, dexmedetomidine, volatile anesthetics) charged from the hospital on the same day, in the evening, with a
b. Short-acting opioids only: fentanyl 0.5 to 2 mcg/kg; avoid scheduled 24-hour follow up phone call and office visit if needed,
long-acting opioids such as hydromorphone and morphine and 1- and 3-week follow-up appointments with the surgeon.
c. Video-assisted laryngoscopy for atraumatic intubation Orthognathic surgery has become widely accepted for correction
d. Nondepolarizing neuromuscular blockade of dentofacial deformities. With modifications over several years to
e. Ondansetron 4 mg the surgical and anesthetic techniques to minimize operating time,
f. Dexamethasone 8 to 10 mg blood loss, fluid overload and edema, and nausea and vomiting; op-
g. General fluid restriction to less than 1 L timize pain control; and eliminate the need for maxillomandibular
h. Avoid intraoperative hypothermia fixation, it is widely accepted that patients undergoing single-jaw
i. Remove Foley catheter before emergence, if used surgeries are able to be discharged the same day and that those under-
5. Surgical management going double-jaw surgeries likely only require a single night stay,
a. Prophylactic antibiotic for clean-contaminated case; con- often with a less than 24-hour discharge. Implementing ERAS pro-
tinue for 24 hours tocols to major oral and maxillofacial surgeries such as orthognathic
b. Minimally invasive, if possible surgery or even head and neck reconstructive surgeries has the follow-
c. Use local anesthesia: 1% to 2% lidocaine infiltration before ing goals: decrease length of hospital stay, reduce readmissions and
incisions emergency department visits, minimize surgical or postoperative
d. Use of virtual surgical planning and/or custom hardware complications, and minimize the physiologic stress or strain imposed
and splints for accuracy and decreased operating time on the body’s systems by a major surgical procedure and its required
e. Light dental elastics only, if possible anesthesia. The secondary gains of these goals are decreased health
f. Antifibrinolytic: tranexamic acid 1g care costs, decreased morbidity, and increased patient satisfaction.
g. Long-acting local anesthesia: 0.25% to 0.5% bupivacaine
or liposomal bupivacaine (10–20 mL) at the end of the
procedure
Discussion
6. PACU considerations
a. Oral medications for analgesia when tolerated: acetamino-
ERAS in Oral and Maxillofacial Surgery
phen/hydrocodone liquid or tablets, NSAID liquid or tablets ERAS protocols are intended for major surgeries and have been
b. Short-acting opioids (fentanyl 25–50 mcg 32) for break- studied in many different surgical specialties. There is no evidence
through/severe pain only for the implementation of these protocols to minor surgical pro-
c. Aggressively treat nausea or vomiting; use nonsedative an- cedures or office-based procedures. Many oral and maxillofacial
tiemetics such as ondansetron or metoclopramide surgeons are currently using components of the proposed ERAS
d. Head of bed up at 45 degrees protocols available in the literature and applying them to major
e. Face tent or mask, humidified: wean to room air as soon as and minor surgeries routinely. To truly use an ERAS protocol,
possible there must be organizational change, education at all levels, and
f. Minimal suctioning, ice to face buy-in and participation by the entire perioperative team.

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 CHAPTER 18 ERAS (Early Recovery After Surgery) Protocol 79

The ERAS concept was first proposed and published by wound care, and how to use her postoperative medications. Her
Dr. Henrik Kehlet in the 1990s as a multimodal approach to caregiver was present for all education.
perioperative patient care to combat the pathophysiologic stress
brought on by surgery and its complications. This idea led to the Perioperative Nutritional Care
formation of a group in the early 2000s that was committed to This is a complex topic for head and neck cancer patients because
researching the best practice for this multimodal perioperative many patients may have preoperative malnutrition, existing dys-
care. The goal of this group was to examine ways to improve peri- phasia, or mechanical obstruction. Screening for malnutrition
operative care and enhance postoperative recovery by implement- and preoperatively optimizing nutritional status are recom-
ing evidence-based practice, audit, education, and research. This mended. This recommendation is based on the existing nutri-
ERAS group reevaluated the traditional methods of perioperative tional care guidelines for patients with head and neck cancers.
care to create a process to shorten hospital stays, reduce complica- Orthognathic patients have a significant diet change in the post-
tions, reduce readmissions, and improve patient satisfaction. The operative period and may need counseling on dietary needs and
ERAS Society was founded in 2010 and has published its studies caloric intake on a nonchew diet. It is recommended that patients
for many surgical specialties and specific surgery types. To date, minimize preoperative fasting and dehydration and implement
the only ERAS protocol publication from this society which ap- complex carbohydrate loading preoperatively followed by early
plies to the oral and maxillofacial surgery (OMS) specialty is for oral intake. This is a component of many ERAS protocols, but the
head and neck reconstructive surgery in the recommendations evidence specifically for head and neck patients is limited. It is
published by Dort et al. (2017). There have been very few pro- therefore extrapolated from protocols involving studies of nutri-
spective and retrospective studies published that address orthog- tional care in other types of cancer. Preoperative carbohydrate
nathic surgery and the authors’ institutional ERAS protocols. loading arises from the hypothesis that these fluids help mitigate
These studies have different outcome measures, and no standard insulin resistance and catabolism brought on by fasting and surgi-
has been published for this type of surgery because of a lack of cal stress, promoting better glucose control and lean tissue preser-
consistent evidence for perioperative care methods for this specific vation. Unfortunately, well-designed trials to support this claim
surgical subset. It would be impossible and impractical to apply a are lacking and needed for the head and neck surgical population.
single ERAS protocol to all surgical procedures, which is why the When to reintroduce oral feeding in a patient with head and neck
need for more prospective, blinded studies are needed to apply cancer can be a complex decision and should involve the consulta-
specifically to the needs of OMS patients. tion with the surgeon, speech-language pathologist, and nutri-
The ERAS protocol for head and neck cancer surgery from the tionist. In this case review, the patient was asked to intake clear
ERAS Society suggests 17 elements of intervention, with 24 rec- fluids up to 2 hours before her surgery and drink a complex car-
ommendations for optimal perioperative care, the majority rated bohydrate clear drink (e.g., Ensure Pre-Surgery Clear Carbohy-
as having moderate to strong levels of evidence. The authors ad- drate Drink or Clear Fast CF Preop Drink) the night before sur-
mit that some of the recommendations have been extrapolated gery and 2 hours before surgery. She was counseled on a nonchew
from research in other surgical specialties. These extensive guide- diet, and a nutrition consultation was optional.
lines may not, or cannot, be realistically implemented in some
institutions or may not even apply to all major head and neck Antibiotic Prophylaxis
cases. Therefore, there is a continued need for simplification and Perioperative antibiotics, given 1 to 2 hours before surgery and
recognition of the core components of each ERAS protocol so continued for 24 hours, have consistently demonstrated a signifi-
they may be more universally applied to OMS patients. Some of cant reduction in wound infections in randomized controlled
these core components are improved patient education, mini- trials. It is therefore standard of care for clean-contaminated head
mally invasive surgery, goal-directed fluid therapy, multimodal and neck surgical procedures and recommended in most ERAS
opioid-sparing analgesia, early oral feeding, and early mobiliza- protocols.
tion. The components of the ERAS protocol used in this case
example are discussed in detail later in this chapter and were cre- Postoperative Nausea and Vomiting Prophylaxis
ated from existing publications on orthognathic perioperative Postoperative nausea and vomiting prophylaxis should be consid-
care, the ERAS Society publication, and other protocols from ered for all patients undergoing oral and maxillofacial surgeries
varying specialties in the literature. because they are at moderate to high risk. Vomiting can cause
wound dehiscence, hematoma, and wound infection, and nausea
Evidence-Based ERAS Elements and vomiting can inhibit early ambulation. The combination of
ondansetron and dexamethasone has been proven efficacious and
Preadmission Education is recommended in head and neck surgery ERAS protocols. Res-
Preparing patients and families for major surgery is believed to be cue antiemetics should be used early if needed, and a different
worthwhile by surgeons and patients. Unfortunately, there is drug class should be considered while avoiding sedative medica-
limited evidence to demonstrate that patient education has a ben- tions such as promethazine. In this case review, the patient was
eficial effect on patient outcomes. In the context of the biobehav- given a preoperative scopolamine transdermal patch and intraop-
ioral model of stress, patient education may decrease the erative ondansetron and dexamethasone to combat PONV.
physiologic effects of stress in the perioperative period, and stress
can negatively affect wound healing and complications. Patients Preanesthetic Medications
and caregivers who are educated and prepared will likely have less According to the ERAS Society publication, data shows that the
anxiety about the process and be more compliant in the periop- prevalence of preoperative anxiety is up to 80%. Nonpharmaco-
erative period. In this case review, the patient was educated on logic interventions can be used; also the use of short-acting benzo-
topics that included the surgery, postoperative course expecta- diazepines has been proven effective in relief of preoperative anxiety.
tions, pain expectations and management, diet, activity, oral and The goal of use of these tactics or medications is to contribute to

t.me/Dr_Mouayyad_AlbtousH
80 S E C TI O N Anesthesia

the overall ERAS goal of decreased physiologic stress, which is analgesia through the use of acetaminophen, local anesthetic
closely linked to psychological stress. In this case review, the pa- wound infiltration, NSAIDs, gabapentin, and short-acting opi-
tient did not have preoperative anxiety because of extensive pre- oids effectively treats pain, facilitates rapid recovery, and mini-
operative education and counseling, and she was well hydrated mizes the doses of opioids used and their associated adverse effects
and was not in a fasting state because of her carbohydrate drink. such as sedation, PONV, pruritis, and ileus. The level of evidence
She was given other preanesthetic medications to contribute to for this recommendation is high and is present in most ERAS
her overall multimodal anesthetic and analgesic approach, to in- protocols.
clude acetaminophen, gabapentin, and an NSAID. This method-
ology was taken from a study that included these medications in Postoperative Mobilization
their institution’s ERAS protocol for orthognathic surgery that Most data on early mobilization are from patients undergoing
demonstrated shorter hospital stays and decreased opioid de- major abdominal procedures, which showed that early mobiliza-
mand. Other studies have shown that preoperative use of acet- tion, as part of a comprehensive treatment protocol, reduced
aminophen and gabapentin resulted in decreased postoperative complications and overall length of hospital stay. A secondary
pain scale scores. analysis of the randomized Laparoscopy in Combination with
Fast Track Multimodal Management (LAFA) study showed that
Standard Anesthetic Protocol early mobilization was a significant independent predictor of a
The general anesthetic principles for ERAS protocols are the fol- good outcome. The data for head and neck surgery specifically is
lowing: perioperative rehabilitation or medical optimization, peri- limited; therefore, the recommendation is based on evidence from
operative nutrition, carbohydrate loading, prevention and treat- other types of surgeries. In this case review, the patient was en-
ment of PONV, aggressive intraoperative warming, prophylactic couraged by PACU nurses to ambulate early on the same day as
antibiotic administration, use of opioid-sparing multimodal anes- her surgery before discharge.
thesia techniques, fluid management, and lung-protective ventila-
tion strategies. ERAS protocols do not suggest the use of any spe- The components from the ERAS Society’s evidence-based topics
cific type of regimen to maintain unconsciousness during surgery. for head and neck cancer surgery that were not used in this orthogna-
In fact, the current literature is silent on this topic. In general, thic case review are ICU admissions, tracheostomy care, prophylaxis
ERAS protocols recommend collaboration with the anesthesia against thromboembolism, urinary catheterization, postoperative flap
team to establish the anesthetic protocol for specific surgeries. monitoring, postoperative wound care, and postoperative pulmonary
physical therapy. These are examples of protocol components that are
Preventing Hypothermia critical for a head and neck cancer reconstruction with a free flap but
Hypothermia is associated with poor surgical outcomes, including do not necessarily apply to orthognathic surgery patients. All 17 ele-
adverse cardiac events, wound infection, and bleeding. Intraop- ments and 24 recommendations can be reviewed in the original
erative hypothermia may also affect graft patency in head and publication cited in the Bibliography.
neck reconstruction, affect drug pharmacokinetics, and interfere
with normal coagulation. Postoperative shivering thermogenesis
increases metabolic rate and oxygen consumption. One study
Implementation of Protocol and Future Studies
showed an increase in length of PACU stay and length of hospital Most ERAS outcome measures have focused on patient length of
stay, therefore increasing costs for patients who experienced peri- stay, complication rates, readmission, and overall cost of hospital
operative hypothermia. Intraoperative normothermia has been stay. In 2017, Lau et al. published a meta-analysis on 42 random-
established as an evidence-based key element to ERAS protocols. ized clinical trials involving ERAS protocols across multiple spe-
cialties. They showed that ERAS programs provided a significant
Perioperative Fluid Management reduction in length of stay of 2.35 days compared with standard
Most ERAS protocols aim for a net-zero fluid balance during the care methods. This finding was confirmed by a study by Visioni
perioperative period. This strategy is also referred to as goal- et al. in 2018. Both the Lau and Visioni studies also demonstrated
directed fluid therapy (GDFT). The GDFT technique has shown a statistically significant reduction in the risk of postoperative
a statistically significant decrease in ICU stays and length of hos- complications between the ERAS and control groups. They dem-
pital stays in patients undergoing high-risk surgeries and does not onstrated no statistical difference in readmissions between the
affect morbidity. The evidence for this recommendation was ERAS and control groups.
moderate, but it is a strong recommendation by the ERAS Society Elements of existing ERAS protocols can be applied to major
studies in most protocols. It is recommended to use balanced oral and maxillofacial surgical procedures to include head and neck
fluids and avoid normal saline. Minimal maintenance fluids are cancer reconstruction and orthognathic surgery, as demonstrated
recommended, and fluid boluses are used to treat objective hypo- in some recent studies and in this case example. But the evidence
volemia. Vasoactive drugs and blood products should be used specific to this specialty and these surgeries is lacking and must be
judiciously. In this case review, it was also recommended that extrapolated from other surgical specialties to create protocols that
no more than 1 L of intraoperative fluids be used, if possible, to fit our patients. Future high-quality studies of these protocols in
reduce surgical site edema. our field would ensure the acceptance of evidence-based practice
for ERAS protocols in major oral and maxillofacial surgeries.
Pain Management
This element has been thoroughly studied in many surgical spe- ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
cialties and in head and neck surgery. Postoperatively, multimodal complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 80.e1

Bibliography Ljungqvist O, Scott M, Fearon KC: Enhanced recovery after surgery: a

review, JAMA Surg 152:292-298, 2017.
Ljungqvist O, Young-Fadok T, Demartines N: The history of enhanced
Bilku DK, Dennison AR, Hall TC, et al: Role of preoperative carbohydrate recovery after surgery and the ERAS Society, J Laparoendosc Adv Surg
loading: a systematic review, Ann R Coll Surg Engl 96:15-22, 2014. Tech A 27:860-862, 2017.
Dort JC, Farwell DG, Findlay M, et al: Optimal perioperative care in Nygren J: The metabolic effects of fasting and surgery, Best Pract Res Clin
major head and neck cancer surgery with free flap reconstruction: a Anaesthesiol 20:429-438, 2006.
consensus review and recommendations from the Enhanced Recovery Pollard RJ, Shapiro FE: Does anesthetic choice affect surgical and recov-
After Surgery Society, JAMA Otolaryngol Head Neck Surg 143(3): ery times?, Evid Based Pract Anesthesiol 21:168-173, 2022.
292-303, 2017. Senturk JC, Kristo G, Gold J, et al: The development of enhanced recov-
Elias KM: Understanding enhanced recovery after surgery guidelines: an in- ery after surgery across surgical specialties, J Laparoendosc Adv Surg
troductory approach, J Laparoendosc Adv Surg Tech A 27:871-875, 2017. Tech A 27:863-870, 2017.
ERAS Society. List of Guidelines. http://erassociety.org/guidelines/list- Stratton M, Waite PD, Powell KK, et al: Benefits of the enhanced recov-
of-guidlines/. ery after surgery pathway for orthognathic surgery, Int J Oral Maxil-
Ferrara JT, Tehrany GM, Chen Q, et al: Evaluation of an Enhanced Re- lofac Surg 51:214-218, 2022.
covery After Surgery Protocol (ERAS) for same-day discharge and Visioni A, Shah R, Gabriel E, et al: Enhanced recovery after surgery for
reduction of opioid use following bimaxillary orthognathic surgery, J non-colorectal surgery? A systematic review and meta-analysis of ma-
Oral Maxillofac Surg 80:38-46, 2021. jor abdominal surgery, Ann Surg 267:57-65, 2018.
Højvig JH, Kehlet H, Bonde CT: Enhanced recovery after head and neck Wilmore DW, Kehlet H: Management of patients in fast track surgery,
cancer reconstruction with a free flap—what is next, J Oral Maxillofac BMJ 322(7284):473-476, 2001.
Surg 78:10-11, 2020. Worrall DM, Tanella A, DeMaria S Jr, et al: Anesthesia and enhanced
Kehlet H: Multimodal approach to control postoperative pathophysiol- recovery after head and neck surgery, Otolaryngol Clin North Am
ogy and rehabilitation, Br J Anaesth 78:606-617, 1997. 52(6):1095-1114, 2019.
Lau CS, Chamberlain RS: Enhanced recovery after surgery programs
improve patient outcomes and recovery: a meta-analysis, World J Surg
41:899-913, 2017.

t.me/Dr_Mouayyad_AlbtousH
19
Respiratory Depression Secondary to
Oversedation
PIY U SH K UM AR P. PAT EL , S TA N F O R D P L AV I N, C L AI R E M I L L S ,
a n d S H A H R O K H C . B AG H ER I

CC anesthesia to identify potential risk factors of intra- or postop-

erative anesthetic complications.
A 45-year-old female presents to your office for cosmetic eyelid The past medical and surgical histories are noncontributory.
surgery (blepharoplasty). This patient is categorized as American Society of Anesthesiologist
(ASA) Class I (Table 19.1). She does not use any medications and
HPI has no known drug allergies. She denies previous problems with
local anesthetics (e.g., methemoglobinemia), IV sedation, or gen-
The patient is an otherwise healthy female for whom treatment was eral anesthetics. (Problems with previous anesthesia or adverse
planned for bilateral upper and lower eyelid blepharoplasties with in- drug reactions should alert clinicians to possible complications
travenous (IV) sedation. After the incision lines had been marked in that may require modification of anesthetic techniques.) There is
the usual manner, electrocardiography, blood pressure, pulse oximeter, no family history of complications with general anesthetics (e.g.,
and a sidestream capnograph monitor were applied. The patient was malignant hyperthermia). She denies a history of drug or alcohol
administered 4 L of oxygen and 2 L of nitrous oxide via nasal hood. use (patients with a previous drug history or alcohol abuse may
(Nitrous oxide decreases the amount of IV sedatives needed.) Sedation require higher doses of sedative–hypnotic drugs), and she does
was achieved using 5 mg of midazolam, 100 mg of fentanyl, and a not smoke. (Smoking decreases oxyhemoglobin concentrations
propofol drip titrated to effect. Verrill’s sign (50% upper eyelid ptosis, and increases pulmonary secretions.)
indicating adequate sedation) was observed. Before administration of
local anesthesia, 40 mg of propofol was administered as a bolus. (Pro- Examination
pofol may cause a 20%–25% drop in systolic blood pressure when
given as a bolus.) Upon administration of local anesthesia, loss of the Preoperative. A thorough preoperative evaluation is important to
capnogram, with no chest wall movement, was observed. (This indi- identify potential risk factors for negative anesthetic outcomes,
cates the presence of central apnea. Capnography is considered to be with an emphasis on airway anatomy.
more sensitive than clinical assessment of ventilation in the detection General. The patient is a well-developed and well-nourished fe-
of apnea. In a study by Soto and colleagues [2004], 10 of 39 patients male in no apparent distress. Her body mass index (BMI) is 24 kg/m2.
[26%] experienced 20-second periods of apnea during procedural (A BMI .30 kg/m2 is considered obese and .40 kg/m2 is considered
sedation and analgesia. All 10 episodes of apnea were detected by morbidly obese.)
capnography but not by the anesthesia providers.) The apnea was at- Airway. Maximal interincisal opening (MIO) is within normal
tributed to the propofol bolus (combined with the respiratory depres- limits. (Difficult intubation occurs with decreased MIO.) Her
sant effects of fentanyl), which was anticipated to resolve shortly. oropharynx is Mallampati class I (soft palate, tonsillar pillars, and
However, the patient continued to be apneic, and her oxygen satura- uvula completely visualized), and the thyromental distance
tion decreased from 99% to 80%. (Pulse oximeter readings are about (TMD) is three fingerbreadths (intubation is more difficult with
30 seconds behind the real-time oxygen saturation.) Nasal flaring, retrognathia, a short TMD, and/or a higher Mallampati classifica-
tracheal tug, and paradoxical chest wall motion were not observed. tion). The cervical spine has a full range of motion. Airway eva-
(These would be signs of upper airway obstruction and inspiratory lauation helps formulate the anesthetic plan for the patient. Other
efforts. An increase in sonorous breath sounds may also be a sign of airway assements that signal diffuclt ventilation/intubation in-
increasing airway obstruction.) The patient began to appear cyanotic clude sternomental distance less than 12.5 cm, neck circumfer-
(bluish hue to facial skin and lips caused by prolonged hypoxemia). ence greater than 17 cm, and enlarged tonsils.
Cardiovascular. Heart is regular rate and rhythm without
PMHX/PDHX/Medications/Allergies/SH/FH murmurs, rubs, or gallops.
Pulmonary. Lung fields are clear to auscultation bilaterally.
A thorough medical history is important during the preopera- (Preoperative wheezing may increase the risk of intraoperative
tive evaluation of all patients undergoing IV sedation or general bronchospasm.)

81
t.me/Dr_Mouayyad_AlbtousH
82 S E C TI O N Anesthesia

TABLE American Society of Anesthesiologists (ASA) Classification System for Stratifying Patients Preoperatively
19.1 by Risk
ASA Category Patient’s Health Status of Underlying Disease Limitations on Activities Risk of Adverse Effects
I Excellent; no systemic disease; excludes None None Minimal
persons at extremes of age
II Disease of one body system Well controlled None Minimal
III Disease of more than one body system Controlled Present but not incapacitated No immediate danger
or one major system
IV Poor with at least one severe disease Poorly controlled or end stage Incapacitated Possible
V Very poor, moribund Incapacitated Imminent

Modified from the American Society of Anesthesiologists: Relative value guide, 2003, Park Ridge, IL, the American Society of Anesthesiologists.

• BOX 19.1 ABCs Treatment

• A (airway): The upper airway is rapidly evaluated and found to be clear of Before the diagnosis of respiratory depression (apnea or hypop-
any obstruction. The patient’s oropharynx is clear (secretions are suctioned nea) as the cause of hypoxemia, possible causes of upper airway
with a tonsillar suction), and no inspiratory or expiratory noises are heard obstruction need to be rapidly ruled out by evaluating the airway,
(stridor or gurgling noises may indicate upper airway obstruction). No tra- jaw position, and possibility of foreign body aspiration. Subse-
cheal tug is present. Chin tilt–jaw thrust maneuvers are applied.
quently, the procedure should be stopped, any open or bleeding
• B (breathing): There are no inspiratory efforts, and no chest wall or abdominal
motion (apnea) is seen. Breath sounds are not heard with the precordial stetho-
wounds should be packed, and necessary assistance should be
scope (placed above the suprasternal notch), and the reservoir bag is motion- elicited. Attempts to arouse the patient with verbal command and
less. The pulse oximetry (Spo2) reading has been steadily falling from 99% to painful stimulus should be made. Unresponsiveness to painful
80%. (An Spo2 of 90% correlates with a Pao2 of 60 mm Hg; values below this stimulus is considered to be a state of general anesthesia.
correspond to the steep portion of the oxygen-hemoglobin dissociation curve.) Respiratory depression secondary to oversedation is a self-
• C (circulation): Blood pressure and heart rate are stable. (Bradycardia and limiting process that requires adequate supportive measures or
hypotension resulting from an extended period of hypoxemia are ominous pharmacologic interventions until spontaneous respirations re-
signs of impending circulatory collapse.) The electrocardiogram shows nor- sume. Respiratory depression causes a reduction in alveolar venti-
mal sinus rhythm without any ST changes. (Leads II and V5 are most sensi-
lation through a decrease in the respiratory rate or tidal volume,
tive in detecting myocardial hypoxia.)
which in turn is caused by a decrease in respiratory drive. All
sedatives, opioids, and potent inhalation general anesthesia agents
have the potential to depress central hypercapnic and peripheral
hypoxemic drives. Opioids primarily depress the central chemo-
Intraoperative. During the course of IV sedation (conscious sensitive area (i.e., hypercapnic drive), whereas inhalation anes-
sedation, deep sedation, or general anesthesia), it is important to thetics and benzodiazepines exert greater influence on the chemo-
continuously monitor the patient’s level of sedation and anesthe- receptors in the carotid and aortic bodies (i.e., hypoxemic drive).
sia (to prevent oversedation and respiratory depression) and to At high doses, all classes can depress both these mechanisms.
survey the ABCs (airway, breathing, and circulation; the ABC Nitrous oxide is not a respiratory depressant; however, when it is
assesment for this patient is shown in Box 19.1). combined with sedatives or opioids that depress ventilation, a more
General. The patient is sedated, unconscious, and unrespon- pronounced and clinically important depression may result. There-
sive to painful stimulus (a state of general anesthesia). fore, it should be discontinued to allow more rapid arousal from an-
esthesia and delivery of 100% oxygen, with subsequent resolution of
Imaging spontaneous respirations. Any anesthetic IV drips should be discon-
Preoperative and serial postoperative photoimaging is mandatory tinued immediately. Jaw-thrust maneuvers or tugging on the tongue
for cosmetic procedures. A preoperative chest radiograph has a anteriorly will improve the opening of the airway for more effective
limited role in healthy individuals and is not warranted unless oxygen delivery. The anesthesia circuit should be flushed to evacuate
dictated by other medical factors. residual nitrous oxide and to deliver a higher flow of oxygen. If these
measures fail, the patient’s breathing can be assisted with positive-
pressure ventilation (PPV) at one breath every 5 seconds (coordinated
Labs with any apparent shallow breathing). If oxygenation proves to be
Routine laboratory tests are not indicated in healthy patients un- successful with PPV, continued ventilatory support is maintained
dergoing cosmetic blepharoplasty with IV sedation. Females of until the sedation lightens and respiratory depression resolves. How-
childbearing age who are sexually active or have missed their last ever, if ventilation is not achieved, rapid reevaluation for other causes
menstrual period may require a urine pregnancy test. (laryngospasm, bronchospasm, foreign body aspiration, chest wall
rigidity) should be considered. The airway is reassessed, and chin
Assessment lift–jaw thrust maneuvers should be optimized. Oral and/or nasal
airways can be inserted if there is continued difficulty with PPV. If
Central apnea secondary to oversedation during IV sedation for cosmetic laryngospasm or bronchospasm is diagnosed, it should be treated
upper and lower eyelid blepharoplasties. promptly (see the discussion of laryngospasm earlier in this chapter).

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 19 Respiratory Depression Secondary to Oversedation 83

If these measures fail to reestablish ventilation, more advanced airway every 20 to 30 minutes if resedation occurs; therefore, close
interventions may be necessary. These include the use of a laryngeal patient observation is paramount.
mask airway, endotracheal intubation, or establishment of a surgical
airway (cricothyrotomy). Despite the infrequency of the latter sce- Discussion
nario, the clinician should be prepared to establish an airway as soon
as possible (see the discussion of emergent surgical airway later in this Various levels of IV sedation can be administered by oral and
chapter). When the oxygen saturation returns above 95%, the clini- maxillofacial surgeons. The American Society of Anesthesiologists
cian can decide whether to cautiously continue with the procedure Continuum of Depth of Sedation, and Definition of General
and intermittently apply PPV as needed or to abort the procedure for Anesthesia and Levels of Sedation/Analgesia are discussed below.
further evaluation. These definitions were approved by the ASA House of Delegates
If prolonged respiratory depression occurs, the sedative effects on October 13, 1999, and last amended on October 23, 2019.
of some agents can be pharmacologically reversed. Flumazenil Minimal sedation (anxiolysis) is defined as “a drug-induced
(Romazicon) reverses the sedative effects of benzodiazepines. It is state during which patients respond normally to verbal com-
given at 0.2 mg intravenously (or 0.01–0.02 mg/kg in small chil- mands. Although cognitive function and physical coordination
dren) every minute up to five doses (maximum total dose, 1 or may be impaired, airway reflexes, and ventilatory and cardiovas-
3 mg/hr) until reversal of sedation is accomplished. It may be re- cular functions are unaffected.”
peated every 20 minutes for resedation. Naloxone (Narcan) is an Conscious sedation (moderate sedation and analgesia) is de-
opioid antagonist that reverses the sedative, respiratory depressant, fined as “a drug-induced depression of consciousness during which
and analgesic effects of opiates. Low doses are recommended (to patients respond purposefully to verbal commands, either alone or
prevent adverse effects of reversal). IV naloxone dosing can vary accompanied by light tactile stimulation. No interventions are re-
depending on the situation, ranging from 0.04 to 0.08 mg for quired to maintain a patent airway, and spontaneous ventilation is
nonemergent oversedation to 0.4 to 2 mg for emergent opioid adequate. Cardiovascular function is usually maintained.”
toxicity. (A higher dosing schedule is used in narcotic overdose.) Deep sedation is defined as “a drug-induced depression of
After sedation has been reversed, the patient needs to be monitored consciousness during which patients cannot be easily aroused but
for resedation because the half-lives of naloxone and flumazenil are respond purposefully following repeated or painful stimulation.
shorter than those of their sedative counterparts, potentially re- The ability to independently maintain ventilatory function may
quiring redosing of the reversal agent(s). There are no reversal be impaired. Patients may require assistance in maintaining a pat-
agents for barbiturates or propofol. Reversal of sedation from these ent airway, and spontaneous ventilation may be inadequate.
agents relies on rapid redistribution of the drugs. It is important to Cardiovascular function is usually maintained.”
remember that hypoxemia and hypercarbia can further contribute General anesthesia is defined as “a drug-induced loss of con-
to central nervous system (CNS) depression. sciousness during which patients are not arousable, even by pain-
In the current patient, supportive measures included 100% oxy- ful stimulation. The ability to independently maintain ventilatory
gen delivered via PPV with a bag-valve-mask device. PPV was easily function is often impaired. Patients often require assistance in
accomplished, and the patient’s oxygen saturation steadily increased maintaining a patent airway, and positive pressure ventilation may
to 99%. After sufficient ventilation and oxygenation, the surgery be required because of depressed spontaneous ventilation or drug-
was resumed. The propofol IV drip was discontinued during the induced depression of neuromuscular function. Cardiovascular
apnea–hypopnea episode and was subsequently titrated down as the function may be impaired.”
procedure was completed. The patient began to have spontaneous Because sedation is a continuum, it is not always possible to
respirations and maintained a normal capnogram and an adequate predict how an individual patient will respond. Hence, practitio-
oxygen saturation, and she arose from sedation shortly after com- ners intending to produce a given level of sedation should be able
pletion of the procedure. Reversal agents were not required. to rescue patients whose level of sedation becomes deeper than
initially intended. Individuals administering moderate sedation
Complications and analgesia (“conscious sedation”) should be able to rescue pa-
tients who enter a state of deep sedation and analgesia, and those
Oversedation and respiratory depression can have devastating administering deep sedation and analgesia should be able to res-
outcomes if not promptly treated as outlined here. In most cir- cue patients who enter a state of general anesthesia.
cumstances, the patient’s airway and breathing can be easily sup- Rescue of a patient from a deeper level of sedation than in-
ported. However, it is important to identify patients at higher risk tended is an intervention by a practitioner proficient in airway
of difficult mask ventilation and endotracheal intubation (see the management and advanced life support. The qualified practitio-
discussion of emergent surgical airway later in this chapter) before ner corrects adverse physiologic consequences of the deeper-
administering deep sedation. The loss of the patient’s airway (can- than-intended level of sedation (e.g., hypoventilation, hypoxia,
not intubate and cannot ventilate scenario) can lead to prolonged and hypotension) and returns the patient to the originally in-
hypoxemia, which can in turn lead to cardiovascular collapse, ce- tended level of sedation. It is not appropriate to continue the
rebral anoxia, and death if not managed promptly. procedure at an unintended level of sedation.
Precipitous reversal of sedation and respiratory depression with Respiratory depression from oversedation can occur during the
opioid antagonists is not without adverse side effects. Naloxone course of a procedure or in the recovery period; however, it is rela-
(Narcan) may cause cardiac arrhythmias, pulmonary edema, se- tively uncommon when sedation is administered by an experienced
vere hypotension, and cardiac arrest when given at higher doses. oral and maxillofacial surgeon. (Short half-lives and lack of active
The analgesic effects are also reversed, which may cause the pa- metabolites are ideal properties of IV anesthetic agents.) The short
tient to experience profound surgical pain accompanied by hyper- duration of action of modern IV anesthetics relies on rapid redistri-
tension and tachycardia. Patients with acute or chronic opioid bution (alpha half-life), rapid metabolism, or both. However, re-
dependence can experience acute withdrawal symptoms. Nalox- peated doses of opioids, benzodiazepines, or barbiturates for longer
one and flumazenil have short half-lives and may require redosing procedures may cause accumulation in inactive tissues (especially

t.me/Dr_Mouayyad_AlbtousH
84 S E C TI O N Anesthesia

adipose tissue), which is later released into circulation to cause de- and expiration. Whereas capnometers and capnographs both display
layed emergence (beta half-life), thereby on occasion requiring a numeric values for end-tidal carbon dioxide (EtCO2) and respiratory
reversal agent. Naloxone is an opioid antagonist that competitively rate, capnography is preferred because visualization of the waveform
binds to mu receptors, effectively reversing the sedative, analgesic, allows continuous assessment of the depth and frequency of each
and respiratory-depressant effects of any given opioid (e.g., fen- ventilatory cycle. Capnography is the noninvasive waveform mea-
tanyl, morphine, sufentanil, alfentanil, remifentanil, meperidine). surement of the partial pressure of CO2 in the exhaled breath.
Flumazenil is a competitive antagonist to benzodiazepines (e.g., The relationship of CO2 concentration to time is graphically
midazolam, lorazepam, diazepam) at the central benzodiazepine represented by the CO2 waveform or capnogram (Fig. 19.1).
receptor (alpha subunits of the gamma-aminobutyric acid recep- (Time capnograms are more commonly used than volume capno-
tor), and it reverses all effects of benzodiazepines (e.g., sedation, grams, on which CO2 is plotted against expired volume.) Pulse
respiratory depression, anxiolysis). The respiratory-depressant ef- oximetry provides real-time information about arterial oxygen-
fects of midazolam (Versed, the most commonly used benzodiaze- ation, whereas capnography provides breath-to-breath informa-
pine) are minimal compared with those of propofol and narcotics. tion of three important physiologic functions (1) ventilation (how
Inadequate local anesthesia or insufficient time allocation for effectively CO2 is being eliminated by the pulmonary system), (2)
its onset may make the sedated patient appear uncooperative or perfusion (how effectively CO2 is being transported through the
undersedated. The clinician may decide to deepen the sedation to vascular system, i.e., a functioning cardiovascular system), and (3)
control the uncooperative patient and overcome the effects of metabolism (how effectively CO2 is being produced). Capnogra-
inadequate local anesthesia. After the painful stimulus is gone or phy provides the most sensitive measurement of ventilation.
the local anesthesia has set in, the patient may return to a deeper Carbon dioxide monitors measure the gas concentration, or
level of sedation or may become oversedated with respiratory de- partial pressure, using one of two configurations, depending on the
pression. The risk of oversedation and respiratory depression can location of the sensor: mainstream or sidestream. Mainstream de-
be minimized by using local anesthesia effectively. vices measure CO2 directly from the airway, with the sensor located
Some additional precautions should be noted when administer- directly on the endotracheal tube. Sidestream devices measure CO2
ing anesthesia to pediatric and older adult patients. Small doses of by sampling from the exhaled breath and analyzing via a sensor
benzodiazepines and opioids can cause significant respiratory depres- located inside the monitor. This distance to the sensor causes a delay
sion in older adult patients. The changes in physiology and medical in measurement of approximately 6 seconds when the monitor is
comorbidities associated with aging are beyond the scope of this approximately 5 feet away from the patient. The sample is taken
section, but a general precaution used by clinicians is “go low and go from a cannula under the nasal hood or integrated into a nasal can-
slow.” It is important to remember that children have a lower func- nula, which simultaneously delivers oxygen. Sampling errors do
tional residual capacity (FRC) and do not tolerate hypoventilation occur with open airway cases and can also result in patients who are
and hypoxemia well, which is evidenced by a more rapid drop in breathing through their mouth. Open airway measurements with
oxygen saturation. Differences in the pediatric airway (larger tongue; sampling via a nasal cannula or hood results in the EtCO2 being 5
lymphoid hypertrophy; more rostrally positioned larynx; long and to 10 mm Hg less than the normal of 40 mm Hg.
floppy epiglottis, narrowest at the cricoid cartilage; more compliant The capnogram, corresponding to a single tidal breath (see
tracheal walls; more caudal anterior cord attachment; underdevel- Fig. 19.1), consists of four phases. Phase I represents the beginning of
oped accessory muscles) are important to recognize. exhalation. Phase II (ascending phase) represents the increase in CO2
Heightened awareness is also required when sedating obese concentration in the breath stream as the CO2 reaches the upper
patients (BMI .30 kg/m2). As a result of the increased abdominal airway. Phase III (alveolar plateau) represents the CO2 concentration
fat in obese patients, the FRC is decreased particulary when su- reaching a uniform level in the entire breath stream (from alveolus to
pine, which leads to shorter desaturation times. Functional Re- nose) and the point of maximum CO2 concentration (EtCO2); this
sidual Capacity reflects the volume of gas remaining in the lungs is the value displayed on the monitor. Phase IV represents the inspira-
at the end of tidal respiration and approximates 2400 mL for the tory cycle, in which the CO2 concentration drops to zero.
average adult. The oxygen content of the gas mixture in the FRC In a normal capnogram, for patients of all ages, the CO2 con-
can be viewed as oxygen reserve. If ventilation ceases, oxygen in centration starts at zero and returns to zero (there is no rebreathing
this reserve continues to diffuse into the pulmonary capillaries.
This impacts the time from onset of apnea until hypoxemia en- Begin inhalation
sues. This is the basis for preoxygenating a patient before the in-
duction of general anesthesia as well as oxygen supplementation 40
III
during sedation and general anesthesia. By increasing the oxygen
content of the FRC, more time will be available for appropriate
mm Hg

intervention if hypoventilation or apnea occurs. Desaturation in

II IV
obese patients can also occur because of increased metabolic
demand for oxygen caused by increased tissue mass, decreased
respiratory compliance caused by abdominal and chest wall fat, I
reduced size of the orohypopharyngeal airway secondary to a large 0
tongue and buccal fat pads, or a decreased ability to extend the 1
neck because of cervical fat. Obese patients are also at an increased Time (s)
chance for aspiration. Begin exhalation
Capnometry uses infrared technology to analyze carbon dioxide in • Fig. 19.1 The relationship of carbon dioxide concentration to time, rep-
exhaled gases. It is the measurement of carbon dioxide concentration resented by a capnograph. (From Krauss B, Hess DR: Capnography for
during the respiratory cycle. Capnography is the proper term for procedural sedation and analgesia in the emergency department, Ann
monitors that display a continuous waveform reflecting inspiration Emerg Med 50:172, 2007.)

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 19 Respiratory Depression Secondary to Oversedation 85

of CO2), a maximum CO2 concentration is reached with each Capnography to monitor ventilation has been shown to pro-
breath (EtCO2), the amplitude is determined by the EtCO2 con- vide the earliest indicator of airway or respiratory compromise. It
centration, the width is determined by the expiratory time, and a is the only single monitoring modality that provides airway,
characteristic shape is seen for normal lung function. breathing, and circulation assessment. The presence of a normal
Capnography has been shown to be one of the earliest indica- waveform denotes that the airway is patent and that the patient is
tors of airway or respiratory compromise; it registers changes well breathing. A normal EtCO2 value (35–45 mm Hg), in the ab-
before pulse oximetry registers a decreasing oxyhemoglobin satu- sence of obstructive lung disease, reflects adequate perfusion.
ration, especially in individuals receiving supplemental oxygen. Unlike pulse oximetry, the capnogram remains stable during pa-
Both central and obstructive apnea can readily be detected by tient motion and is reliable in low-perfusion states. Capnography
capnography (Table 19.2). Central apnea is confirmed with the has been shown to trigger early intervention and decrease the in-
loss of the capnogram in conjunction with no chest wall move- cidence of oxygen desaturation. Capnography can forewarn of
ment and no breath sounds on auscultation. Obstructive apnea is impending hypoxia by about 5 to 240 seconds. Administration of
characterized by loss of the capnogram, chest wall movement, and supplemental oxygen delays the onset of desaturation after apnea;
absent breath sounds. Two types of drug-induced hypoventilation therefore, relying on pulse oximetry alone delays the intervention.
occur during procedural sedation and analgesia (see Table 19.2): A systematic review and meta-analysis by Saunders and col-
bradypneic hypoventilation (type 1), which is commonly seen leagues of recent randomized controlled trials comparing visual
with opioids, and hypopneic hypoventilation (type 2), which is assessment of ventilation and pulse oximetry monitoring with and
commonly seen with sedative–hypnotic drugs. without capnography during procedural sedation and analgesia
The EtCO2 may initially be high (bradypneic hypoventila- (PSA) showed that the odds of oxygen desaturation and assisted
tion) or low (hypopneic hypoventilation) without significant ventilation events were significantly reduced with the use of cap-
changes in oxygenation, especially with the use of supplemental nography. The results showed that the addition of capnography to
oxygen. Therefore, drug-induced changes in the EtCO2 do not patient monitoring during PSA results in increased patient safety,
necessarily lead to oxygen desaturation and thus may not require with clinically meaningful significant reductions in mild and se-
intervention. vere levels of oxygen desaturation, as well as the need for assisted
Hypopneic hypoventilation can remain stable, with low tidal ventilation.
volume breathing resolving over time as CNS drug levels de- Since January 2014, capnography has been required for proce-
crease with redistribution, or it may lead to periodic breathing, dural sedation in oral surgery offices.
with intermittent apneic pauses (which may resolve spontane-
ously or progress to central apnea) or progress directly to central ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
apnea. complete set of bibliography.

TABLE
19.2 Capnographic Airway Assessment for Procedural Sedation and Analgesia

Diagnosis Waveform Features Intervention

Normal 40 Spo2 Normal No intervention required
[CO2] Continue sedation
0 EtCO2 Normal
Time

Waveform Normal
RR Normal
Hyperventilation 40 Spo2 Normal No intervention required
[CO2] Continue sedation
0 EtCO2 ↓
Time

Waveform Decreased amplitude and width

RR ↑
Bradypneic 40
Spo2 Normal Reassess patient
hypoventilation [CO2] Continue sedation
(type 1)
0
Time EtCO2 ↑
Waveform Increased amplitude and width

RR ↓↓↓
OR Spo2 ↓ Reassess patient
Assess for airway obstruction
EtCO2 ↑ Provide supplemental oxygen
Waveform Increased amplitude and width Stop medication or reduce
dosing
RR ↓↓↓

Continued

t.me/Dr_Mouayyad_AlbtousH
86 S E C TI O N Anesthesia

TABLE
19.2 Capnographic Airway Assessment for Procedural Sedation and Analgesia—cont’d

Diagnosis Waveform Features Intervention

Hypopneic hy- 40 Spo2 ↓ Reassess patient
[CO2]
poventilation 0 Continue sedation
(type 2)
Time
EtCO2 ↓
Waveform Decreased amplitude
RR ↓
OR Spo2 ↓ Reassess patient
Assess for airway obstruction
EtCO2 ↓ Provide supplemental oxygen
Waveform Decreased amplitude Stop medication or reduce
dosing
RR ↓
Hypopneic hy- 40
Spo2 Normal or ↓ Reassess patient
poventilation [CO2] Assess for airway obstruction
with periodic
0
Time
EtCO2 ↓ Provide supplemental oxygen
breathing Waveform Decreased amplitude Stop medication or reduce
dosing
RR ↓
Other Apneic pauses
Physiologic vari- Spo2 Normal No intervention required
ability Continue sedation
EtCO2 Normal
Waveform Amplitude and width vary
RR Normal
Bronchospasm 30
Spo2 Normal or ↓ Reassess patient
[CO2] Bronchodilator therapy
0
Time
EtCO2 Normal, ↑, or ↓ a Stop medication
Waveform Curved
RR Normal, ↑, or ↓a
Other Wheezing
Partial airway ob- 40 Spo2 Normal or ↓ Reassess patient
struction [CO2] Stimulation
0
EtCO2 Normal Bag-mask ventilation
Time

Waveform Normal Reversal agents (where ap-

propriate)
Partial laryngo- RR Variable Stop medication
spasm
Other Noisy breathing and/or inspiratory stridor
Apnea Spo2 Normal or ↓a Reassess patient
40
[CO2] Stimulation
0
EtCO2 0 Bag-mask ventilation
Time

Waveform Absent Reversal agents (where ap-

propriate)
RR 0 Stop medication
Other No chest wall movement or breath
sounds
Complete airway Spo2 Normal or ↓a Airway patency restored with
obstruction airway alignment
EtCO2 0
Waveform present
Complete laryn- Waveform Absent Airway not patent with air-
gospasm way alignment
RR 0 No waveform
Other No chest wall movement or breath sounds Positive pressure ventilation

a
Depending on the duration and severity of bronchospasm.
↓, Decreased; ↑, Increased; ↓ ↓ ↓, Significantly decreased; EtCO2, end-tidal carbon dioxide; OR, ***; RR, respiratory rate; SpO2, oxygen saturation
From Krauss B, Hess DR: Capnography for procedural sedation and analgesia in the emergency department, Ann Emerg Med 50:172, 2007.

t.me/Dr_Mouayyad_AlbtousH
 86.e1

Bibliography Perrott DH, Yuen JP, Andresen RV, et al: Office-based ambulatory anes-
thesia: outcomes of clinical practice of oral and maxillofacial surgeons,
J Oral Maxillofac Surg 61:983-995, 2003.
Becker DE, Casabianca DM: Respiratory monitoring: physiological and Roberts JR, Hedges JR: Clinical Procedures in Emergency Medicine, ed 5,
technical considerations, Anesth Prog 56(1):14-22, 2009. St Louis, 2010, Saunders.
Becker DE, Haas DA: Recognition and management of complications Rodgers SF: Safety of intravenous sedation administered by the operating
during moderate and deep sedation. Part 1. Respiratory consider- oral surgeon: the first 7 years of office practice, J Oral Maxillofac Surg
ations, Anesth Prog 58(2):82-92, 2011. 63:1478-1483, 2005.
Becker DE, Rosenberg M: Nitrous oxide and the inhalation anesthetics, Salman SO, Dembo J: Obesity and obstructive sleep apnea. In Mizukawa
Anesth Prog 55(4):124-131, 2008. M, McKenna S, Vega L (eds): Anesthesia Considerations for the OMS,
Bennet J: Intravenous anesthesia for oral and maxillofacial office practice, Batavia, IL, 2017, Quintessence, p 400.
Oral Maxillofac Surg Clin North Am 11(4):601-610, 1999. Saunders R, Struys MMRF, Pollock RF, et al: Patient safety during pro-
Bosack RC, Lee K: Limitations of patient monitoring during office-based cedural sedation using capnography monitoring: a systematic review
anesthesia. In Bosack RC, Lieblich S (eds): Anesthesia Complications in and meta-analysis, BMJ Open 7:e013402, 2017. doi:10.1136/ bmjo-
the Dental Office, Hoboken, NJ, 2014, Wiley, pp 163-169. pen-2016-013402.
Burton JH, Harrah JD, Germann CA, et al: Does end-tidal carbon diox- Soto RG, Fues ES, Miguel RV: Capnography accurately detects apnea
ide monitoring detect respiratory events prior to current sedation during monitored anesthesia care, Anesth Analg 99(2):379-382, 2004.
monitoring practices? Acad Emerg Med 13:500-504, 2006. Vezeau PJ: Anesthetic and medical management of the elderly oral and
D’Eramo EM, Bookless SJ, Howard JB: Adverse events with outpatient maxillofacial surgery patient, Oral Maxillofac Surg Clin North Am
anesthesia in Massachusetts, J Oral Maxillofac Surg 61:793-800, 2003. 11(4):549-559, 1999.
Dripps RD, Eckenhoff JE, Vandam LD (eds): Introduction to Anesthesia: Winikoff SI, Rosenblum M: Anesthetic management of the pediatric
The Principles of Safe Practice, ed 7, Philadelphia, 1988, Saunders. Krauss patient for ambulatory surgery, Oral Maxillofac Surg Clin North Am
B, Hess DR: Capnography for procedural sedation and analgesia 11(4):505-517, 1999.
in the emergency department, Ann Emerg Med 50:172, 2007.
Orr TM, Mizukawa M: Monitoring the patient. In Mizukawa M,
McKenna S, Vega L (eds): Anesthesia Considerations for the OMS,
Batavia, IL, 2017, Quintessence, pp 87-88.

t.me/Dr_Mouayyad_AlbtousH
20
Trigeminal Neuralgia
M AYO O R PAT E L , FA R I B A FA R H I DVA S H , a n d P IYU SH K U M A R P. PAT E L

CC depressed, and fearful of recurring attacks. (Quality of life is se-

verely impaired with TN; depression is common, and suicides
A 52-year-old White female is referred by her physician for evalu- have been reported.) She is married and has two young children.
ation of an 11-month history of intermittent severe, stabbing pain At present, she does not work because of her symptoms. (Talking
and dull throbbing pain in the right maxillary zygomatic buttress provokes attacks in 74% of patients.)
area. (Trigeminal neuralgia [TN] is more common in females
than in males by a ratio of 3 to 2. The condition usually affects Examination
middle-aged or older adults; however, young adults and children
can also be affected.) The patient is anxious; she appears well developed and well nour-
ished. (Some patients limit their diet and thus exhibit signs of
HPI undernourishment.) There is no extraoral swelling or asymmetry.
On palpation, there is tenderness of the temporalis and masseter
The patient reports the pain over her right cheek area as stabbing on her right side. She is very resistant to any palpation over her
and at times shocklike, superimposed on a dull background pain zygomatic area and to opening her mouth for fear of eliciting
of varying duration (95% of the time, TN is located in the lower sharp, shooting pain. Her opening is 42 mm with lateral excur-
face or malar region). She rates her pain severity as a 9 on a 0 to sions of 11 mm bilaterally and protrusive movement of 6 mm.
10 visual analog scale (VAS). (Most patients with TN rate their Cranial nerve examination is noncontributory, and sensory test-
pain as 9 or 10 on a VAS.) These episodes last about 10 to 35 ing results are normal. (This potentially differentiates between
seconds and are triggered by chewing, washing her face, or brush- symptomatic and idiopathic TN.) Oral hygiene is poor, with sig-
ing her teeth. (Triggering stimuli may include talking [76%], nificant plaque buildup on the buccal surfaces of her right premo-
chewing [74%], touch [65%], cold temperature [48%], wind, lar area. No evidence of dental caries is noted. Percussion and
applying makeup, and shaving. Intraoral TN triggers are associ- palpation over her premolars were negative. Gingival tissue is in-
ated with the gingiva.) Between attacks, the individual has periods flamed, primarily because of plaque buildup.
of temporary remission, called refractory periods, when it is impos- The physical examination in patients with TN is generally
sible or extremely difficult to trigger pain. (Trigger zones charac- normal. Diagnosis of TN is largely based on an accurate clinical
teristic of TN are not clinically identifiable in 40%–50% of history (sudden onset of severe, unilateral facial pain lasting sec-
cases.) The pain does not wake her from sleep unless she has slept onds) and necessary imaging (magnetic resonance imaging [MRI]
on her right side. (Pain occurs on the right side over the left by a with contrast or computed tomography [CT] scan) to differenti-
ratio of 3 to 2; it is typically unilateral, with bilateral pain re- ate between symptomatic and idiopathic TN, regardless of age.
ported in 1%–4% of cases.) Ruling out ear, mucosal, sinus, teeth, and temporomandibular
joint pathologies is necessary because problems in these areas may
PMHX/PDHX/Medications/Allergies/SH/FH cause facial pain (see Table 20.3 for differential diagnoses).

The patient's medical history is unremarkable. (The presence of Imaging

hypertension increases the risk of TN 2.1 times in females and 1.5
times in males; multiple sclerosis [MS] increases the risk by a fac- Obtaining a panoramic radiograph (and, when indicated, periapi-
tor of 20.) Her dental history indicates that she saw a dentist cal radiographs) is prudent to rule out the presence of dental pa-
shortly after her symptoms began. She had received two root ca- thology.
nals on her upper right first and second molars. Her symptoms Radiologic investigations are important to distinguish between
did not resolve, and both teeth were subsequently extracted. symptomatic and idiopathic TN. An MRI scan with gadolinium
(Because of its location and paroxysmal nature, TN has often enhancement can demonstrate arterial compression of the nerve
been confused with dental pathology, leading to unnecessary den- or rule out tumor or demyelination, as is seen in MS. (Compres-
tal treatment in 33%–65% of cases.) She still experiences bouts of sion lesions, such as vestibular schwannomas, meningiomas, epi-
pain that are triggered by eating, and she was treated for a tem- dermoid cysts, and other tumors, can cause symptomatic TN.)
poromandibular disorder (TMD) with oral appliance therapy. Magnetic resonance angiography (MRA) is useful diagnostically
(Pain with chewing is consistent with TMD.) She is anxious, and can aid surgical treatment of an offending blood vessel.

87
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88 S E C TI O N Anesthesia

(Compression of the fifth or the ninth nerve root by a blood Assessment

vessel, usually a tortuous artery at the root entry zone into the
brainstem, is the most common source of neuropathic pain in Idiopathic TN predominantly involving the second division of the
idiopathic TN.) If neither MRI nor MRA is available, contrast- right trigeminal nerve (V2).
enhanced CT scanning is effective in ruling out neoplastic causes.
In the current patient, the panoramic radiograph revealed Treatment
multiple missing teeth. No osseous pathology was noted, and the
results were otherwise unremarkable. The MRI scan of the head For newly diagnosed TN, medical management is the first-line
was within normal limits. therapy. (It reduces or eliminates pain in approximately 75% of
patients.) Medications used in the medical management of TN
Labs can be divided into antiepileptic drugs (AEDs) and non-AEDs
(Tables 20.1 and 20.2).
There are no specific laboratory tests required for diagnosis of TN. Patients with TN do not respond to conventional analgesic
However, because TN is a diagnosis of exclusion, specific tests can drugs. However, almost all these patients (80%–90%) respond to
be ordered to rule out other infectious or inflammatory conditions. carbamazepine (Tegretol) or oxcarbazepine (Trileptal), and some

TABLE
20.1 Antiepileptic Drugs Most Commonly Used for Trigeminal Neuralgia

Mechanism
Generic Brand Classification of Action Dosing Guidelines Side Effects Comments
1
Carbamazepine Tegretol Anticonvulsant Sodium (Na ) Start at 200 mg BID; Dizziness; rash; vertigo; drowsi- Serologic assessments of
(CBZ) channel increase to ness; fatigue; can increase liver liver function and hemato-
blockade 600–1200 mg/day enzyme levels; can cause mar- logic status required; regu-
row depression; aplastic ane- lar blood tests to ensure
mia, causing irreversible cardiac drug is in suggested thera-
or hepatic damage; reversible peutic range; hyponatre-
leukopenia; SJS (in patients mia may occur (at higher
with genetic predisposition) doses)
Oxcarbazepine Trileptal Anticonvulsant Sodium (Na1) Start at 150 mg BID; Hyponatremia (at high dose), ver- Serologic assessments not re-
channel increase to 1800– tigo, fatigue, nausea, SJS (in ge- quired; drinking milk daily
blockade 2400 mg/day netically predisposed patients) can prevent hyponatremia
Gabapentin Neurontin Anticonvulsant Unknown Start at 100–300 mg Somnolence, dizziness, ataxia, fa- No drug–drug interaction;
hs; increase by tigue, nervousness, weight gain, considered in patients with
300 mg every third nausea, headache altered liver function; bet-
day to a maximum ter tolerated than CBZ
of 3600 mg
Pregabalin Lyrica Anticonvulsant Unknown Start at 25 mg TID; Dizziness, somnolence, peripheral No drug–drug interaction;
increase to edema, weight gain, nausea, considered in patients with
100–200 mg TID headache altered liver function; rapid
escalation possible
Lamotrigine Lamictal Anticonvulsant Mixed Start at 25 mg/day; Dizziness, sedation, ataxia, nystag- Slower titration, recom-
increase to a mus, irritability, diplopia, skin mended in combination
maximum of rash (rapid dose escalation), in- with another anticonvul-
100–400 mg/day somnia sant for refractory pain
Topiramate Topamax Anticonvulsant Mixed Start at 15–25 mg hs; Abnormal delusional, psychotic No drug–drug interaction
increase to a maxi- thinking, impairment of word
mum of 600 mg/day finding, renal stones
in divided doses
Divalproex Depakote Anticonvulsant GABA agonist Start at 15 mg/kg/day; Nausea, vomiting, anorexia, ataxia, Second-line drug for patients
sodium increase to a sedation, tremor who have not responded
maximum of 60 mg/ to other anticonvulsants or
kg/day have developed significant
side effects from them
Dilantin Phenytoin Anticonvulsant Sodium (Na1) Start at 200 mg; Nausea, vomiting, constipation, Structurally similar to CBZ;
channel increase to 300– epigastric pain, dysphagia, loss gingival hyperplasia may
blockade 500 mg BID of taste, anorexia, weight loss, develop
headache, behavioral changes,
folate deficiency (prolonged use)

BID, Twice a day; GABA, gamma-aminobutyric acid; hs, at bedtime; SJS, Stevens-Johnson syndrome; TID, three times a day.

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 CHAPTER 20 Trigeminal Neuralgia 89

TABLE
20.2 Non-Antiepileptic Drugs Most Commonly Used for Trigeminal Neuralgia

Generic Brand Mechanism

Name Name Classification of Action Dosing Guidelines Side Effects Comments
Clonazepam Klonopin Anticonvulsant GABA Start at 0.5 mg TID; in- Can elevate liver function Indicated when CBZ is ineffective or
agonist crease to 15 mg/day values; drowsiness, ataxia, cannot be tolerated
respiratory depression
Baclofen Lioresal Skeletal GABA agonist Start at 5 mg TID; in- Drowsiness, dizziness, muscle Can be used as a substitute for CBZ in
muscle crease 5–10 mg weakness, constipation, nonresponding patients taking CBZ;
relaxant every 2–3 days to headache, itching, prescribed in combination with CBZ
80 mg/day TID hypotension, nausea or gabapentin if effectiveness of
these medications decreases

CBZ, Carbamazepine; GABA, gamma-aminobutyric acid; TID, three times a day.

Modified from Reisner L, Pettengill CA: The use of anticonvulsants in orofacial pain, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 91:2-7, 2001.

clinicians use this response as a diagnostic criterion. Although the and at 3 months, with no significant changes seen while the pa-
initial response is good, the long-term response is not as favorable, tient was taking the medication. After 3 months, the patient was
and a significant number of patients may become refractory as the experiencing some attacks, although not as frequently as before.
symptoms increase. The dose of the medication should be slowly Baclofen 10 mg three times a day was added to her regimen,
increased until the pain disappears or the patient experiences side which helped control her pain. After she had been pain free for
effects. After the pain has been adequately controlled for 6 to 3 months, her medications were tapered over a 1-month period.
8 weeks, it is advisable to titrate the dosage of the medication to the (If mild pain remains, maintenance at a low dose of an effective
lowest level that controls the pain. Although both medications are drug is preferable.)
effective, oxcarbazepine has a better side effect profile and tends to
be better tolerated. Regular monitoring of sodium levels for both Complications
medications are needed, and complete blood count monitoring is
needed for long-term carbamazepine use. Medication management comes with its own risks and benefits.
Over time, many patients with TN taking carbamazepine or Carbamazepine, although an effective drug, produces several ad-
oxcarbazepine experience “breakthrough” pain attacks and require verse effects that need to be considered and monitored. Carbam-
increased dosages for pain control or adjunct therapy. Medications azepine is metabolized by the liver cytochrome P450 enzyme 3A4;
that may be added for pain control include lamotrigine, baclofen, in addition, it induces the several cytochrome P450 enzyme sys-
gabapentin, and pregabalin, among others. (See Table 20.1 for tems, thus altering the circulation levels of other medications. It
AED medications and dosing.) is necessary to conduct serologic assessments of the patient’s liver
Other strategies worth considering for acute management of function and hematologic status and to determine whether the
TN pain attacks are peripheral local anesthetic block (injecting drug is in the suggested therapeutic range, the patient must have
the trigger zone), intravenous (IV) lidocaine (100 mg infused at regular blood tests. (These are repeated monthly for 3 months and
20 mg/min), and IV AED administration. Several case studies then once every 3–6 months.) The administration of carbamaze-
have reported on the use of botulinum toxin A (50 U), which is pine during pregnancy has been associated with various birth de-
injected into trigger zones, in patients who are drug refractory. fects, ranging from neural tube defects to congenital heart disease.
This approach was shown to improve the pain threshold, and a (See Table 20.1 for additional information.)
stronger stimuli was necessary to provoke pain. In one open-label Surgical procedures that produce destructive lesions in the tri-
trial, topical capsaicin (Zostrix), applied locally to the trigger geminal system usually provide effective pain control. However,
zone, was helpful for TN pain. these procedures do not treat the cause of the TN, which leads to
Surgical treatment options are divided into procedures that di- the recurrence of pain over time. In addition, these procedures are
rectly decompress the trigeminal nerve (involving a posterior fossa more likely to produce other sensory disturbances involving the
craniectomy and translocation of the offending structures), proce- trigeminal nerve; these can vary from minor dysesthesias to more
dures that destructive (ablative) (percutaneous thermal radiofre- severe symptoms, such as analgesia dolorosa or anesthesia dolorosa.
quency ablation, percutaneous glycerol rhizotomy, mechanical
balloon compression, trigeminal rhizotomy, and stereotactic radio- Discussion
surgery), and palliative procedures (deep pain stimulation). Factors
such as the patient’s age, the location of the pain, and any associated Patients with TN report that they have severe head pain that lasts
comorbidities all are considered before a decision is made on which for hours to days; however, they may not specify that the indi-
procedure to perform. vidual unit of pain is brief (lasting seconds to 1–2 minutes) but
The current patient was started on carbamazepine 200 mg two occurs repetitively over the duration of the attack. Generally, the
times a day, which relieved her attacks for 1 month only. For her first attack is totally unexpected, and most patients describe it as
recurrent episodes, the carbamazepine dosage was increased to by far the worst pain they have ever experienced. The details of the
1000 mg/day. The patient's liver function test results and com- first attack generally are remembered forever. The pain is de-
plete blood count were monitored before medication initiation scribed as lancinating, resembling an electric shock, stabbing, or

t.me/Dr_Mouayyad_AlbtousH
90 S E C TI O N Anesthesia

feeling as if glass is grinding into the face (Table 20.3). Patients distribution. About 14% to 50% of patients also describe con-
may comment that attacks can be precipitated by various stimuli tinuous pain in the same distribution. This pain may be described
to the face. No neurologic deficits are present except when a sec- as dull, aching, or throbbing in nature, may last hours to days,
ondary cause exists (e.g., tumor or MS). Pain is confined to the and is less severe than the paroxysmal pain.
distribution of the trigeminal nerve and is almost always unilat- In deciding on the treatment options for a patient with TN,
eral. It is estimated that in 5% to 8% of cases, TN is precipitated the clinician must take into account various clinical factors. The
by trauma, most commonly an acute flexion–extension injury. International Headache Society has classified TN into two catego-
The pain is more commonly located in the V3.V2.V1 nerve ries: classic (idiopathic) and secondary (symptomatic). The two

TABLE
20.3 Types of Facial Pain

Diagnosis Location Quality Intensity Duration Triggers Other Characteristics

Trigeminal Second and third divi- Stabbing, sharp, Severe Seconds Touching or washing No sensory or motor paral-
neuralgia sions of trigeminal shooting; elec- the face, eating, ysis in idiopathic cases
nerve; unilateral tric shock–like chewing, smiling,
Rarely, first division talking, brushing
teeth, shaving
Postherpetic Usually ophthalmic or Burning, tingling, Severe Continuous Touch, movement Allodynia, hyperalgesia,
neuralgia maxillary branch of shooting altered sensation
fifth cranial nerve;
unilateral
Glossopharyn- Ear, tonsils, neck, Sharp, shooting, Severe Seconds Swallowing, chewing, Unilateral
geal neural- posterior tongue stabbing yawning, coughing, Rule out eagle syndrome
gia touch because of similar pain
associations
Atypical facial One side of face, na- Aching, burning, Mild to Constant Depressive and anxiety
pain solabial fold or side, often stabbing severe states
chin, jaw, neck;
poorly localized
TMD Jaw, mandible, Dull, aching, Mild to Minutes to hours Prolonged chewing, Clicking, crepitus, limited
preauricular re- throbbing, moderate talking, opening opening, deviation of
gion, masticatory sharp, stab- wide mandible on opening, ear
muscles bing pain or fullness, tinnitus
Tolosa-Hunt Mainly retro-orbital; Aching Severe Constant Ophthalmoplegia, sensory
syndrome unilateral loss over forehead, ptosis
Carotidynia Face, ear, jaws, teeth, Throbbing Moderate Constant Compression of com- Compression of common
upper neck; unilat- mon carotid artery carotid at or below
eral bifurcation reproduces
pain in some
Temporal arte- Temporal region; uni- Throbbing, dull, Moderate to Constant Pressure over temporal Jaw claudication
ritis lateral or bilateral aching, tender severe artery Usually seen in older adults
Elevated ESR and CRP
Temporal artery biopsy
(4- to 6-cm segment) to
confirm diagnosis
Alveolar Affected bone Sharp, aching, Moderate to Continuous 4–5 Open socket Loss of clot, exposed bone,
osteitis throbbing severe days postextrac- halitosis
(dry socket) tion
Mucosal Affected mucosa Sharp, burning, Mild to Intermittent Touch Erosive or ulcerative
pathology tingling severe lesions, redness
Pulpitis Teeth Intermittent, Mild to Minutes to hours Mechanical, cold, heat, Deep caries, extensive
throbbing severe lying supine restoration
Maxillary si- Over affected sinus; Dull, aching Mild to Constant Touch, bending History of URTI, nasal dis-
nusitis unilateral or moderate charge, fullness over
bilateral cheek with or without
erythema over cheek

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 CHAPTER 20 Trigeminal Neuralgia 91

TABLE
20.3 Types of Facial Pain—cont’d

Diagnosis Location Quality Intensity Duration Triggers Other Characteristics

Burning mouth Tongue, palate, lips, Burning, tingling, Mild to Constant Stress; spicy, acidic Altered taste, xerostomia
syndrome pharynx tender moderate foods; vitamin and
iron deficiency; can-
didiasis
Cluster Orbital, suborbital, Boring, throbbing Severe Minutes to hours Alcohol, smoking, Autonomic symptoms
headache and/or temporal; stress, heat, cold,
unilateral REM sleep
Tension-type Frontotemporal and/or Pressure, tight Mild to Minutes to days Stress Not aggravated by routine
headache parietal; bilateral moderate physical activity
Migraine Frontotemporal, or- Pulsating, Moderate to Hours Physical activity, Aura (in migraine with aura)
bital; usually uni- throbbing severe stress, foods, odors, Nausea or vomiting, photo-
lateral estrogen, alcohol, phobia or phonophobia
lack of sleep, baro-
metric pressure
Paroxysmal Periorbital, temple; Boring Moderate to Paroxysmal: 1–40 Neck movement Autonomic features
hemicrania unilateral severe attacks/day last-
ing 2–30 min
SUNCT or First and second Stabbing Moderate to Recurring: 1–200 Cutaneous triggers Tearing, conjunctival
SUNA divisions of severe attacks/day, injection
trigeminal nerve; 10–250 seconds
unilateral each
Orofacial Variable Variable (atypical) Severe Jaw movement Frequently neurologic signs,
tumors WBC abnormalities

CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; REM, rapid eye movement; SUNA, short-lasting unilateral autonomic headaches; SUNCT, severe unilateral neuralgiform headache with
conjunctival injection and tearing; TMD, temporomandibular disorder; URTI, upper respiratory tract infection; WBC, white blood cell.
Modified from Agostoni E, Frigerio R, Santoro P: Atypical facial pain: clinical considerations and differential diagnosis, Neurol Sci 26:s71-s74, 2005.

categories present with similar symptoms, but they differ with and severity of the attacks until the symptoms become continuous
respect to causality. Classic TN includes neuralgia that is idio- without remission. The character of the pain may also change,
pathic or caused by compression of the trigeminal nerve by a with an aching or burning sensation accompanying the shooting
nearby blood vessel (arterial loop of the basilar artery, most com- pains.
monly anterior inferior cerebellar or superior cerebellar), and it is Trigeminal neuralgia was originally called tic douloureux (pain-
by far more common (90%) than the secondary type. Secondary ful tic) because the patient, when experiencing the pain, grimaces,
TN accounts for cases triggered by structural abnormalities (tu- especially on the ipsilateral side. Before the onset of TN, some
mors, vascular malformation, or demyelinating diseases). Rarely, patients have a prodrome of discomfort or moderate pain in the
TN results from bony compression of the nerve (e.g., caused by tooth, face, or jaw. In some cases, this may precede an actual TN
an osteoma or deformity resulting from osteogenesis imperfecta). attack by weeks to months. During this period, patients usually
Trigeminal neuralgia rarely occurs bilaterally; when it does, it present to a dentist and in many cases have teeth extracted, root
is usually secondary to MS. TN never crosses the midline but on canal procedures, and sometimes oral appliance therapy. A timely,
rare occasions may switch to the opposite side in different attack accurate diagnosis of TN is particularly important because a vari-
periods. Typically, the time pattern of the pain is episodic, and the ety of specific treatments can greatly reduce or eliminate TN pain
pain lasts for a few weeks to approximately 1 month. This can be symptoms in many patients.
followed by a remission period of several weeks, months, or years.
Over time, there is a tendency to exacerbations and remissions, ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
with an overall progressive increase in the frequency, duration, complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 91.e1

Bibliography Krafft RM: Trigeminal neuralgia, Am Fam Physician 77(9):1291-1296, 2008.

Linskey ME, Jannetta PJ: Differential diagnosis: look-alike diseases,
atypical trigeminal neuralgia. In Jannetta PJ (ed): Trigeminal Neural-
Bagheri SC, Farhidvash F, Perciaccante VJ: Recognition and management gia, New York, 2011, Oxford University Press, pp 74-86.
of trigeminal neuralgia, J Am Dent Assoc 135:1713-1717, 2004. Love S, Coakham HB: Trigeminal neuralgia: pathology and pathogene-
Bendtsen L, Zakrzewska JM, Heinskou TB, et al: Advances in diagnosis, sis, Brain 24:2347-2360, 2001.
classification, pathophysiology, and management of trigeminal neu- Pawl RP: Trigeminal neuralgia and atypical facial pain, Curr Pain Head-
ralgia, Lancet Neurol 19:784-796, 2020. ache Rep 1:175-181, 1997.
Bohluli B, Motamedi MHK, Bagheri SC, et al: Use of botulinum toxin Reisner L, Pettengill CA: The use of anticonvulsants in orofacial pain,
A for drug refractory trigeminal neuralgia: preliminary report, Oral Oral Surg Oral Med Oral Pathol Oral Radiol Endod 91:2-7, 2001.
Surg Oral Med Oral Pathol Oral Radiol Endod 111:47-50, 2011. Scrivani SJ, Keith DA, Bassiur JP, et al: Nonsurgical management of fa-
Clark GT, Teruel A: Anticonvulsant agents used for neuropathic pain cial pain. In Bagheri SC, Bell RB, Khan HA (eds): Current Therapy in
including trigeminal neuralgia. In Clark GT, Dionne RA (eds): Oro- Oral and Maxillofacial Surgery, Philadelphia, 2011, Elsevier/Mosby,
facial Pain: A Guide to Medications and Management, West Sussex, pp 247-264.
UK, 2012, Wiley-Blackwell, pp 95-114. Scrivani SJ, Keith DA, Mathews ES, et al: Percutaneous stereotactic dif-
Cohen J: Current medical therapy. In Jannetta PJ (ed): Trigeminal Neu- ferential radiofrequency thermal rhizotomy for the treatment of tri-
ralgia, New York, 2011, Oxford University Press, pp 56-73. geminal neuralgia, J Oral Maxillofac Surg 57(2):104-111; discussion,
Elias WJ, Burchiel KJ: Trigeminal neuralgia and other neuropathic pain syn- 111-112, 1999.
dromes of the head and face, Curr Pain Headache Rep 6:115-124, 2002. Scrivani SJ, Mathews ES, Maciewicz RJ: Trigeminal neuralgia, Oral Surg
Olesen J, Steiner TJ: International Headache Society, Headache Classifi- Oral Med Oral Pathol Oral Radiol Endod 100:527-538, 2005.
cation subcommittee: the international classification of headache Zakrzewska JM, Linksey ME: Trigeminal neuralgia. In Zakrzewska
disorders, second edition, Cephalgia 24(Suppl 1):808–811, 2004, JM (ed): Orofacial Pain, New York, 2009, Oxford University Press,
doi:10.1136/jnnp.2003.031286. pp 119-133.
Jannetta PJ, Hadeed GJ: Medical therapy: the dentist’s perspective. In Zakrzewska JM, McMillan R: Trigeminal neuralgia: the diagnosis and
Jannetta PJ (ed): Trigeminal Neuralgia, New York, 2011, Oxford Uni- management of this excruciating and poorly understood facial pain,
versity Press, pp 46-50. Postgrad Med J 87:410-416, 2011.
Jannetta PJ: Typical and atypical symptoms. In Jannetta PJ (ed): Trigeminal
Neuralgia, New York, 2011, Oxford University Press, pp 41-45.

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21
Malignant Hyperthermia
Z A K I R H U S S E I N E S U FA L I

CC (Box 21.1). Therefore, the clinician must constantly reevaluate

the clinical situation to determine the likelihood that MH
A 15-year-old male is undergoing an open reduction with internal may exist. The presence of only one sign or symptom decreases
fixation (ORIF) of a left mandibular angle fracture in the operating the likelihood of MH. In general, several coexist in an MH
room. (The incidence of malignant hyperthermia [MH] is highest reaction.
in children and is more common in males). He had presented to the Hypermetabolism is the hallmark feature of MH and is caused
emergency department complaining of pain, swelling, and maloc- by disordered calcium homeostasis in skeletal muscle. Because
clusion. He has previously had ear tubes and a tonsillectomy under skeletal muscle makes up about 50% of body weight, the changes
general anesthesia without anesthesia complication. to the physiological state can be profound.
Changes in Etco2 concentration are usually the first sign of
HPI MH. However, these changes may vary depending on the mode of
ventilation and the stage of the process when the change is ob-
While playing ball, the patient sustained an accidental blow to the served. In a spontaneously breathing patient under general anes-
left side of the jaw from an opponent’s elbow. He was diagnosed thesia, the first sign may be hypocarbia, or a decrease in expired
with a fractured mandible and subsequently was admitted to the carbon dioxide concentration. Early in an MH episode, a sponta-
hospital for treatment of his injury under general anesthesia. The neously breathing patient will breathe more rapidly and with larger
patient was induced with propofol, given succinylcholine, and tidal volumes to offset metabolic acidosis and maintain acid–base
nasotracheally intubated without difficulty. He was maintained balance. However, as the patient’s metabolic acidosis worsens and
on sevoflurane (halogenated inhaled anesthetic) and intravenous fatigue ensues, they will not be able to compensate fully, and hy-
(IV) agents. The patient had a smooth anesthetic course for the percarbia (increased Etco2) will occur. This leads to a combined
first 20 minutes of the procedure before the onset of unexplained metabolic and respiratory acidosis. In a patient who is mechani-
tachycardia and elevation in his end-tidal carbon dioxide (Etco2, cally ventilated, the carbon dioxide concentration increases much
the earliest signs of MH). The diagnosis of MH was considered. earlier provided the tidal volume and respiratory rate on the venti-
lator are not altered because the mechanically ventilated patient
PMHX/PDHX/Medications/Allergies/SH/FH cannot alter their respiratory pattern on their own.
Although increased Etco2 is highly sensitive for MH (its ab-
The patient underwent tonsillectomy and adenoidectomy at sence basically rules out the diagnosis), the differential diagnosis
6 years of age under general anesthesia without any surgical or of this increased sign is extensive. An exhausted soda lime canister,
anesthetic complications. (Fifty percent of MH cases occur in a stuck expiratory valve, light anesthesia, or an increase in surgical
patients with two or more prior uneventful experiences with anes- stimulation may all cause an increase in Etco2. These and other
thetics.) His family history is negative for MH. (MH is an autoso- conditions must be considered during the evaluation of the pa-
mal dominant inherited disorder. However, many patients present tient (see Box 21.1).
with MH without any prior documented family history.) Early in MH, tachycardia and hypertension are common and
are caused by sympathetic nervous system activation. The increases
Examination in circulating epinephrine and norepinephrine lead to increases in
heart rate and vasoconstriction with resultant hypertension.
Malignant hyperthermia may present immediately upon induc- Sympathetic nervous system responses in MH appear to be sec-
tion of anesthesia, especially with inhalation induction or with the ondary to hypercarbia and acidosis.
use of succinylcholine. Alternatively, it may onset during the Sweating also results from sympathetic activation and helps to
procedure. Occasionally, MH may become apparent hours after regulate body temperature when hyperthermia begins.
the operation. In all situations, the progression from onset to full- Hyperthermia is caused by increased metabolism with corre-
blown MH is extremely rapid. sponding increases in heat production (because metabolic reac-
The clinical presentation of MH comprises a spectrum of tions are exothermic). It must be emphasized that hyperthermia is
signs, symptoms in an awake patient, and laboratory values. a late sign, and thus the presence of other signs with a normal
Many of these manifestations (discussed later) are nonspecific, temperature does not preclude MH. The rate of rise in core body
and many conditions in an anesthetized patient can mimic MH temperature may be as much as 2°C every 5 minutes.

92
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 CHAPTER 21 Malignant Hyperthermia 93

• BOX 21.1 Conditions That May Mimic Malignant after injection. If prolonged or exaggerated, such increase in jaw
Hyperthermia in an Anesthetized Patients muscle tension in the absence of temporomandibular joint dys-
function or myotonia is referred to as masseter muscle rigidity
Anaphylaxis (MMR). The rigidity is so profound that manual mouth opening,
Becker’s or Duchenne muscular dystrophy direct laryngoscopy, and tracheal intubation are rendered un-
Carbon dioxide absorption during laparoscopy or endoscopy achievable. This “jaws of steel” phenomenon should alert the cli-
Diabetic coma nician to the possibility of MH. Up to 50% of people with MMR
Drug toxicity have a predisposition to MH. If MMR is accompanied by rigidity
Equipment malfunction
of other muscles, then MH is inevitable. However, in patients
Hyperthyroidism
Inadequate anesthesia or analgesia who have MMR with limb flaccidity, MH may still occur.
Malignant catatonia Current consensus states that if the procedure is elective, it is
Myotonias prudent to cancel the procedure and monitor for signs and symp-
Neuroleptic malignant syndrome toms of MH for 24 hours. If the procedure is emergent, then
Osteogenesis imperfecta continuation with nontriggering agents is acceptable, with intra-
Pheochromocytoma operative and postoperative surveillance for MH evolution.
Preexisting fever Masseter muscle rigidity is most common in children, with its
Rhabdomyolysis highest incidence between 8 and 12 years of age. Because a high per-
Sepsis centage of patients with MMR progress to having fulminant MH, it
Serotonin syndrome
Systemic inflammatory response syndrome
seems prudent to avoid the routine use of succinylcholine in children.
Overwarming In addition, the use of succinylcholine in pediatric anesthesia is
Ventilation problems (hypoventilation) also relatively contraindicated because of the possibility of undiag-
nosed myopathies. The most common such myopathy is muscular
dystrophy. The muscle weakness leads to an upregulation of acetyl-
choline receptors, which can precipitate massive release of intracel-
lular potassium ions upon administration of succinylcholine. The
Hypoxia is attributable to increased oxygen consumption. The resulting hyperkalemic arrest may be even more difficult to resusci-
practitioner may find that increased inspired oxygen concentrations tate in the pediatric population. It should be noted that the mecha-
are required to maintain oxygen saturation despite little change in nism of hyperkalemia in these myopathies should be distinguished
stimulation or clinical state during the procedure. Hypoxia results in from the hyperkalemia that occurs in MH. The management,
an increase in anaerobic metabolism with the production of lactate, however, is the same in all episodes of hyperkalemia.
causing lactic acidosis and increased membrane permeability.
Later in the progression of MH, hypertension is replaced by hy- Labs
potension. This stems partly from increases in serum lactate and
carbon dioxide, which cause vascular smooth muscle relaxation and Laboratory values in MH may be severely altered. The destruction
vasodilation. Second, myocardial oxygen consumption increases of muscle cells leads to myoglobinuria, increased creatine kinase
dramatically because of increases in sympathetic nervous system ac- levels, and hyperkalemia. Arterial blood gas analysis will show
tivity, predisposing to myocardial ischemia and decreased cardiac hypoxemia, increased arterial carbon dioxide levels (although this
output. The effects on cardiac muscle are not a direct effect of de- value may be decreased early on in a spontaneously breathing
rangements in calcium metabolism but rather caused by sympathetic patient), elevated lactate, a decrease in bicarbonate, and an anion
overactivity induced by hyperthermia, acidosis, and hyperkalemia. gap metabolic acidosis. The pH may be normal early in an MH
Arrhythmias in MH begin with sinus tachycardia but can crisis if respiratory compensation has taken place but will eventu-
progress to ventricular ectopy, ventricular tachycardia, and ven- ally decrease as metabolic exhaustion ensues. The gradient of
tricular fibrillation. alveolar to arterial oxygen will increase, reflecting inadequate tis-
Muscle rigidity is caused by sustained muscle contraction me- sue perfusion. Acute renal failure is reflected by an increased cre-
diated by unopposed calcium release. atinine value and is caused by dehydration combined with the
The breakdown of muscle, or rhabdomyolysis, leads to accu- toxic effects of myoglobin on renal tubules.
mulation of myoglobin (the hemoglobin of skeletal muscle), and On diagnosis of MH, a full set of serum electrolytes, liver
the resultant myoglobinuria renders the urine cola colored. function tests, urinalysis, and arterial blood gases should be or-
Myoglobinuria can contribute to renal failure in those with MH. dered to aid in the correction and diagnosis of electrolyte and
Myoglobin has a direct toxic effect on proximal renal tubules, and acid–base disturbances.
it may bind to proteins in the distal tubules (Tamm-Horsfall pro- The laboratory findings characteristically reflect the following
tein) to form casts. metabolic conditions:
Cerebral oxygenation may be impaired in an MH episode be- • Acidemia (elevated Pco2 and metabolic acidosis). (Of cases
cause of the increased metabolic state, causing hypoxia and anaero- seen between 1987 and 2006, 78.6% presented with both
bic metabolism. Hyperthermia and acidosis are poorly tolerated by muscular abnormalities and respiratory acidosis; only 26% had
cerebral tissues and may compound the insult, leading to transient metabolic acidosis.)
or permanent neurologic sequelae. • Hyperkalemia (secondary to acidosis)
• Hypercalcemia (secondary to reduced uptake of calcium from
Masseter Muscle Rigidity the sarcoplasmic reticulum of skeletal muscles)
• Elevated serum transaminases and creatinine kinase (CK) and
The use of succinylcholine normally causes a transient increase in subsequent rhabdomyolysis, causing myoglobinuria (second-
tone of the masseter and lateral pterygoid muscles immediately ary to hypermetabolic skeletal muscle activity)

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The standard for diagnostic testing for suspected susceptibility high levels of contractile force suggest MH susceptibility. A ten-
to MH is the caffeine-halothane contracture test (CHCT), which sion of 0.3 g in a caffeine-exposed muscle strip or of 0.7 g in a
is performed on muscle biopsy specimens at specialized centers. halothane-exposed muscle strip deems the patient MH suscepti-
Electrocardiography (ECG) changes and dysrhythmias can oc- ble. For halothane, a result of 0.5 to 0.69 g of muscle tension is
cur; these are late findings. They are caused by elevated potassium classified as MH equivocal. The incorporation of ryanodine or
levels from muscle breakdown. They can occur more rapidly in 4-chloro-m-cresol (a ryanodine receptor agonist) can increase the
muscular patients. accuracy of the CHCT.
The presence of premature ventricular contractions may indicate These diagnostic thresholds have been adjusted to maximize
a life-threatening hyperkalemia and is an ominous sign because this sensitivity of the test (i.e., to minimize false-negative results).
condition may degrade into ventricular tachycardia or ventricular Obviously, a false-negative result could be detrimental because
fibrillation. exposure of a patient who has tested negative for MH susceptibil-
ity to halothane or succinylcholine could lead to a catastrophic
Biopsy and Testing outcome if the patient is indeed positive. Sensitivity of the CHCT
is reported to be 97% to 99%. This high sensitivity sacrifices
Testing for MH susceptibility is offered to patients who may dis- specificity, and the false-positive rate ranges from 10% to 20%.
play MH signs or symptoms intraoperatively or to first-degree Because treatment of MH-susceptible patients can be achieved
relatives of patients who have known MH susceptibility. easily and cost effectively, the lower specificity of the CHCT can
Patient selection is vital to ensure that those who warrant test- be tolerated. The main disadvantage of false-positive test results is
ing receive such testing while avoiding unnecessary intervention. the possible labeling of patients and their entire families as MH
A clinical grading scale has been developed to assess the probabil- susceptible. Another drawback to muscle biopsy testing is the in-
ity that an MH reaction has occurred and can guide decisions vasiveness of the procedure. The CHCT is not performed in
regarding testing. The criteria are as follows: children younger than 5 years of age because of the significant loss
1. Generalized or masseter muscle rigidity of muscle that would result. Finally, the test can be restrictive
2. CK greater than 20,000 units/L, cola-colored urine, myoglo- because of its high cost, which is approximately $6000.
binuria, or hyperkalemia, Creatine kinase levels may facilitate the diagnosis of MH suscep-
3. Etco2 greater than 55 mm Hg or arterial PCO2 greater than tibility. An elevated resting CK value in a first-degree relative of a
60 mm Hg patient with known MH susceptibility confers MH susceptibility
4. Rapidly increasing temperature or temperature greater than without the need for further testing. There should be no history of
38.8°C recent trauma before testing because muscle trauma elevates CK.
5. Unexplained sinus tachycardia, ventricular tachycardia, or However, a normal CK concentration does not exclude the possibil-
ventricular fibrillation ity of MH susceptibility, thereby necessitating a muscle biopsy.
6. Family history of MH
7. Elevated resting creatine kinase Assessment
8. pH less than 7.25
9. Rapid reversal of signs of MH with dantrolene Acute onset of MH during ORIF of a mandibular fracture.
Malignant hyperthermia testing can be achieved, in theory,
through either physiological or genetic testing. However, wide Triggers Versus Safe Agents
genetic heterogeneity exists in expression of MH susceptibility,
and this renders genetic testing difficult. One patient may have During general anesthesia, the known triggering agents are the
one mutation, and another member of the same family may have volatile inhalational anesthetics and the depolarizing muscle relax-
a different mutation. Both patients may possess MH susceptibil- ant succinylcholine. Examples of volatile anesthetics include
ity. Practically, therefore, physiological testing via muscle biopsy is ether, cyclopropane, halothane, enflurane, isoflurane, sevoflurane,
more definitive. and desflurane. In dental facilities where sleep dentistry is being
The demonstration by Kalow and Britt that caffeine accentu- administered, the triggering agents for MH are administered by a
ated the response of muscles in vitro to halothane formed the professional who is licensed to administer general anesthesia (i.e.,
basis of the CHCT. Physiological testing involves the exposure of a dental or medical anesthesiologist).
strips of muscle excised from the vastus medialis or vastus lateralis It should be emphasized that all local anesthetics, both esters and
to caffeine and halothane. Because direct infiltration of local an- amides, are safe in those with MH. Although amide local anesthet-
esthetic to the site may interfere with tissue viability, the surgical ics increase calcium efflux from the sarcoplasmic reticulum and
procedure is performed with a nerve block and sedation. The induce contractions in vitro, the concentrations necessary to do so
muscle biopsy must be performed at specialized centers where are far greater than those used in clinical practice. Thus a dental
the analysis of the fibers will take place. There are five centers in the practitioner who is treating a patient with a local anesthetic alone
United States and one in Canada. Because the muscle degrades need not be concerned about the risk of MH in such a patient.
quickly, testing must be performed within 5 hours of biopsy. Drugs that are typically used for conscious sedation do not
Failure to do so may render a false-negative test result. To main- trigger MH. Thus, benzodiazepines such as valium, chlordiazepox-
tain viability, the muscle must not be cauterized or stretched. The ide, triazolam, and midazolam are all safe to administer. Opiates,
viability of the muscle is confirmed by electrical stimulation of including fentanyl, remifentanil, codeine, morphine, and hydro-
the fibers, which should result in muscle contraction. Six muscle morphone, may be used in patients with MH as well. The seda-
fibers are then mounted and attached to a force transducer. They tive–hypnotic propofol and the N-methyl-D-aspartate (NMDA)
are inserted into a muscle bath and exposed to solutions of caf- receptor antagonist ketamine have not been shown to trigger MH.
feine of 0.5, 1, and 2 mM, as well as to 3% halothane. The tension Furthermore, nitrous oxide, which is a nonvolatile inhalational
generated within the muscles is measured. Disproportionately anesthetic, is safe to use as well.

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 CHAPTER 21 Malignant Hyperthermia 95

If muscle relaxation is required in an MH-susceptible patient, Repeated doses of dantrolene of 2 mg/kg may be administered
the nondepolarizing agents must be used. These include pan- every 5 minutes until signs and symptoms subside. The maximum
curonium, rocuronium, cis-atracurium, vecuronium, and mivac- dose of dantrolene is 10 mg/kg.
urium. They do not precipitate an MH reaction in such patients. Hyperventilation with 100% oxygen limits hypoxemia and
In fact, nondepolarizers mitigate the effects of succinylcholine in aids in offsetting the metabolic acidosis. Because the increased
triggering MH. metabolism of MH leads to increased carbon dioxide production,
increased ventilation is necessary to eliminate increased levels of
this waste product. In a mechanically ventilated patient, this is
Treatment achieved by increasing both the respiratory rate and tidal volume.
Management of the Acute Episode Because MH can induce significant skeletal muscle weakness
caused by patient fatigue, a spontaneously breathing patient will
Treatment of the acute episode begins with cessation of the pro- likely be unable to increase minute ventilation sufficiently or for
cedure as soon as possible. If the crisis is occurring in an outpa- a prolonged period during treatment of an MH crisis. Therefore,
tient facility, 911 must be notified. it is prudent to intubate the patient and control ventilation with
Malignant hyperthermia triggers are discontinued immedi- the goal of maintaining normocarbia.
ately. The goals of treatment are to normalize acid–base balance, Crystalloid infusion in MH corrects dehydration, restores tis-
achieve normothermia, and rehydrate the patient. sue perfusion, and helps reverse acute renal failure.
Dantrolene is the main drug of choice in the treatment of Hyperthermia is managed with cooled or iced fluids, cooling
patients with MH. Dantrolene is classified as a skeletal muscle blankets, and the use of gastric and bladder lavage. Again, cooling
relaxant, and it acts by inhibiting calcium release from the sarco- of the patient should occur after dantrolene administration if
plasmic reticulum. Unlike classic muscle relaxants, which act adequate help is not available. Cooling should be halted at 38°C
postsynaptically, dantrolene acts intracellularly, presumably by to avoid inadvertent hypothermia.
antagonizing the ryanodine receptor and inducing a conforma- Bladder catheterization is useful to monitor urine output and
tional change in the receptor. This inhibits excitation–contraction help assess volume status. A diuresis of 1 mL/kg/hr should be
coupling and muscle contraction. In addition to MH, dan- maintained. Cola-colored urine aids in the diagnosis of myoglo-
trolene is used to treat spasticity or muscle spasms in patients binuria. Finally, bladder lavage with cooled fluids may be achieved
with spinal cord injuries, stroke, multiple sclerosis, or cerebral with a urinary catheter.
palsy. Its main side effect is muscle weakness, and this may Sodium bicarbonate corrects the metabolic acidosis that ac-
persist for 24 hours after a therapeutic dose. The effect of dan- companies MH. The recommended dose of bicarbonate is 2 to 4
trolene plateaus. Even with high doses, the ability to cough and mEq/kg. Bicarbonate administration may need to be repeated
breathe deeply is maintained. Other common side effects in- because lactate may continue to diffuse slowly from intracellular
clude drowsiness, dizziness, diarrhea, and sterile thrombophlebi- to extracellular fluid down the concentration gradient. This results
tis. Infusion of dantrolene through a large-bore IV line aids in in ongoing metabolic acidosis.
preventing thrombophlebitis. Life-threatening hyperkalemia may occur in MH because of
Dantrolene is available in an oral and IV formulation. For cell lysis. Because ongoing hyperkalemia may lead to arrhythmias
treatment of an MH crisis, IV dantrolene is administered in a and may hinder effective defibrillation, it should be treated ag-
dose of 2.5 mg/kg. The IV form is classically supplied as a ly- gressively. In an outpatient facility where laboratory analysis is not
ophilized powder in a dose of 20 mg and requires reconstitution available, hyperkalemia may be suspected by peaked T waves on
in 60 mL of sterile water to be administered. The powder also the ECG tracing. It is managed with agents that shift potassium
contains sodium hydroxide to achieve a pH of 9 to 10, as well as intracellularly. These include calcium, insulin, and sodium bicar-
mannitol to achieve isotonicity. Sterile water is the ideal solvent bonate. It should be noted that although massive amounts of
because it is void of molecules that may promote precipitate for- calcium are released in MH, IV calcium is still effective for the
mation. The resulting solution is a clear yellow to yellow-orange treatment of hyperkalemia. Calcium chloride is given in a dose of
color. The solution may be run under warm tap water or auto- 10 mg/kg. Insulin administration (10 units of regular insulin)
claved if there is difficulty in dissolving the dantrolene. If crystals must be accompanied by administration of glucose (50 mL of
are a concern, dantrolene can also be administered through a 50% dextrose) to prevent hypoglycemia. Sodium bicarbonate is
blood filter. Because a 70-kg patient would initially require 175 administered in a dose of 1 to 2 mEq/kg. It needs to be reiterated
mg, or 9 vials, of dantrolene, extensive help is required in its that these measures, although effective, simply shift potassium
preparation during the management of an MH crisis. A newer into cells. Hyperkalemia will recur if the underlying cause is not
formulation of dantrolene called Ryanodex is available, which is treated. Ultimately, dantrolene prevents ongoing hyperkalemia by
250 mg and can be mixed with only 5 mL of sterile water. This inhibiting excitation–contraction coupling, muscle contraction,
would allow for a much more rapid increase in plasma concentra- hypermetabolism, acidosis and cell death.
tions of dantrolene. Operating rooms and outpatient facilities Calcium channel blockers, especially of the nondihydropyri-
where general anesthesia is performed must have a supply of dine type (e.g., verapamil and diltiazem), may interact with
dantrolene available if triggering agents are used. dantrolene to produce hyperkalemia and profound myocardial
It must be emphasized that dantrolene, as opposed to symp- depression. The resulting decrease in organ perfusion can cause
tomatic control of vital signs, is the hallmark of treatment for worsening of acidosis and hyperkalemia. Thus, calcium channel
MH. Treatment of sympathetic signs and correcting physiologic blockers should not be used to treat patients with hypertension
parameters alone will not decrease the severity of the disease and or tachycardia in an MH crisis.
will likely lead to patient death. Dantrolene prevents the ongoing Signs of stability during treatment of an MH crisis include
homeostatic disruption caused by uncontrolled calcium release normal or decreasing Etco2, correction of hyperthermia, absence
from the sarcoplasmic reticulum. of dysrhythmias, and resolution of muscle rigidity.

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96 S E C TI O N Anesthesia

Serial measurements of laboratory values aids in assessing the More than a dozen mutations of RyR1 have been linked to
need for and the response to treatment of an MH crisis. MH susceptibility in humans.
After resolution of the acute episode, the patient must be Although rare cases follow an autosomal recessive pattern, MH
monitored for recurrence of signs and symptoms, preferably in an is mainly inherited in an autosomal dominant pattern. Therefore,
intensive care unit setting. If recrudescence does not occur, dan- 50% of children, parents, and siblings of an MH susceptible pa-
trolene may be discontinued. However, if MH manifestations tient will possess MH susceptibility.
persist or reappear, dantrolene may need to be readministered Malignant hyperthermia has been observed in pigs, rabbits,
approximately twice daily because the half-life of dantrolene is 10 and humans.
to 15 hours. The half-life of dantrolene is lower in children, neces- The porcine model of MH has been widely studied to learn
sitating readministration every 6 to 8 hours. about MH in humans. In swine, it can be elicited by a wide range
The Malignant Hyperthermia Association of the United States of triggers. Even seemingly minor stressors, such as heat, exercise,
(MHAUS) provides health care professionals with advice on the environmental stress, and the flight-or-fright response, may cause
management of MH crises. The MH hotline is accessible 24 hours an MH reaction. This phenomenon is known as awake triggering.
a day, 7 days a week, and the phone number is 800-644-9737. In humans, MH is mostly observed during general anesthesia
The MHAUS website (mhaus.org) also provides valuable resource and is initiated by specific triggering agents. However, evidence
material. does suggest that awake triggering may exist in humans, albeit at
a much lower incidence than in swine. Anxiety may precipitate an
Discussion MH-like response.
It may occur with exercise or exposure to noxious stimuli.
Malignant hyperthermia, also known as malignant hyperpyrexia, Awake triggering may manifest as heat stroke, unusual stress and
is a hypermetabolic disease of skeletal muscle. The basic physio- fatigue, myalgias, or sudden unexpected death.
logical derangement in MH is a massive and sustained release of When MH susceptibility exists, not every anesthetic with trig-
intracellular calcium ions, to concentrations that are 500 times gering agents will produce an MH reaction. This is evidenced by
the levels seen in the relaxed state. Sustained muscle contraction one patient who had multiple uneventful anesthetics before devel-
ensues, leading to supraphysiological increases in metabolism, oping an MH crisis. When an MH reaction occurs, it may present
with resultant hyperthermia, muscle rigidity, acidosis, and cell on induction of anesthesia, especially with inhalation induction
death. or when succinylcholine is used for intubation. It also may manifest
Skeletal muscle contraction involves a process known as excita- intraoperatively and rarely even postoperatively. Thus, clinicians
tion–contraction coupling. This process was first described by should always include the possibility of MH in the differential
Sandow in 1950 and involves a precise series of steps beginning diagnosis when classic signs or symptoms appear. Prompt recogni-
with the generation of an action potential in skeletal muscle fibres tion and treatment are potentially lifesaving.
and ending in increased muscle tension. A neuronal signal that The incidence of MH is reported to be 1 in 250,000 anesthet-
reaches the neuromuscular junction causes the release of the neu- ics. However, if one only looks at cases in which triggering agents
rotransmitter acetylcholine into the synaptic cleft. The acetylcho- are used, this incidence increases to 1 in 62,000 anesthetics. The
line activates nicotinic receptors on the motor end plate. The suspicion of MH in this study arose in 1 in 16,000 anesthetics
opening of sodium channels in the end plate creates an end plate and in 1 in 4200 anesthetics in which triggering agents were ad-
potential, which allows the signal to propagate throughout the ministered. Therefore, we can extrapolate that if the suspicion of
muscle membrane. Complex invaginations of the muscle cell MH arises, there is a 1 in 15, or 7%, chance that fulminant MH
membrane known as T-tubules allow the action potential to will ensue.
spread diffusely throughout the muscle cell. The changes in The first reports of MH-like reactions were between 1915 and
membrane potential are detected by dihydropyridine receptors 1925, when one family experienced a cluster of three anesthetic
(DHPRs), which are L-type (L stands for long-lasting) calcium deaths. These deaths were preceded by muscle rigidity and hyper-
channels. These DHPRs interact with ryanodine receptors (RyRs), thermia. MH susceptibility was eventually identified several de-
which are calcium-release channels located in the sarcoplasmic cades later in three descendants in this family. Ombredanne, in
reticulum (the endoplasmic reticulum of skeletal muscle). Nor- 1929, noted postoperative hyperthermia and pallor in children
mally, the DHPR keeps the RyR in a closed state. Depolarization who were given anesthesia. However, he did not recognize familial
of the muscle cell membrane induces a conformational change in patterns. In 1960, Denborough and Lovell presented the case of
the DHPR, thereby mediating the opening of the RyR. The re- a 21-year-old Australian male with an open femur fracture who
sulting influx of calcium leads to a rise in calcium concentrations was terrified of receiving anesthesia because 10 of his relatives had
in the myoplasm. This initiates a chain of events that lead to acti- died in the perioperative period. Lovell, being the anesthetist,
vation of the actin–myosin complex, the so-called contractile ap- commenced the anesthetic with the newfound inhalational agent
paratus, causing muscle contraction. Relaxation of the muscle halothane but aborted and administered a spinal anesthetic when
occurs when specialized pumps transport calcium back into the signs of MH appeared.
sarcoplasmic reticulum, and intracellular calcium concentrations
fall below threshold values. Other Disorders
In other words, the release of calcium in excitation–contrac-
tion coupling is through calcium release channels and is mediated The muscular dystrophies are a group of muscle diseases that vary
by the RyR. This receptor has three subtypes, and mutations of in their presentation, disease progression, and inheritance. The
subtype 1 (RyR1) confer susceptibility to MH by causing overac- most common, Duchenne muscular dystrophy (DMD), is char-
tivation of the calcium release channel. This prevents calcium acterized by a deficiency in the muscle protein dystrophin. It is
concentrations from falling sufficiently, leading to sustained inherited in an X-linked recessive manner, primarily affecting
muscle contraction. males with an incidence of 1 in 3500 births. Muscle weakness

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 CHAPTER 21 Malignant Hyperthermia 97

presents early in childhood, with a median age of diagnosis of medications, which inhibit dopaminergic transmission to varying
5 years. Patients with DMD usually die in their 20s because of extents. The latter scenario may occur if Parkinson’s disease medica-
respiratory failure and cardiac muscle dysfunction. tions are suddenly stopped. The typical presentation is one of mental
Patients with muscular dystrophies are prone to perioperative status changes, rigidity, fever, and autonomic instability developing
complications, including hyperthermia, tachycardia, rhabdomy- in that order, over 1 to 3 days. With the antipsychotic medications,
olysis, and hyperkalemic cardiac arrest, on exposure to volatile it classically presents after about 2 weeks of use, although it may oc-
anaesthetics or succinylcholine. Although the clinical presentation cur after a single dose or after years of chronic therapy. Mental status
may be indistinguishable from MH, the underlying pathophysiol- changes include stupor and coma. Extreme muscle rigidity and in-
ogy is seemingly different. One study analyzed the ryanodine re- tense muscle contractions are the effect of a deficit in dopamine in
ceptor gene in 47 patients with DMD. None of these patients had the extrapyramidal system of the brain. This results in a hypermeta-
alterations of known gene segments that have conferred MH bolic state resembling MH. Increased muscle metabolism leads to
susceptibility. The mechanism of succinylcholine-induced cardiac hyperpyrexia. Last, autonomic instability may manifest, with tachy-
arrest was outlined earlier (see the discussion of MMR). The sus- cardia, diaphoresis, tachypnea, and elevated or labile blood pressure.
ceptibility of patients with DMD to volatile anaesthetics is more Respiratory muscle rigidity leads to decreased chest wall compliance
puzzling and may involve disruption of cell membrane integrity and predisposes to hypoventilation and aspiration pneumonia.
caused at least in part by the absence of dystrophin. Muscle breakdown eventually ensues, resulting in rhabdomyolysis,
Central core disease (CCD) is a congenital myopathy with an myoglobinuria, acute tubular necrosis, and acute renal failure.
autosomal dominant pattern of inheritance. As with MH suscep- Neuroleptic malignant syndrome may mimic MH, but the
tibility, the defect is in the ryanodine receptor gene RyR1. There diagnoses differ in several ways. The patient with NMS may have
is a high association between CCD and MH. In fact, Denbor- recently started or had an increase in dosage of a neuroleptic
ough’s original patient was later found to have CCD. It is charac- medication. In NMS, autonomic instability is a late sign, but this
terized by central cores, which are areas of decreased oxidative feature typically presents earlier in MH.
activity stemming from mitochondrial depletion. Histologically, Treatment of NMS begins with discontinuation of the offend-
central cores may not be identified early in the disease even with ing drug and treatment with dopamine receptor agonists such as
symptoms. Thus, their absence does not exclude the diagnosis. bromocriptine or amantadine. Many of the treatment modalities
Clinically, hypotonia and nonprogressive proximal muscle weak- used in MH, such as rehydration, cooling, and hyperventilation,
ness are evident, especially in the hip and trunk muscles. Ortho- are effective in the management of NMS. Dantrolene, although
pedic complications include hip dislocation, scoliosis, and foot not the mainstay of treatment, is useful because it decreases body
deformities. Most patients with CCD are able to walk indepen- temperature by reducing muscle contraction. Because dantrolene
dently. Respiratory and cardiac involvement are rare. Extreme also relaxes skeletal muscle while preserving the ability to breathe
caution should be taken in anesthetizing patients with CCD be- deeply and cough, it may improve chest wall compliance and help
cause of the high likelihood of MH susceptibility. avoid the need for intubation. In contrast with the more rapid
King-Denborough syndrome (KDS) is a rare disease with an response to treatment in MH, improvement of NMS requires
unclarified mode of genetic transmission characterized by myopa- several days.
thy, dysmorphic features, short stature, musculoskeletal abnor- In summary, MH is a hypermetabolic disorder of skeletal
malities, delay in motor development, and MH susceptibility. muscle that mainly manifests under anesthesia with specific trig-
Dysmorphic features include downslanting palpebral fissures, gers. The anesthesiologist should always have a high index of
malar hypoplasia, a high-arched palate, dental malocclusion, mi- suspicion as to its possibility because prompt recognition and
crognathia, low-set ears, and a webbed neck. Musculoskeletal treatment are usually lifesaving. A thorough personal and family
changes include kyphosis, lumbar lordosis, and pectus excavatum. history of anesthesia-related problems can lead the clinician to
The RyR1 locus appears to play a key role in KDS, thereby ex- suspect an increased likelihood. Although much is already known
plaining the link between KDS and MH susceptibility. about MH, further research will make the diagnosis and treat-
Neuroleptic malignant syndrome (NMS) is a life-threatening ment of patients with this disorder easier in the future.
condition that may occur with the use of dopamine antagonists or
with the abrupt discontinuation of dopamine receptor agonists. The ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
former situation may be encountered with all classes of neuroleptic complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 97.e1

Bibliography Krodel DJ, Bittner EA, Abdulnour R, et al: Case scenario: acute postop-
erative negative pressure pulmonary edema, Anesthesiology 113:200-
207, 2010.
Adnet P, Lestavel P, Krivosic-Horber R: Neuroleptic malignant syn- Larach MG, Lacalio AR, Allen GC, et al: A clinical grading scale to pre-
drome, Br J Anaesth 85(1):129-135, 2000. dict malignant hyperthermia susceptibility, Anesthesiology 80:771-
Allen GC, Larach MH, Kunselman AR: The sensitivity and specificity of 779, 1994.
the caffeine halothane contracture test: a report from the North Lister D, Hall GM, Lucke JN: Porcine malignant hyperthermia. III: ad-
American malignant hyperthermia registry, Anesthesiology 88:579, 1998. renergic blockade, Br J Anaesth 48:831, 1976.
Barasch. *** Maxwell BG, Mihm FG: Questioning diuretic use in negative-pressure
Bendixen D, Skovgaard LT, Ording H: Analysis of anaesthesia in patients pulmonary edema, Anesthesiology 114:461, 2011.
susceptible to malignant hyperthermia before diagnostic in vitro con- Miller RD, Cucchiara R, Miller ED, et al: Anesthesia, ed 5, vol 1, 1033-
tracture test, Acta Anaesth Scand 41:480, 1997. 1052, 2000.
Calderon JC, Bolanos P, Caputo C: The excitation-contraction coupling Monnier N, Procaccio V, Stieglitz P, et al: Malignant hyperthermia sus-
mechanism in skeletal muscle, Biophys Rev 6(1):133-160, 2014. ceptibility is associated with a mutation of the alpha-1 subunit of the
Coronado B, Morrissette J, Sukhareva M, et al: Structure and function of human dihydropyridine-sensitive L-type voltage-dependent calcium-
ryanodine receptors, Am J Physiol 266:C1485, 1994. channel receptor in skeletal muscle, Am J Hum Genet 60:1316, 1997.
Denborough MA, Lovell RRH: Anaesthetic deaths in a family, Lancet Ogletree JW, Antognini JF, Gronert GA: Postexercise muscle cramping
2:45, 1960. associated with positive malignant hyperthermia contracture testing,
Dowling JJ, Lillis S, Amburgey K, et al: King-Denborough syndrome Am J Sports Med 24:49, 1996.
with and without mutations in the skeletal muscle ryanodine receptor Ording H: Investigation of malignant hyperthermia susceptibility in
(RYR1) gene, Neuromusc Disord 21(6):420-427, 2011. Denmark, Dan Med Bull 43:111, 1996.
Fletcher R, Ranklev E, Olsson AK, et al: Malignant hyperthermia syn- Pollock N, Hodges M, Sendall J: Prolonged malignant hyperthermia in
drome in an anxious patient, Br J Anaesth 53:993, 1981. the absence of triggering agents, Anaesth Intensive Care 20:520, 1992.
Gavel G, Walker RWM: Laryngospasm in anaesthesia, Contin Educ Quinlivan RM, Muller CR, Davis M, et al: Central core disease: clinical,
Anaesth Crit Care Pain 14(2):47-51, 2014. pathological and genetic features, Arch Dis Child 88:1051-1055, 2003.
Gronert GA: Malignant hyperthermia, Anesthesiology 53:395, 1980. Roewer N, Dziadzka A, Greim CA, et al: Cardiovascular and metabolic
Haggendal J, Jonsson L, Carlsten J: The role of sympathetic activity in responses to anesthetic-induced malignant hyperthermia in swine,
initiating malignant hyperthermia, Acta Anaesthesiol Scand 34(8): Anesthesiology 83:141, 1995.
677-682, 1990. Rohde D, Schmitt H, Hubert J, et al: Duchenne muscular dystrophy and
Hall GM, Lucke JN, Lister D: Porcine malignant hyperthermia and malignant hyperthermia, Eur J Anaesthesiol 31(6):341-342, 2014.
neuromuscular blockade, Br J Anaesth 48;1135, 1976. Rubin AS, Zablocki AD: Hyperkalemia, verapamil, and dantrolene,
Harrison GG, Isaacs H: Malignant hyperthermia: an historical vignette, Anesthesiology 66:246, 1987.
Anaesthesia 47:54, 1992. Ryan JF, Tedeschi LG: Sudden unexplained death in a patient with a
Jungbluth H: Central core disease, Orphanet J Rare Dis 2:25, 2007. family history of malignant hyperthermia, J Clin Anaesth 9:66, 1997.
Kalow W, Britt BA, Terreau ME, et al: Metabolic error of muscle metabo- Saltzman LS, Kates RA, Corke BC, et al: Hyperkalemia and cardiovascu-
lism after recovery from malignant hyperthermia, Lancet 2(7679): lar collapse after verapamil and dantrolene administration in swine,
895–898, 1970. Anesth Analg 63:272, 1984.
Karan SM, Crowl F, Muldoon SM: Malignant hyperthermia masked by Tong J, Oyamada H, Demaurex N, et al: Caffeine and halothane sensitiv-
capnographic monitoring, Anesth Analg 78:590, 1994. ity of intracellular Ca21 release is altered by 15 calcium release channel
Kim TW, Nemergut ME: Preparation of modern anesthesia workstations (ryanodine receptor) mutations associated with malignant hyperther-
for malignant hyperthermia-susceptible patients: a review of past and mia and/or central core disease, J Biol Chem 272:26332, 1997.
present practice, Anesthesiology 114(1):205-212, 2011. van der Spek AFL, Reynolds PI, Fang WB, et al: Changes in resistance to
Kolb ME, Horne ML, Martz R: Dantrolene in human malignant hyper- mouth opening induced by depolarizing and non-depolarizing neuro-
thermia: a multicenter study, Anesthesiology 56:254, 1982. muscular relaxants, Br J Anaesth 64:21, 1990.

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22
Emergent Surgical Airway Management
M AG G I E M. M O U ZO U R A K I S a n d ER I C P. H O L MG R E N

CC the patient’s airway has been historically. If the patient has had a
prior spinal fusion, this may limit neck mobility. Previous history
This is a 57-year-old male with a history pertinent for a known of neck surgery is associated with altered anatomy and scar tissue,
broken tooth #19 who has been treated multiple times over the resulting in a more challenging surgical airway. Traumatic intuba-
past 6 months with amoxicillin for periapical dental abscesses and tions are associated with subglottic stenosis.
pain. Over the past 48 hours, he has had increasing left-sided Medical comorbidities affect the course of management. Dia-
gingival and floor of mouth swelling extending to the bilateral betes is a reversible cause of immunosuppression; better glucose
sublingual space and submandibular space suggestive of Ludwig’s control is associated with an improved overall prognosis. Always
angina (see Ludwig’s angina in Chapter 23). As of the past few screen for coagulopathies, malignant hyperthermia, and family
hours, he can no longer swallow. He has been carrying a stack of history of anesthesia intolerances in all patients being assessed for
tissues to collect his drool. He has to sit upright to be comfortable airway concerns.
breathing. It is painful to close his mouth completely or to open
it farther. He is a choir tenor singer, but his voice now is very faint Examination
and sounds gravelly characteristic of dysphonia.
A concise and focused history is critical to timely recognition General. Well-developed, thin male in severe respiratory distress
of a patient with an impending airway and appropriate manage- sitting upright. The patient has biphasic soft audible stridor. In-
ment. Key facts include duration of relevant airway symptoms tercostal retractions are noted. No supraclavicular retractions or
(the 3Ds [dysphagia, odynophagia, dysphonia], trismus, and nasal flaring.
shortness of breath or stridor). Patients with rapidly progressive Vital signs. Heart rate is 120 bpm, blood pressure is
symptoms raise more clinical concern, as do those whose condi- 168/94 mm Hg, respiratory rate is 27 beats per minute, tempera-
tion worsens with maximal medical treatment (antibiotics and ture is 38.1°C, and oxygen saturation is 96% on room air.
steroids). The timing of steroids medications may affect the pre- Maxillofacial. Bilateral submandibular, sublingual, and sub-
sentation. Intravenous (IV) dexamethasone (Decadron) takes 1 mental cellulitis, tender to palpation, woody, warm, and ery-
hour to have full effect and has a half-life of 4 hours, with possibil- thematous (which are suggestive signs of Ludwig’s angina). There
ity of refractory symptoms as the medication wears off. is notable level II submandibular swelling; however, the thyroid
Developing the differential diagnosis that guides treatment notch, cricoid, and trachea rings are palpable. The trachea is mid-
starts with the history. The most important questions to ask in- line, and the cervical spine has full range of motion.
clude those about their progression of symptoms and whether the Intraoral. Oral examination is limited; there are two finger
patient is able to lie flat and tolerate secretions. Other relevant widths of trismus. The floor of the mouth is elevated, tender, and
questions include when their last meal was and an assessment of edematous. The tongue is large and protruding, and the uvula and
allergies and previous reactions to anesthesia. During the initial soft palate are not visible (Mallampati class IV). Teeth #18, 19,
evaluation, every patient should be counseled on their desires for and 30 are grossly carious.
the next steps and goals of care. Patients should be counseled if Fiberoptic nasopharyngoscopy. Fig. 22.1 shows that there is
necessary on the possibility of needing intubation or a surgical diffuse edema along the base of the tongue, the esophageal inlet
airway for airway compromise. and arytenoid towers are visible, and the epiglottis and vocal cords
cannot be visualized.
PMHx/Medications/Allergies/SH/FH Assessment of sublingual swelling, trismus, and Mallampati
score help in assessing challenges in accessing the airway. Based on
The patient has a history of type 2 diabetes mellitus (well con- this patient’s examination findings, his trismus and limited Mal-
trolled) and hypertension. No other relevant history is reported. lampati score mean that it would be exceedingly challenging to
He had a cholecystectomy 5 years ago without complication. No align his oropharynx, pharynx, and glottic airway in one plane for
previous surgeries of the neck or intubation related trauma was direct visualization intubation. Classic signs of increased work of
reported. He has no allergies or intolerances to anesthesia. breathing include tachypnea, intercostal retractions, supraclavicu-
A targeted assessment of the past medical history is necessary lar retractions, and nasal flaring. Late symptoms include hypox-
to prepare for further management steps of the airway. Intubation emia, altered mental status, and lactic acidosis when compensation
history and prior surgeries are helpful to know how challenging mechanisms start to fail. Drooling, biphasic stridor, and tripod

98
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 CHAPTER 22 Emergent Surgical Airway Management 99

Left arytenoid

Esophageal inlet

Swelling along BOT

• Fig. 22.2 Epiglottitis, with swelling right worse than left, resulting in chal-
lenges visualizing the glottis airway.

In the setting of impending airway decline, any attempt to

• Fig. 22.1 Nasopharyngeal fiberoptic evaluation. The examination is con- obtain imaging studies should be delayed until a secure airway has
cerning for imminent airway compromise because of the following findings: been established. To take a CT scan, the patient has to be able to
intolerance to secretions in tripod position, increased work of breathing,
tolerate lying flat for up to 5 minutes while managing secretions.
biphasic stridor, and rapidly progressive symptoms. Base of tongue (BOT)
swelling is also noted.
Loss of an airway in the radiology suite, where personnel and
backup airway equipment may not be available, can be devastat-
ing. For this reason, upon evaluation of the patient, the surgeon
must quickly decide either to proceed to the OR, where optimal
positioning are signs of an impending airway obstruction. Stridor personnel and equipment for advanced airway intervention are
can be characterized as inspiratory, biphasic, and expiratory. In- available or, in a sudden emergency, proceed with immediate
spiratory stridor is usually more indicative of an upper airway placement of a surgical airway in the emergency department
supraglottic pathology than expiratory stridor, which can be (ED). In the most emergent scenarios, even transport to the OR
more suggestive of intrathoracic tracheal pathology. Biphasic can have perils, if there is the risk of loss of airway midway. Im-
stridor is usually suggestive of a fixed airway obstruction, such as mediate intervention should be considered when the circum-
in this instance in which diffuse tissue edema along the sublin- stances limit other options.
gual space and base of the tongue is impinging on the glottic If the patient is deemed stable, with no immediate threat to
airway. Further airway evaluation can be performed with fiberop- airway obstruction, a panoramic radiograph (to evaluate possible
tic nasopharyngoscopy (visualizing the hypopharynx, base of the odontogenic sources of infection) and a CT scan with contrast (to
tongue, pharyngeal walls, epiglottis, and vocal cords) to deter- localize loculated areas of abscess formation and to assist in airway
mine airway patency and the extent of airway edema. The scope evaluation) can be obtained. Magnetic resonance imaging (MRI)
examination shown in Fig. 22.1 is worrisome because the glottis is usually not the modality of choice because of concern for the
larynx cannot be visualized. However, if a patient is breathing, patient remaining in the radiology suite for extended periods of
one must remember that there has to be a tenuous area of air time without monitoring. The activated magnet in the MRI suite
passage. In patients with severe airway distress, the fiberoptic also prevents immediate access to the patient for an emergency
nasopharyngoscopy should be considered to be performed in the and access to airway equipment. For patients with contrast allergy,
operating room (OR) because any manipulation of the airway pretreatment regimens often require multiple hours of steroid
may result in sudden compromise. This is especially the case if treatments. Although there is an IV acceleration desensitization
there is suspected epiglottitis (Fig. 22.2). Landmarks for a surgi- dose, the consequence of improperly treating a patient with a se-
cal airway (thyroid notch, cricoid ring, and tracheal rings) should vere iodine contrast allergy may include angioedema, which could
be palpated and examined in any patient with airway concerns to further complicate an already precarious airway. Securing or pro-
assess challenges one may encounter should a surgical airway be tecting the airway should always remain the priority.
necessary (Fig. 22.3). A lateral neck radiograph is a study that can be obtained at the
Imaging. No computed tomography (CT) scan was able to be bedside. It can provide important information regarding the glot-
obtained. The patient was unable to tolerate lying flat on a tic airway (the width of the epiglottis should be ,5 mm in an
stretcher. adult) and posterior airway space (prevertebral soft tissue should

t.me/Dr_Mouayyad_AlbtousH
100 S E C TI O N Anesthesia

Hyoid bone

Thyroid membrane

Superior thyroid artery (cut) Common carotid artery

Superior thyroid vein (cut)

Thyroid cartilage
Internal jugular vein
Cricothyroid membrane
Thyroid gland (cut)
Cricoid cartilage

1st and 2nd tracheal rings Middle thyroid vein (cut)

Right recurrent laryngeal nerve

Subclavian artery Inferior thyroid vein (cut)

Brachiocephalic vein Sternal notch

Aortic arch

• Fig. 22.3 The surgical landmarks related to the airway; these are the thyroid notch, cricothyroid mem-
brane, cricoid cartilage, and suprasternal notch.

authors recommend measuring the narrowing of the airway

shadow, thickening of the epiglottis, and comparing this with
known values to evaluate any obtained neck radiographs.

Labs
The white blood cell count (WBC) is 18,000/mm3 (left shift with
increased neutrophils). Basic metabolic panel (BMP) results are
within normal limits. Lactate is normal.
The patient has an elevated WBC reflecting ongoing infection.
Lactate is normal; no changes on BMP are suggestive of sepsis or re-
spiratory acidosis at this time.
Laboratory studies should not delay the establishment of a se-
cure airway. In cases of severe airway compromise such as epiglot-
titis, triggering procedures such as blood draws should always wait
until the airway is secured. When possible, a complete blood
count with differential and a BMP are indicated for evaluation of
• Fig. 22.4 Failed cricothyroidotomy planned superior to the thyroid notch the systemic response and metabolic derangements associated
resulting in submental intubation. Conversion to tracheostomy in the op-
with severe odontogenic fascial space infections. Arterial blood gas
erating room was necessary. analysis can be used to determine the adequacy of ventilation and
assess for sepsis with whole-blood lactate. Venous blood gas is an
alternative to arterial blood gas and may also provide useful infor-
be ,7 mm at the level of C3 and 20 mm at the level of C7). mation such as carbon dioxide retention, acid–base levels, and
However, with the recent advent of fiberoptic nasopharyngoscopy whole-blood lactate. The laboratory risk indicator for necrotizing
and the use of CT, lateral cephalographs are rarely used today. fasciitis score is used to assess the severity of disease. Laboratory
Lateral cephalometric radiographs must also be properly obtained values included are C-reactive protein, WBC count, hemoglobin,
to be useful. Often, distortions of the airway shadow can occur sodium, creatinine, and glucose. High values are independently
because of twisting or poor positioning. As with any testing, associated with worsening prognosis. Blood cultures are also use-
before ordering, there should be adequate clinical suspicion for ful in febrile or septic patients and should ideally be obtained
upper airway compromise warranting radiography evaluation; before starting antibiotics. Other laboratory values are ordered
objective measures should also be used to evaluate the scans. The based on pertinent medical information.

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 CHAPTER 22 Emergent Surgical Airway Management 101

Assessment severe maxillofacial trauma, infection, tumors, congenital or de-

velopmental deformities, laryngospasm, foreign body obstruc-
A 57-year-old male with Ludwig’s angina, now complicated by an tion, and edema. Determination of the exact cause of airway
impending loss of airway. compromise is based on physical and radiographic finding, in
addition to the chronologic progression. A true loss of the airway
Treatment is defined as the inability to ventilate (with a bag-valve-mask air-
way, a laryngeal mask airway, or a Combitube) and the inability
In the current patient, an awake fiberoptic nasal intubation was to intubate. Although airway loss is usually progressive, it may
performed in the OR with a bronchoscope. The patient was anes- have a sudden onset and occur before the patient’s arrival in the
thetized with 4% topical lidocaine through the nares and oral OR, during attempted intubation, after extubation, or during IV
cavity before the intubation. The patient received ketamine with sedation. Treatment should be specific to the cause and degree of
dexmedetomidine from anesthesia for conscious sedation without airway compromise.
reducing respiratory drive. An endotracheal tube was successfully Upon suspicion or diagnosis of impending airway compro-
passed through the glottic larynx under direct visualization. An mise, the anesthesia team and OR or ED staff must be notified
airway table was set up in the room with oral and nasal airways, immediately. The surgeon and anesthesiologist (if available) must
backup endotracheal tubes, laryngeal airways (slits cut and re- decide on the safest means of rapidly obtaining a secure airway.
moved so a bronchoscope could pass through if needed), bougie, Risk factors that predispose patients to difficult mask ventilation
GlideScope, extra 4% topical lidocaine, a Combitube (purposed and intubation should be identified in anticipation of using ad-
for esophageal intubation), ventilating rigid bronchoscope, and vanced airway intervention techniques. Such risk factors include
14-gauge angiocatheter, as well as a surgical airway crash cart. The high metabolic needs (pregnancy), obesity, a short neck, a rigid
jet ventilation system was checked and also ready for use. neck, microstomia, low hyoid, retrognathia, Mallampati class III
On prior discussion before arriving in the OR, the plan had or IV, and prominent upper incisors. An awareness of these fac-
been for conscious sedation and fiberoptic intubation under local tors by the surgeon contributes greatly to successful management
anesthetic. If this fails, the patient would remain spontaneously of a compromised airway.
breathing, and support could be provided with mask ventilation Patients deemed difficult to intubate are potential candidates
and oxygen. If the airway became further compromised and the for awake fiberoptic nasal intubation or an elective awake trache-
patient stopped spontaneously breathing, the first step would be otomy in a controlled OR setting. However, it is possible for a
for mask ventilation with an oral or nasal airway, next would be “routine” intubation procedure to develop into a difficult airway
for an attempt at laryngeal mask airway or Combitube placement. scenario. During the course of a difficult laryngoscopy, the anes-
If this failed, an attempt would be made to intubate once with a thetist or anesthesiologist may not be able to intubate or ade-
GlideScope with a plan in case of failure to convert to a needle quately ventilate the patient, requiring an emergent surgical airway
cricothyroidotomy with jet ventilation and conversion to trache- (fortunately, this is uncommon). With each attempt to intubate,
ostomy afterward. The patient was thin with palpable neck land- there may be worsening supraglottic edema that will make subse-
marks and excellent neck mobility, likely making the surgical quent procedures more challenging.
airway management feasible. For emergent intervention for a comprised airway in the adult
At most, three attempts for awake fiberoptic intubation would patient, a cricothyroidotomy is the procedure of choice. Tracheos-
be allowed. If all three attempts failed and the patient remained tomy is used for emergency surgical airways in pediatric patients
spontaneously breathing, the plan would be to convert to an awake younger than 10 to 12 years of age. The small size of the cricothy-
tracheostomy. Both the anesthesia and surgical teams had experi- roid membrane (3 mm) and the poorly defined anatomic land-
ence performing awake fiberoptic intubations and cricothyroidot- marks make performing a cricothyroidotomy extremely difficult
omy. Extra supplies were available in the room to improvise in case in children. There is also an increased risk of laryngeal injury with
the opportunity arose. The OR staff and anesthesia and surgical cricothyroidotomy in this age group.
teams had worked together in the past in emergent scenarios. Needle cricothyroidotomy with jet insufflation can also be
The patient had a successful intubation on first attempt with fiber- performed by skilled anesthesia personnel (providing temporary
optic evaluation. Backup measures were set up to escalate airway oxygenation but not ventilation). The patient can be oxygenated
management in case of failure. while the surgeon establishes a definitive surgical airway (trache-
Noninvasive initial interventions can include starting medical otomy or cricothyroidotomy). The needle jet ventilation may also
treatment, humidified oxygen, heliox, placing a nasopharyngeal increase tracheal pressures, resulting in temporary stenting of the
airway in an awake patient, and starting bilevel positive-pressure airway that can enable subsequent successful intubation. In a pa-
air therapy. Heliox works by decreasing airway resistance and is tient who has a large neck and poorly palpated landmarks, it is
indicated in critical care settings for upper airway obstruction. worthwhile to check after initiating jet ventilation whether the
The nasopharyngeal airway is useful in awake patients, bypassing patient can be intubated from above again. If a surgical cricothy-
a potentially elevated and swollen tongue with sublingual celluli- roidotomy is performed, conversion into a formal tracheotomy
tis. These are measures that are possible in awake patients to help should be considered, primarily depending on the anticipated
provide support. duration of the surgical airway (patients requiring prolonged ven-
Treatments should be specific to the cause and problem. It is tilatory support should be converted to a tracheotomy.)
important to differentiate loss of the airway from loss of protec-
tive airway reflexes, in which the patient has an upper airway
obstruction that can be alleviated with chin lift–jaw thrust ma-
Needle Cricothyroidotomy With Jet Insufflation
neuvers, placement of an oral or a nasal airway, or positive-pres- Ideally, the patient should be supine or semisupine with a shoul-
sure mask ventilation. The possible causes of airway compromise der bolster to hyperextend the neck. The cricothyroid membrane
(loss of airway) secondary to upper airway obstruction include (the slight depression between the thyroid cartilage and cricoid

t.me/Dr_Mouayyad_AlbtousH
102 S E C TI O N Anesthesia

cartilage) is palpated, and the larynx is stabilized using the thumb Complications associated with surgical cricothyroidotomy in-
and forefinger. In a thin neck with prominent landmarks, an inci- clude all the acute events discussed previously with the needle
sion is not usually needed, and direct puncture through the skin cricothyroidotomy procedure in addition to chronic complica-
and cricothyroid membrane can be accomplished. Otherwise, it tions associated with the surgical intervention. Creation of a false
may be necessary to make a small incision through the skin over passage into the surrounding connective tissue and damage to the
the identified region of the cricothyroid membrane. A 3-cc sy- larynx and vocal cords can result from improper or forced intro-
ringe is then attached to a 14-gauge angiocatheter, and the cath- duction of the endotracheal tube. Subsequent laryngeal stenosis
eter and needle are inserted through the cricothyroid membrane or vocal cord paralysis may occur, resulting in permanent damage.
at a 45-degree angle caudally. Negative pressure is applied by
withdrawing the plunger of the syringe while the needle is ad- Retrograde Intubation
vanced (aspiration of air indicates entry into the tracheal lumen).
The 14-gauge needle is removed from the angiocatheter, leaving The practice of retrograde intubation has fallen out of popularity
the angiocatheter in the trachea. When in place, the catheter can since fiberoptic technology has become more prevalent. The pro-
be insufflated with oxygen to provide aeration of the lungs. The cedure involves a cricothyroidotomy approach with passage of a
intent is to provide oxygen to the lungs and to allow passive exha- guidewire to the oral cavity or nasopharynx. The wire is then used
lation. Pressures can be as high as 50 psi, balanced with the risk to guide either an endotracheal tube or ventilating catheter in
of barotrauma. Various “kits” are commercially available that ac- place. Risks can include soft tissue injury, blind approach to the
complish this; however, the effect can be obtained by cutting a airway, and accidental esophageal intubation. Limitations include
small hole in the oxygen tubing near the attachment to the 3-cc that this technique cannot be performed in an awake patient.
syringe (can also be attached to a 7.5 endotracheal tube connector). Regardless, this can be considered another tool to be used under
The hole is occluded for 1 second and left open for 4 seconds, limited circumstances for management of a difficult airway. Pro-
forcing oxygen into the trachea and allowing for some passive exha- viders with experience with retrograde intubation discuss expedi-
lation (if any). Adequate oxygenation can be maintained for 30 to ency as one of the advantages.
45 minutes, but hypercarbia results from inadequate ventilation.
Therefore, preparations should be made to convert the airway to a Discussion
tracheotomy to secure a patent, reliable airway.
Airway distress is a life-threatening emergency that an oral maxil-
Surgical Cricothyroidotomy lofacial surgeon may encounter. Key elements to patient survival
include early detection and management, team communication,
The nondominant hand is used to stabilize the laryngeal cartilage, and preparation. Early management may include steroid medica-
and a vertical skin incision is made using a #15 or #11 scalpel tions, supportive measures, and antibiotics with the goal of reduc-
blade over the cricothyroid membrane. (This provides the option ing edema and preventing further airway compromise. Preventing
of superior-inferior extension of the incision, if needed.) The inci- airway compromise should be thought of as the first goal, whereas
sion is carried through the skin and superficial fat layer, immedi- establishing a definitive airway is salvage therapy in failing medi-
ately over the cricothyroid membrane, which is also vertically in- cal management. During medical management, an assessment of
cised with the blade. The scalpel handle is inserted into the the resources of the institution should occur. This means seeing if
incision site and rotated 90 degrees to provide access into the there is anesthesia, general surgery, or otolaryngology backup
tracheal lumen. The lumen is further dilated with finger dissec- available in case anything occurs. Having a second set of hands
tion or with the use of a Trousseau dilator. A small, cuffed endo- may prove to be invaluable in caring for a patient with a difficult
tracheal tube or a tracheotomy tube is inserted, and the patient is airway. Communication regarding airway concerns should occur
ventilated. A positive return of carbon dioxide is the best means early in the process so all teams involved are aware of the patient.
of confirming correct tube placement. The tube is secured, and If the best resources available to care for the patient are not pres-
the chest is auscultated for bilateral breath sounds. ent at the institution, the decision to transfer the patient should
be discussed. Preparing a patient with an impending airway for
Complications transport is a challenging process. The patient needs to be thor-
oughly assessed to see if a definitive airway should be established
The most feared complication of a needle cricothyroidotomy pro- early for the purposes of safe transport. This decision is made al-
cedure is inadequate oxygenation and ventilation, leading to an- most always by the provider with the patient. Airway compromise
oxic brain injury and cardiovascular collapse. Proper placement of during transport on a helicopter or ambulance can be devastating,
the insufflating needle is paramount for a successful outcome. so this needs to be considered thoroughly. Patients can deteriorate
Placement and manipulation of the 14-gauge needle under emer- quickly and circumstances can change. If you are preparing to
gency circumstances is also a grave concern. After the needle is receive a patient in transport from another hospital with impend-
removed, the 14-gauge catheter may bend, kink, or be otherwise ing airway, a tiered airway plan and discussion of securing the
displaced, immediately compromising the airway again. Lacera- airway before transport should occur as well. Team communica-
tion of adjacent structures, including the thyroid, posterior tra- tion and approaches are important in managing patients with
cheal wall, and the esophagus, can occur, leading to severe hemor- challenging airways. In the ideal situation, the team caring for the
rhage, which can further compromise the airway. Improper patient will have had experience working together in caring for
placement of the needle can also result in subcutaneous or medi- similar patients. Awareness of where equipment is located, per-
astinal emphysema or even tension pneumothorax, further com- sonnel in the room, and the skill levels of people present is impor-
promising pulmonary function leading to devastating outcomes. tant. If a time-out needs to occur for planning a surgical airway
Barotrauma from jet ventilation may also lead to subcutaneous or intubation, this should always happen before the patient re-
emphysema and pneumothorax. ceives any anesthetics that may worsen airway compromise. This

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 22 Emergent Surgical Airway Management 103

often means performing a time-out while the patient is fully checked on a regular basis. All critical personnel should be aware
awake. An order of events for establishing the airway should oc- of where an airway crash cart, fiberoptic airway equipment, and
cur. Studies have shown that repeating the same procedure to es- surgical airway kit may be found. If able, regular education ses-
tablish a definitive airway despite prior failure is associated with sions should occur for the OR or procedural room staff to review
morbidity. Staff should be aware of the next steps if plans A or B the equipment available and answer any questions. After each
fail. In prior studies analyzing airway incidents, the majority of emergent airway case, after the patient has been stabilized and
patients who died from airway compromise were not thought of taken care of, the team should have a conversation to debrief. This
as having a difficult airway. Underestimating an airway is highly provides the opportunity to review concerns and near misses and
associated with poor patient outcomes, such as hypoxia, cerebro- to improve care for the future.
vascular events, and asphyxiation. Surveying at each institution all
equipment available for addressing a compromised airway should ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
happen routinely. Used equipment needs to be restocked and complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 103.e1

Bibliography Lewis RJ: Tracheostomies: indications, timing and complications, Clin

Chest Med 13(1):137-149, 1992.
Matrka L, Soldatova L, deSilva BW, et al: Airway Surgery Communica-
Altman KW, Waltonen JD, Kern RC: Urgent airway intervention: a tion Protocol: a quality initiative for safe performance of jet ventila-
3-year county hospital experience, Laryngoscope 115:2101-2104, 2005. tion, Laryngoscope 130:S1-S13, 2020.
ATLS Subcommittee, American College of Surgeons’ Committee on Patel RG: Percutaneous transtracheal jet ventilation: a safe, quick, and
Trauma, & International ATLS working group: Advanced trauma life temporary way to provide oxygenation and ventilation when conven-
support (ATLS®): the ninth edition, J Trauma Acute Care Surg tional methods are unsuccessful, Chest 116(6):1689-1694, 1999.
74(5):1363-1366, 2013. Paw HG, Sharma S: Cricothyroidotomy: a short-term measure for elec-
Bernard AC, Kenady DE: Conventional surgical tracheostomy as the tive ventilation in a patient with challenging neck anatomy, Anaesth
preferred method of airway management, J Oral Maxillofac Surg Intensive Care 34(3):384-387, 2006.
57(3):310-315, 1999. Putz L, Mayné A, Dincq AS: Jet ventilation during rigid bronchoscopy
Bobek S, Bell RB, Dierks EJ, et al: Tracheotomy in the unprotected air- in adults: a focused review, Biomed Res Int 2016:4234861, 2016.
way, J Oral Maxillofacial Surg 69:2198-2203, 2011. Spitalnic SJ, Sucov A: Ludwig’s angina: a case report and review, J Emerg
Chandradeva K, Palin C, Ghosh SM, et al: Percutaneous transtracheal jet Med 13:499, 1995.
ventilation as a guide to tracheal intubation in severe upper airway ob- Standley TD, Smith HL: Emergency tracheal catheterization for jet ven-
struction from supraglottic oedema, Br J Anaesth 94(5):683-686, 2005. tilation: a role for the ENT surgeon, J Laryngotology Otol 119(3):235-
Dierks EJ: Tracheotomy: elective and emergent, Oral Maxillofacial Surg 236, 2005.
Clin North Am 20:513-520, 2008. Stauffer JL, Olsen DE, Petty TL: Complications and consequences of
Hashemian SM, Fallahian F: The use of heliox in critical care, Int J Crit endotracheal intubation and tracheostomy, Am J Med 70:65, 1981.
Illn Inj Sci, 4(2):138-142, 2014. Stock CR: What is past is prologue: a short history of the development
Haspel AC, Coviello VF, Stevens M: Retrospective study of tracheostomy of tracheostomy, Throat 66(4):166-169, 1987.
indications and perioperative complications on oral and maxillofacial Taicher S, Givol N, Peleg M, et al: Changing indications for tracheos-
surgery service, J Oral Maxillofac Surg 70:890-895, 2012. tomy in maxillofacial trauma, J Oral Maxillofac Surg 54(3):292-295,
Heidegger T: Management of the difficult airway, N Engl J Med 384(19): 1996.
1836-1847, 2021. Vadepally AK, Sinha R, Kumar AVSSS: Retrograde intubation through
Hoesl V, Kempa S, Prantl L, et al: The LRINEC score-an indicator for nasal route in patients with limited mouth opening undergoing oral and
the course and prognosis of necrotizing fasciitis? J Clin Med 11(13): maxillofacial surgery, J Oral Biol Craniofac Res 8(1):30-34, 2018. Walts
3583, 2022. PA, Murphy SC, DeCamp NM: Techniques of surgical tracheos-
Johnson DB, Lopez MJ, Kelley B: Dexamethasone. In StatPearls. Trea- tomy, Clin Chest Med 24(3):413-427, 2003.
sure Island (FL), May 2, 2023, StatPearls Publishing. Wijesinghe HS, Gough JE: Complications of a retrograde intubation in
Kim MH, Lee SY, Lee SE, et al: Anaphylaxis to iodinated contrast media: a trauma patient, Acad Emerg Med 7(11):1267-1271, 2000.
clinical characteristics related with development of anaphylactic Wong DT, Lai K, Chung FF, et al: Cannot intubate-cannot ventilate and
shock, PLoS One 9(6):e100154, 2014. difficult intubation strategies: results of a Canadian national survey,
Kim KH, Kim YH, Lee JH, et al: Accuracy of objective parameters in Anesth Analg 100(5):1439-1446, 2005.
acute epiglottitis diagnosis: a case-control study, Medicine 97(37): Wood DE: Tracheostomy, Chest Surg Clin N Am 6(4):749-764, 1996.
e12256, 2018.
Kumar A, Verma S, Tiwari T, et al: A comparison of two doses of ket-
amine with dexmedetomidine for fiberoptic nasotracheal intubation,
Natl J Maxillofac Surg 10(2):212-216, 2019.

t.me/Dr_Mouayyad_AlbtousH
23
Ludwig’s Angina
NI CHO L A S C A L L A HA N , S H A N N O N G R E EN , LO R EN M O LE S, K AR L CU DDY,
R O B E R T C R O NY N , a n d MI C H A E L M A R K I E W IC Z

CC are 30 breaths per minute (tachypnea), temperature is 40°C (fe-

brile), and oxygen saturation is 96% on room air.
A 45-year-old male patient with alcohol abuse disorder and no Maxillofacial. The patient has severe facial swelling and edema
other known medical conditions presents to the emergency de- with induration of the bilateral face in the mandibular regions
partment (ED), complaining “My face and neck are swollen and and submandibular regions with a slightly greater prominence on
hurt; they blew up overnight, and it hurts to swallow. This started the right side (Fig. 23.1). There is marked submandibular and
when my tooth started hurting 3 days ago.” submental induration, and the mandibular border is not palpable
in its full extent bilaterally. The swelling is warm to touch and
HPI erythematous over the mandibular and submandibular regions
bilaterally. No subcutaneous crepitus (indicative of subcutaneous
The patient’s clinical examination progressively worsened with air from gas-producing organisms) is present. Unable to palpate
increased facial and neck swelling bilaterally and difficulty tolerat- any appreciable cervical lymphadenopathy, although this may be
ing his secretions over the past 2 days. The patient reports he has masked by significant edema in these regions.
bad teeth, and several of his teeth cause him pain intermittently. Intraoral. The patient has trismus as mentioned, leading to a
The patient has not seen a dentist in several years. The patient limited intraoral examination. Maximum interincisal opening
reports chills in the preceding days, dysphagia (difficulty swallow- is approximately 15 mm. The floor of the mouth and tongue
ing) and odynophagia (painful swallowing), but he denies any are elevated, and the floor of mouth is indurated and edematous
changes to his voice (dysphonia, which is usually present with
edema of the vocal cords and upper airway).

PMHX/PDHX/Medications/Allergies/SH/FH
The patient is a poor historian, only reporting alcohol use and
denying any other known medical conditions.

Examination
General. The patient is sitting slouched slightly forward with his
jaw hanging slightly open, with obvious saliva pooling in his an-
terior oral cavity. The patient appears to be having difficulty tol-
erating his secretions and is holding a Yankauer suction to help
manage his saliva. He appears to be in mild respiratory distress,
but no stridor is present.
Airway. It is difficult to examine the airway given the patient’s
extremely limited mouth opening (trismus, or “locked jaw,”
which is restriction of the movement of the jaw). The anterior
neck over the trachea is edematous and indurated to palpation. A
computed tomography (CT) scan of the face and neck would be
useful in evaluating the airway in terms of edema and any devia-
tion or narrowing of the airway caused by surrounding edema.
Flexible nasopharyngoscopy could be considered to assess for
discharge in the supraglottic larynx or oropharynx, which could
complicate anesthetic management.
Vital signs. The patient’s blood pressure is 145/90 mm Hg • Fig. 23.1 Brawny cellulitis and erythema of the bilateral submandibular
(hypertensive), heart rate is 115 bpm (tachycardic), respirations and submental spaces.

106
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 23 Ludwig’s Angina 107

bilaterally (indicative of sublingual space involvement). Unable to and determine whether the airway is deviated or compromised. A
visualize the oropharynx. CT scan is the gold standard for evaluation and treatment plan-
Cardiovascular. The patient is tachycardic and hypertensive ning for deep space infections of the head and neck, and CT scans
consistent with pain and clinical examination. should be performed with intravenous (IV) contrast to be accu-
Pulmonary. Lungs are clear to auscultation bilaterally, without rate for diagnosing and visualizing a fluid collection or abscess.
any wheezing, rales, or rhonchi. When chest CT is deemed unnecessary, chest radiographs (pos-
Imaging. A panoramic radiograph is the initial screening teroanterior and lateral views) can be an important screening tool
study of choice because it provides an excellent overview of the to detect a widened mediastinum, which may be indicative of
dentition, identifying any odontogenic sources of infection. How- descending mediastinitis.
ever, many times in ED cases, panoramic imaging modality is not This patient was deemed to be too unstable to undergo imaging
readily available. CT scans of the neck with contrast material are without a secure airway; therefore, the patient was intubated be-
indicated when evaluating deep space neck infections. (Chest CT fore obtaining CT scan of the face and neck. A CT scan of the face
should be included if there is a suspicion of descending mediasti- and neck with IV contrast was obtained (Fig. 23.2) and revealed
nitis.) This study can help determine the anatomic spaces in- extensive rim-enhancing fluid collections in the bilateral subman-
volved, localize any fluid collections (loculations of purulence), dibular and sublingual spaces and the right pterygomandibular,

A B

C D
• Fig. 23.2 A, Axial view, soft tissue computed tomography (CT) neck scan with contrast, showing an
enhancing fluid collection in the submental space. B, Axial view, soft tissue CT neck scan with contrast,
showing enhancing fluid collections in the submental and bilateral submandibular spaces. C, Axial view,
soft tissue CT neck scan with contrast, showing an enhancing fluid collection in the right sublingual space.
Note that Wharton’s duct, seen on this view, confirms that this abscess is above the mylohyoid muscle.
D, Sagittal reconstruction, soft tissue CT neck scan with contrast, showing a large submandibular space
abscess extending from the inferior border of the anterior mandible to the hyoid bone.

t.me/Dr_Mouayyad_AlbtousH
108 S E C TI O N Oral and Maxillofacial Infections

lateral pharyngeal, and parapharyngeal spaces. There was diffuse Treatment must begin with evaluation and stabilization of the
soft tissue edema consistent with cellulitis in the involved spaces patient’s airway. Airway evaluation begins the moment the patient
and surrounding fat stranding. No subcutaneous emphysema was walks in. Is the patient in distress, or are they resting comfortably?
seen in the cervical tissues. (Subcutaneous gas collection is consid- Anyone in distress, with stridulous respiration, must be considered
ered a hallmark of cervical necrotizing fasciitis and is seen in up to at high risk for airway embarrassment. Physical examination must
46%–67% of cases.) The endotracheal tube was visualized with include both through intra- and extraoral exams. The oral cavity
significant edema around the airway, and the airway was deviated examination can be exceedingly difficult to examine because pa-
to the right postintubation even though most edema was present tients often have significant trismus and discomfort. Patients with
on the right side. This patient did not initially undergo CT chest Ludwig’s angina typically have elevation and fullness of the tongue
imaging because the most inferior extent of the fluid collection was and floor of the mouth with limited space between the soft palate
visualized and did not violate the mediastinum. and tongue. Pharyngeal wall edema may also be seen.
A fiberoptic nasopharyngoscopy can augment the oral exami-
Labs nation, especially in patients with limited opening. This also al-
lows for direct visualization of the vocal cords and any potential
A complete blood count and complete metabolic panel are indi- airway obstruction in the posterior oropharynx. If the patient is
cated during the workup of patients with severe odontogenic infec- not stable, a definitive airway should be obtained as soon as pos-
tions. The presenting white blood cell (WBC) count is a marker of sible. Intubation may be extremely difficult or impossible. Awake
infection severity, and this value should be followed during the fiberoptic nasal intubation may be required. Videolaryngoscopy
course of treatment. C-reactive protein (CRP) is an acute-phase (e.g., GlideScope) has also been shown to decrease the difficulty
reactant released in response to inflammation and can be used to of intubation and increase the chance of success for experienced
monitor the response to therapy. Studies have also suggested that a and inexperienced providers. A surgical team should be on
remarkably high CRP level at the time of admission is a predictor standby to convert to an emergency front of neck access (cricothy-
of a complicated hospital course. Electrolyte disturbances (sodium, roidotomy or tracheostomy; see Chapter 22 on surgical airways)
potassium, magnesium, calcium) are common among patients if a nonsurgical airway cannot be obtained.
with severe head and neck infections, especially when the patient Supportive measures should be initiated right away. Many of
is not able to tolerate oral intake because of swelling or pain. Blood these patients are hypovolemic because of the combination of
urea nitrogen (BUN) and creatinine levels are useful to evaluate for decreased oral intake and sepsis or septic shock. Standard moni-
prerenal azotemia caused by hypovolemia. Blood cultures are indi- tors of fluid resuscitation, such as heart rate, blood pressure, and
cated in patients who meet sepsis criteria or with persistent fever. urine output, should be used. Patients who continue to have he-
An electrocardiogram should be obtained when there is suspicion modynamic instability with adequate fluid resuscitation may re-
of mediastinitis. Arterial blood gas measurement is warranted in quire vasopressor therapy. Tight glycemic control (blood glucose,
critically ill patients presenting with septic shock. The current pa- 90–110 mg/dL) has also been shown to improve overall survival
tient presented with these lab values: WBC count of 21,000 cells/ in patients with sepsis.
mm3 with a 35% bandemia, BUN of 30 mg/dL (reference range, Patients with Ludwig’s angina have a mixed aerobic–anaerobic
7–18 mg/dL), and creatinine of 1.2 mg/dL (reference range, 0.6– polymicrobial infection, and broad empiric antimicrobial therapy
1.2 mg/dL). The BUN-to-creatinine ratio was 25. (A ratio .20 is should be initiated immediately. Coverage with Zosyn (piperacil-
indicative of prerenal azotemia.) The remainder of his electrolyte lin tazobactam 3.375 g given intravenously every 6 hours) and
values were within normal limits. vancomycin (1 g given intravenously every 12 hours) are appro-
priate empiric antibiotic selections for these patients. In non–
Assessment critically ill patients, penicillin-based drugs are the treatments of
choice. Because of high incidence of beta-lactamase (or other
Angina is typically used to refer to a type of chest pain that is as- mechanism of resistance to beta-lactam antibiotics), a penicillin
sociated with reduced blood flow to the cardiac musculature, yet with a beta-lactamase inhibitor should be used. Unasyn (ampicil-
Ludwig’s angina has nothing to do with the heart. Angina is de- lin sulbactam 3 g given intravenously every 6 hours) has excellent
rived from Latin and Greek words meaning “choke” or “strangle,” coverage with minimal side effects. Clindamycin (clindamycin
which refers to the feeling of asphyxiation that these patients may 900 mg given intravenously every 8 hours) was previously
experience. Ludwig’s angina was first described in 1836 by the thought to be the antibiotic of choice in penicillin-allergic pa-
German physician Karl Friedrich Wilhelm von Ludwig. It was tients, but because of increasing amount of resistance in the
described as a rapidly progressing, gangrenous cellulitis in the sub- population and a poor side effect profile, it should be avoided if
mandibular region. The definition has evolved over time to mean possible. As soon as possible, antibiotics should be narrowed using
any infections that simultaneously affect the bilateral submandibu- cultures and sensitivity results.
lar, sublingual, and submental spaces. Classically, Ludwig’s is sec- These patients require early aggressive surgical drainage and
ondary to a carious or infected mandibular second or third molar source control. Patients with delays in definitive treatment have
with 70% to 90% of all cases being of odontogenic origin. worse outcomes. Cultures should be taken by aspiration before
definitive drainage to prevent contamination from normal skin
Treatment flora. It is unnecessary to make large incisions unless there is con-
current necrotizing fasciitis. Incisions 1 to 2 cm in size should be
Death in patients with Ludwig’s angina is almost always from made in the submandibular and submental areas, at least 2 cm
airway compromise. At the time of its initial description, patients from the inferior border of the mandible for protection of the
would succumb to their disease process more than 50% of the marginal branch of the facial nerve. Blunt dissection used to ex-
time. Improvements in quality, access to care, and antibiotics have plore all involved spaces, first with an instrument and then with
decreased this incidence to less than 10%. finger dissection to break up any loculations. All infected teeth

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 23 Ludwig’s Angina 109

should be removed, and a subperiosteal dissection should be com-

pleted in these areas, with connection to the neck debridement to
allow for dependent drainage. The wounds should be irrigated
with copious amounts of normal saline. Red rubber catheters or
Penrose drains should then be placed. It has been shown that
there is no benefit to irrigating surgical drains over nonirrigating
drains. Drains can be slowly advanced out or removed outright
after drainage ceases. If patients do not improve, repeat CT scan
or repeat surgical drainage in the operating room (OR) may be
necessary.
The current patient was given 8 mg of dexamethasone intrave-
nously in the ED, IV fluid resuscitation was initiated, and empiric
intravenous antibiotics were administered. Antibiotic therapy
consisted of ampicillin–sulbactam (Unasyn) 3 g every 6 hours.
The patient was urgently taken to the OR for incision and drain-
age of the involved anatomic spaces of the neck via intra- and
extraoral spaces and via multiple surgical incisions and extraction
of carious teeth #1, 2, 17, 18, and 19. The patient was already
intubated before entering the OR. An 18-gauge needle was used
to aspirate purulent exudate from the submandibular space,
which was sent for Gram stain, aerobic and anaerobic cultures,
and antibiotic sensitivity studies. The surgical drainage consisted
of three incisions, which were 1.5 to 2 cm in length 2 cm below
the inferior border of the mandible anterior to the antegonial
notch bilaterally and an incision anteriorly in the submental area.
• Fig. 23.3 A patient with Ludwig’s angina and descending mediastinitis
Consideration should be given to placement of the incisions to
via the anterior paratracheal spaces and bilateral carotid spaces. Note the
allow dependent drainage and within existing skin creases when soft tissue edema and erythema of the anterior neck tracking down to the
possible. Blunt dissection with a hemostat and a Kelly clamp was sternum.
carried out to explore all involved spaces. Copious amounts of
purulence and necrotic tissue were expressed from the surgical
sites. Teeth #1, 2, 17, 18, and 19 were elevated and extracted.
Elevation of the gingival cuff was completed, and subperiosteal
dissection was carried out along the lingual and buccal aspects of
the mandible to enter the sublingual and submandibular spaces
from multiple approaches. All the incisions were connected to
each other in the subplatysmal and subperiosteal planes. Irrigation
was performed with copious amounts of sterile saline, and Pen-
rose drains were placed in the submandibular, sublingual, and
submental spaces (Fig. 23.3). All drains were irrigated with copi-
ous amounts of antibiotic irrigation, normal saline irrigation, or
both. The patient was kept intubated postoperatively because of
surgical and airway edema. The patient was taken back to the OR
for two subsequent washouts and further incision and drainage.
The patient eventually required tracheostomy. After tracheostomy,
the patient continued to have thick secretions around the trach
and was failing pressure support trials. A repeat CT face and neck
with contrast was obtained (Fig. 23.4), revealing significant fluid
collection within the trachea above the tracheostomy tube. Pa-
tient was taken to the OR for direct laryngoscopy, bronchoscopy,
debridement of previous surgical sites, and tracheal toileting. Af-
ter significant resolution of the infection and edema and weaning
from ventilatory support, he had a positive cuff leak test result and
subsequently passed a capping trial. He was decannulated before
discharge from the hospital to a subacute rehabilitation facility.

,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for • Fig. 23.4 The fascial spaces seen as a transverse section cut at an
complete set of bibliography. oblique angle.

t.me/Dr_Mouayyad_AlbtousH
 109.e1

Bibliography Martins JR, Chagas OL, Velasques BD, et al: The use of antibiotics in
odontogenic infections: what is the best choice? A systematic review,
J Oral Maxillofac Surg 75(12):2606.e1-2606.e11, 2017. Available
Allen D, Loughnan TE, Ord RA: A re-evaluation of the role of tracheos- from https://doi.org/10.1016/j.joms.2017.08.017.
tomy in Ludwig’s angina, J Oral Maxillofac Surg 43(6):436-439, 1985. Ord R, Coletti D: Cervico-facial necrotizing fasciitis, Oral Dis 15(2):133-141,
Available from https://doi.org/10.1016/s0278-2391(85)80051-3. 2009. Available from https://doi.org/10.1111/j.1601-0825.2008.01496.x.
Ardila C, Bedoya-García J: Antimicrobial resistance in patients with Poeschl PW, Spusta L, Russmueller G, et al: Antibiotic susceptibility and
odontogenic infections: a systematic scoping review of prospective resistance of the odontogenic microbiological spectrum and its clini-
and experimental studies, J Clin Exp Dent 14(10):e834-e845, 2022. cal impact on severe deep space head and neck infections, Oral Surg
Available from https://doi.org/10.4317/jced.59830. Oral Med Oral Pathol Oral Radiol Endod 110(2):151-156, 2010.
Bali RK, Sharma P, Gaba S, et al: A review of complications of odonto- Available from https://doi.org/10.1016/j.tripleo.2009.12.039.
genic infections, Natl J Maxillofac Surg 6(2):136-143, 2015. Available Qu L, Liang X, Jiang B, et al: Risk factors affecting the prognosis of de-
from https://doi.org/10.4103/0975-5950.183867. scending necrotizing mediastinitis from odontogenic infection, J Oral
Bridwell R, Gottlieb M, Koyfman A, et al: Diagnosis and management Maxillofac Surg 76(6):1207-1215, 2018. Available from https://doi.
of Ludwig’s angina: an evidence-based review, Am J Emerg Med 41: org/10.1016/j.joms.2017.12.007.
1-5, 2021. Available from https://doi.org/10.1016/j.ajem.2020.12.030. Saifeldeen K, Evans R: Ludwig’s angina, Emerg Med J 21(2):242-243,
Chang JS, Yoo KH, Yoon SH, et al: Odontogenic infection involving the 2004. Available from https://doi.org/10.1136/emj.2003.012336.
secondary fascial space in diabetic and non-diabetic patients: a clinical Sakamoto H, Aoki T, Kise Y, et al: Descending necrotizing mediastinitis
comparative study, J Korean Assoc Oral Maxillofac Surg 39(4):175, because of odontogenic infections, Oral Surg Oral Med Oral Pathol
2013. Available from https://doi.org/10.5125/jkaoms.2013.39.4.175. Oral Radiol Endod 89(4):412-419, 2000. Available from https://doi.
Christensen BJ, Racha D, Hinkle R, et al: Risk factors for reoperation in org/10.1016/S1079-2104(00)70121-1.
patients hospitalized for odontogenic infections, J Oral Maxillofac Severe odontogenic infections with septic progress – a constant and in-
Surg 79(1):141-151, 2021. Available from https://doi.org/10.1016/j. creasing challenge: a retrospective analysis, SpringerLink. Available
joms.2020.06.032. from https://link.springer.com/article/10.1186/s12903-019-0866-6.
Dowdy RAE, Emam HA, Cornelius BW: Ludwig’s angina: anesthetic Accessed December 28, 2022.
management, Anesth Prog 66(2):103-110, 2019. Available at: https:// Swift JQ, Gulden WS: Antibiotic therapy—managing odontogenic in-
doi.org/10.2344/anpr-66-01-13. fections, Dental Clin North Am 46(4):623-633, 2002. Available from
Ludwig’s angina - KURIEN - 1997 - Clinical Otolaryngology & Allied Sci- https://doi.org/10.1016/S0011-8532(02)00031-9.
ences, Wiley Online Library. Available from https://onlinelibrary-wiley-
com.proxy.cc.uic.edu/doi/abs/10.1046/j.1365-2273.1997.00014.x?casa_
token=cCMNbTGvamgAAAAA:f64jk8cSvHFjOTY1NvJFqUAnzVFrr
BWgtUngESrUzasrlihtkOHD3dg0bqh7L1LBu_FG15FfMElnRE4.
Accessed December 28, 2022.

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24
Buccal and Vestibular Space Abscess
K EI T H A . S O NNE V E L D

CC Intraoral. He has a full dentition in overall good condition.

Several direct restorations are present. Tooth #13 with a carious
The patient says, “My tooth is hurting, and it started swelling fracture and mobile palatal cusp is present. The maxillary buccal
yesterday.” vestibule is slightly edematous and tender to palpation, with no
remarkable fluctuance, and is only mildly indurated. Maximum
HPI incisal opening is slightly restricted to about 35 mm. The floor of
mouth is nonraised and nontender.
A 39-year-old male presented to your office initially about 1
month ago, referred for extraction and eventual implant recon- Imaging
struction for tooth #13. It had been bothering him for a while,
and he has had several courses of antibiotics, which calmed the The panoramic radiograph (Fig. 24.1) is consistent with clinical
pain temporarily, but he does not remember what kind of antibi- examination showing a full dentition other than absent third
otics they were. He said that finances will limit the ability to molars #16 and #32. Root canal-treated tooth #14 appears clini-
perform implant placement immediately after extraction and cally stable. Tooth #13 is slightly supererupted compared with
would likely not be able to afford an implant until the next calen- adjacent teeth, with no significant periapical radiolucency or
dar year when his insurance benefits reset. The patient never coronal radiolucency visible on panoramic radiograph.
scheduled an appointment until yesterday when he experienced A contrast-enhanced computed tomography (CT) scan would
significantly worsening pain and some swelling in his gums that allow visualization and characterization of any fluid collections or
has only worsened. You were able to fit him into your schedule for cellulitic changes, but based on the clinical examination, the ex-
urgent evaluation and treatment today. tent of any fascial space involvement appears to be localized to the
buccal vestibule, so CT is not indicated.
P Labs
MHX/PDHX/Medications/Allergies/SH/FH
Not obtained. For a minor vestibular abscess without signs or
Noncontributory. His medical history is only significant for hyper- symptoms of systemic inflammatory response, laboratory values
tension and allergic rhinitis. His hypertension is controlled using are not indicated.
losartan, and he treats his allergic rhinitis with over-the-counter
antihistamines. He has no drug allergies and reports his only aller- Assessment
gies are to grass and cat dander. He has no other remarkable history.
Buccal vestibular abscess secondary to pulpal necrosis secondary to an
Ellis class III fracture involving the palatal cusp of tooth #13.
Examination
General. He is a well-developed, well-nourished adult male with
an overall nontoxic appearance. He has normal mentation and
shows mild signs of distress.
Vital signs. Temperature is 98.9°F, blood pressure is 153/98
mm Hg, pulse rate of 103 bpm, and respiratory rate of 14 breaths
per minute. The patient’s nontoxic appearance and lack of fever
indicate that there is no significant systemic inflammatory response
present. His blood pressure and pulse rate are elevated above a nor-
mal range; however, this may be an indication of several things such
as pain from his oral condition, inadequate medication regimen, or
noncompliance with his medication regimen.
Maxillofacial. No significant extraoral edema or erythema is
noted. His neck shows full range of motion. There is no remark- • Fig. 24.1 Panoramic radiograph. No remarkable periapical radiolucen-
cies are noted.
able lymphadenopathy on palpation. The inferior border and
angle of the mandible are easily palpable and nontender.
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110

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 CHAPTER 24 Buccal and Vestibular Space Abscess 111

Treatment have the same considerations as mentioned before; however, if his

blood pressure was lower and pulse rate had greater elevation in
The treatment recommended and accepted by the patient was conjunction with a toxic appearance and fevers, the suspicion for
incision and drainage (I&D) of the vestibular space abscess and a more serious systemic inflammatory response is raised.
extraction of tooth #13 to be performed under nitrous oxide anx- Maxillofacial. There is extraoral edema and erythema overly-
iolysis and local anesthesia. You also recommend considering the ing the left cheek inferior to the malar eminence with some edema
findings during the procedure to determine whether socket pres- extending to the lateral portion of his lower eyelid and the lateral
ervation and membrane placement would be performed. commissure of the upper lip (Fig. 24.2). There is some induration
A mixture of nitrous oxide and oxygen was administered and of the skin over the height of swelling. His neck shows full range
titrated to 3L:3L/min. The patient reported feeling the effects of of motion. No remarkable lymphadenopathy is felt on palpation.
the nitrous oxide. Local anesthetic was injected via an extraoral Intraoral. The buccal cheek tissue shows significant edema
approach to an infraorbital nerve block, approximately 0.5 cc of and some induration, but a fluctuant mass in the cheek adjacent
articaine 4% with 1:100,000 epinephrine. When the nerve block to the extraction site is present, with tenderness to palpation. The
had taken effect, more local anesthetic was administered via local previous incision in the buccal vestibule is no longer patent, and
infiltration using approximately 3 cc of articaine 4% with there is no drainage visible. The extent of the lesion is easily pal-
1:100,000 epinephrine and 2 cc of mepivacaine 3%. pable and ends just posterior to the first molar, and the size of the
After anxiolysis and local anesthesia were reached, a full- fluctuant mass can be estimated to be 3 cm in diameter. The ex-
thickness incision was made in the most dependent aspect of the traction site is healing appropriately with the sutures overlying the
swelling in the unattached mucosa. Subperiosteal dissection was bone graft and membrane intact. Maximum incisal opening is
carried out through the extent of the abscess cavity, but only scant now reduced to approximately 25 mm with a soft end-feel. Limi-
amounts of frank purulence was noted. On evaluating the abscess tation of opening as a sequalae of an orofacial infection is called
cavity, there was a bony dehiscence in the buccal plate tracking to “trismus” and can be a characteristic finding in an infection in-
the root apex of tooth #13. Attention was then paid to the tooth, volving the masticator space or lateral space infection and gener-
from which the grossly mobile fractured segment was removed ally has a more definite hard end-feel that is more likened to
without any issue. The soft tissue was relieved and was mobilized someone with anterior disc displacement without reduction of a
using elevators, but given the extent of the fracture, there was no temporomandibular joint. “Guarding” is the term given to lim-
stable place to grasp using forceps. The handpiece was used to ited passive mouth opening with a softer feel on opening because
conservatively trough around the root, which was then mobilized the limitation is generally because of a habit that limits greater
and delivered in full with elevators. The socket was thoroughly opening as it exacerbates the pain of whatever condition is present
debrided and irrigated, and the abscess cavity was thoroughly ir- that is causing the pain.
rigated with sterile saline. Because of the buccal dehiscence and
condition of the socket, the decision was made to proceed with
socket preservation bone graft, which was performed using par-
ticular allograft and a bovine collagen membrane.
Because of the source control and surgical treatment of the
abscess as well as the very minute amount of purulence noted in
the abscess cavity, no drain was placed. The patient was prescribed
oral amoxicillin 500-mg tablets with directions to take one tablet
every 8 hours until the course is completed after 7 days.

Follow-up History
The patient returns to your clinic for evaluation 3 days after the
initial procedure with a complaint of worsening swelling and
pain, which is now bigger than the swelling before the initial
procedure. He reports being compliant with his antibiotics but
feels like it is continuing to grow in size and developed some red-
ness and worsening pain. He said he may have felt slightly warm
but denies any significantly high fevers and has no dysphagia,
odynophagia, shortness of breath, or difficulty breathing.

Follow-up Examination
General. No significant changes in his general appearance. He
continues to be a well-developed, well-nourished adult male with
an overall nontoxic appearance. He has normal mentation and
shows only mild signs of distress.
Vital signs. Temperature is 99.1°F, blood pressure is 155/96
mm Hg, pulse rate is 99 bpm, and respiratory rate is 14 breaths
per minute. His slightly elevated temperature and reports of sub-
jective warmth may be indications of impending systemic inflam- • Fig. 24.2 Left-sided facial swelling with overlying erythema and inferior
matory response. The elevated blood pressure and pulse rate may displacement of the left labial commissure.

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112 S E C TI O N Oral and Maxillofacial Infections

Imaging the decision-making criteria. Keen observation of the patient and

taking all factors into account are important in managing these
A contrast-enhanced CT scan may be considered to further char- infections, which have the potential to make the patient acutely
acterize the extent of the abscess cavity and cellulitis. In this case, ill or develop more permanent complications.
the extent of the abscess infection is easily demarcated through Specific to vestibular space and buccal space abscess, some
examination and the involved spaces are fairly obvious, so no potential complications may result from surgical treatment. It is
contrast-enhanced CT was obtained. important to consider adjacent anatomic structures when decid-
ing where to place an incision because improper placement may
Labs pose a risk of injury to a peripheral branch of the trigeminal nerve
(infraorbital nerve, long buccal nerve, mental nerve), some vascu-
No labs were obtained at this point. There were no strong indica- lar structure (the facial artery and vein follows a tortuous and
tions for a need to obtain laboratory values in this case given the somewhat unpredictable pathway as it branches along the buccal
patient’s presentation. Further elaboration on this topic is done in tissue), and Stenson’s duct if located in the posterior buccal space.
the discussion section. Care must also be taken when dissecting the abscess cavity to not
be too aggressive in dissection because branches of the facial nerve
Assessment may be in close proximity and at risk for injury to these as well.
Whenever blunt dissection is being carried out in tissue planes
Buccal space abscess secondary to Ellis class II fracture of #13. not directly visible (as is often the case when performing an
I&D), the hemostats must never be clamped while out of view.
Treatment Overaggressive spreading and clamping of the beaks may cause
traction injuries to the structures lying within the abscess cavity.
The patient was recommended for immediate I&D of the buccal
space abscess with nitrous oxide anxiolysis. The process for ad- Discussion
ministration of nitrous oxide and local anesthetic was similar for
this second I&D as the first procedure. After adequate anesthesia Treatment of orofacial infections, especially those of odontogenic
was achieved, an incision was made in the buccal mucosa overly- origin, are best treated in a systematic manner. Already extensively
ing the most dependent aspect of the abscess. Blunt dissection was described in oral and maxillofacial surgery (OMS) literature, the
carried out with a hemostat into the abscess cavity, expressing systematic approach by Flynn follows an eight-step approach.
purulence. The incision from the first procedure was opened The clinician must (1) determine the severity of infection,
again, dissection was carried out to connect the two incisions, and (2) evaluate host defenses, (3) decide on setting of care, (4) treat
all purulence was drained. The abscess cavity was then thoroughly surgically, (5) support medically, (6) choose and prescribe antibi-
irrigated with copious amounts of sterile saline, and a ¼-inch otics, (7) administer the antibiotic properly, and (8) evaluate the
Penrose drain was placed in the abscess cavity through the buccal patient frequently.
incision and secured using a 3-0 silk suture. These steps do not take a linear 1-to-8 approach and can be
After the procedure, a new prescription was given to the pa- roughly broken down into preoperative, operative, and postop-
tient, changing the antibiotic to clindamycin 300-mg capsules to erative phases. Steps 1 to 3 generally occur within the first
be taken every 8 hours until the course is complete after 7 days. moments of an encounter with a patient who has an infection.
This decision was made to do this as a change in empiric antibi- The ultimate decision of how and where to treat the infection is
otic therapy because of the persistent infection and that he did dictated by the severity of infection, location of infection, and any
report several courses of unknown antibiotics to treat this tooth in immune system compromise that may be present. The initial
the past. It is reasonable to assume that it may have been some “gestalt” acquired when first seeing a patient can tell the practitio-
penicillin antibiotic, potentially amoxicillin with or without cla- ner much about the severity of the infection. If the patient has a
vulanate, which may have conferred some resistance to the toxic appearance or appears to be in great distress, it may be more
amoxicillin prescribed at the time of the first I&D. likely that the infection is more severe than in a patient who does
The patient was followed closely, and after 3 days, the drainage not have this appearance. The location and extent of infection also
ceased. He reported significant improvement in the swelling, and plays a major role in deciding on setting of care because certain
pain resolved. The Penrose drain was removed, and he continued areas of infection are at higher risk of spread into more precarious
to resolve without any other remarkable sequelae. deep areas of the head and neck. For most vestibular space and
buccal space infections, the extent of the abscess cavity can be
Complications determined with a thorough clinical examination. The role of
contrast-enhanced CT is beneficial in characterizing the infection,
In this particular case, the complication of the procedure of per- but this is not available in the outpatient clinic setting and for
sistent infection and expansion of the abscess has several potential vestibular or buccal space infections is often not necessary. If the
causes. In evaluation of the case, several things could have been spaces involved or extent of the infection cannot be established
done differently such as forgone socket preservation at the time of with clinical examination, it would behoove the practitioner to
extraction, placement of a Penrose drain in the abscess cavity at obtain advanced imaging to determine this. In an immunocom-
the initial procedure, or use of a different antibiotic. Further petent patient, the host defenses are not impaired, but any status
elaboration on this is given in the discussion section. that may create immunocompromise may indicate treatment in a
In general, complications of treating a vestibular space abscess higher level of care than an outpatient clinic setting.
or buccal space abscess can become serious very fast. Often, the The involved spaces and surgical approach to drain any abscess
points when complications can occur result from either inade- collection may indicate a necessity for general anesthetic for pa-
quate treatment or lack of recognition of some consideration in tient comfort (full dissection of involves spaces that may not be

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 CHAPTER 24 Buccal and Vestibular Space Abscess 113

achieved under local anesthesia), management of medical comor- Much of the current research on bone grafting in infected sites
bidities, and protection from airway embarrassment. In this par- fails to differentiate between acute infections or acute exacerba-
ticular case, the decision to treat under nitrous oxide anxiolysis for tions of chronic infections versus purely chronic infections. In
both surgical procedures was made because the patient was a other words, the current studies support the success of bone graft-
healthy male with no signs of systemic involvement of the infec- ing in “infected” sites, assuming full debridement of any infec-
tion and no indication of impaired host defenses. tious debris, but they do not specify if any of the cases had active
It is also important to consider the role of source control to swelling with even a small amount of purulence. If a drain had
allow for resolution of an infection. Vestibular abscesses often been put in the I&D site, reaccumulation of purulence in the
involve pulpal and periapical infectious sources eroding through buccal space may have been avoided. In contrast, if a drain is not
the buccal plate and creating the vestibular swelling, which can placed but the bone graft has also not been performed, reaccumu-
then advance into the buccal space as it compromises the barrier lation of purulence in the buccal space may have been avoided. It
provided by the buccinator muscle. The most definitive method also may not have mattered because these are not the only factors
of source control of an odontogenic infection is extraction; how- associated with the aggressiveness of an infection.
ever, the role of caries excavation and endodontic treatment is an Regarding antibiotic choice for this particular patient, it may
option depending on the restorability of the tooth. The decision have been indicated to use an antibiotic other than amoxicillin
of extraction versus endodontic therapy should be made in con- after the initial procedure. The patient reported that he had been
junction with the restorative provider and patient. on more than one course of antibiotics during the past several
Steps 5 to 8 occur not only postoperatively but also play a large months. Although he did not remember the particular medica-
role in the patient’s recovery after surgical intervention. Steps 5 to tions administered, it is likely that it was some beta-lactam anti-
7 are not within the scope of this chapter, but it could go without biotic because they are very commonly used empiric antibiotics
saying that patients whose medical comorbidities are well con- for the oral flora. With the repeated administration to quell the
trolled generally do better in recovering than someone whose are symptoms of the infectious process present in this patient, the
not. Antibiotic choice becomes very important with deeper space organisms likely became selectively resistant to beta-lactam, ren-
involvement, immune system compromise, and persistent infec- dering it ineffective despite source control by extracting the tooth
tion despite appropriate surgical treatment. For uncomplicated and I&D. In cases like this, it may be wise to consider choosing a
vestibular abscesses in an immunocompetent patient, empiric different antibiotic with different organism coverage or mecha-
antibiotic therapy is often enough when used in conjunction with nism of action.
source control and adequate surgical treatment. Odontogenic infections occur fairly frequently, especially
Retrospection on cases with less-than-ideal outcomes is neces- within the OMS office, with vestibular infections being the
sary in an attempt to improve outcomes for future treatment. In most common primary abscess observed and treated. This case
this particular case, it was already mentioned that several alterna- shows the progression that can occur from a vestibular abscess
tives may have changed the outcome, including placement of a into a buccal space abscess. Vigilant observation of the patient is
drain at initial I&D, forgoing socket preservation graft, and anti- important to reduce the potential for these infections to get out
biotic choice. The questioning of drain placement and not per- of hand.
forming socket preservation appeals to the same consideration,
that maintaining a pathway to avoid accumulation of purulence ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
within the tissue would avoid a persistent infection. complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 113.e1

Bibliography Flynn TR: Principles of management of maxillofacial infections. In

Miloro M, Ghali GE, Larsen PE, et al., eds. Peterson’s Principles of Oral
and Maxillofacial Surgery, ed 3, Shelton, 2012, People’s Medical
Chrcanovic BR, Martins MD, Wennerberg A: Immediate placement of Publishing House, pp 841-860.
implants into infected sites: a systematic review, Clin Implant Dent Kim JJ, Ben Amara H, Chung I, et al: Compromised extraction sockets:
Relat Res 17(S1):e1-e16, 2015. doi:10.1111/cid.12098. a new classification and prevalence involving both soft and hard tissue
Flynn TR, Shanti RM, Hayes C: Severe odontogenic infections, part 2: loss, J Periodontal Implant Sci 51(2):1-14, 2021. doi:10.5051/jpis.
prospective outcomes study, J Oral Maxillofac Surg 64(7):1104-1113, 2005120256.
2006. doi:10.1016/j.joms.2006.03.031. Shahriari A, Patel PP, Bagheri SC: Buccal and vestibular space abscess. In
Flynn TR, Shanti RM, Levi MH, et al: Severe odontogenic infections, Bagheri SC, ed. Clinical Review of Oral and Maxillofacial Surgery: A
part 1: prospective report, J Oral Maxillofac Surg 64(7):1093-1103, Case-Based Approach, ed 2, St. Louis, 2014, Elsevier, pp 103-107.
2006. doi:10.1016/j.joms.2006.03.015.

t.me/Dr_Mouayyad_AlbtousH
25
Lateral Pharyngeal and Masticator
Space Infection
C L A IR E M I L L S , PI YU SH K U M A R P. PAT E L , a n d S H A H R O K H C . B AG H ER I

CC the disease course and prevent patients from developing decay and
subsequent odontogenic infections.
A 25-year-old male presents to the emergency department with
the complaint that “my throat is swollen, and I cannot swallow.” PMHX/PDHX/Medications/Allergies/SH/FH
HPI The past medical and dental histories are unremarkable. The pa-
tient lives in a shelter and does not currently hold a job.
Approximately 1 week earlier, the patient began to experience acute (Although masticator space infections can be seen in individuals
pain localized to the posterior mandibular molars, with subsequent of all socioeconomic strata, the condition is far more predominant
development of edema in his left posterior oropharynx 3 days later. in the population with less access to health care, including fre-
He reports the onset of limited mouth opening, progressively worsen- quent dental examinations.)
ing dysphagia (difficulty swallowing), and globus (sensation of a Despite the lack of coexisting medical diseases in this patient,
lump in the throat) that eventually prompted him to seek care. (Trismus it is important to consider any conditions that impair the im-
and dysphagia have been shown to be significant indicators of severe mune system, such as HIV/AIDS, diabetes mellitus, chronic
odontogenic infection.) He has difficulty swallowing his secretions, corticosteroid therapy, or chemotherapy. Patients should be ques-
either drooling or spitting them out. (This is an important clinical tioned about risk factors for HIV infection and appropriately
note because it denotes life-threatening oropharyngeal edema.) He tested as needed. Masticator space infections can have very aggres-
explains that he has had minimal oral intake with the onset of fever sive behavior in the face of immunosuppression. Patients with
and chills. At this time, he does not report any difficulty with breath- HIV presenting with deep space neck infections are more likely to
ing, but he feels more comfortable when sitting up (an important develop Ludwig’s angina, leading to airway obstruction as well as
clinical sign of dangerous oropharyngeal edema). The patient has other complications, including sepsis, mediastinitis, jugular vein
a muffled, “hot potato” voice (secondary to supraglottic edema). thrombosis, and pneumonia. They also often have longer hospital
Multiple studies have found that pain, fever, trismus, odynophagia, stays and higher mortality rates. The factors in this group most
dysphagia, reduced oral intake, and raised floor of mouth are signifi- associated with complications are being 55 years of age or older
cantly associated with patients requiring hospital admission. and having a CD4 count of 350 cells/mm3 or less.
Dental infections have become the most common cause of
deep neck infections in the Western world, involving the mastica- Examination
tor, parapharyngeal, and submandibular spaces. More than 50%
of patients presenting with infection involving these spaces have General. The patient is a thin and unkempt-appearing male with
an odontogenic cause, making oral and maxillofacial surgeons a a noticeable pungent odor (indicative of neglect to health and
preferred provider of surgical care for this group. In addition, hygiene). The patient is not in respiratory distress. (It is important
Seppanen et al. reports that despite antibiotic advancements, the to assess the need for advanced airway intervention immediately
incidence of odontogenic infections has continued to increase. upon examination.) He appears anxious, sitting up holding an
Many odontogenic infections arise because of carious decay. emesis basin to catch his secretions as they drool from his mouth
Using a caries risk assessment tool such as Caries Management by (difficulty maintaining secretions).
Risk Assessment (CAMBRA) is very beneficial for all dental pro- Vital signs. His blood pressure is 104/68 mm Hg (hypoten-
viders to use during their clinical examinations. This approach sion secondary to dehydration), heart rate is 116 bpm (tachycar-
assesses each patient for their risk of developing dental caries that dia secondary to hypotension and fever), respirations are 20
can then lead to decay. Based on the assessment, the provider can breaths per minute, and temperature is 39.2°C (febrile), with an
suggest interventions and lifestyle changes that can stop or reverse oxygen saturation of 98% on room air.

114
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 CHAPTER 25 Lateral Pharyngeal and Masticator Space Infection 115

Maxillofacial. There is significant swelling and induration of cause of lateral pharyngeal infections.) Mucous membranes of the
the left side extending from the level of the hyoid bone anterior buccal mucosa are dry (secondary to dehydration).
to the sternocleidomastoid to the zygomatic arch. Cranial nerves
II through XII are grossly intact. The pupils are equal, round, and Imaging
reactive to light and accommodation, with no proptosis or ptosis
of the eyelids. (These would be suggestive of cavernous sinus in- Before any further diagnostic imaging, the treating surgeon must
volvement.) decide whether the patient (and the airway) is stable enough for
Intraoral. Maximal interincisal opening is 17 mm (trismus) obtaining further studies, or arrangements should be made to
(Fig. 25.1A). The floor of the mouth is soft (sublingual space not proceed directly to the operating room (OR) and establish a secure
involved). The patient is able to protrude his tongue past the airway (endotracheal or nasotracheal intubation, tracheostomy,
vermillion–cutaneous border of the upper lip. (The ability to pro- cricothyrotomy). Any possibility of acute respiratory obstruction
trude the tongue past the vermilion border of the upper lip is a should prompt the surgeon to proceed directly to the OR. Imaging
reliable sign that the sublingual space is not severely involved.) studies can be safely obtained to guide further treatment at a
There is significant fluctuant swelling of the left oropharynx to- later time.
ward the right tonsillar area, with the tip of the uvula touching When available, a panoramic radiograph is an important imag-
the right pharyngeal wall (Fig. 25.1B). The operculum overlying ing study for evaluation of suspected odontogenic infections. It
the partially bony impacted left mandibular third molar is edem- provides an excellent overview of the mandible and maxilla and
atous, erythematous, and tender to palpation, with no obvious serves as a screening tool for evaluation of the dentition. Also, in
purulent discharge. (Mandibular third molars are a common patients with trismus, other dental radiographs may be difficult to
obtain. Because mandibular third molars are the most common
odontogenic cause of parapharyngeal space infections, this radio-
graph becomes necessary to evaluate the third molars. In addition,
it delineates the relationship to adjacent structures, such as the
inferior alveolar canal, and other possible bony pathology.
The combination of contrast-enhanced computed tomography
(CT) scans and clinical examination has the highest sensitivity and
specificity in the diagnosis of deep neck infections. The use of
contrast improves the ability to identify the hyperemic capsule of
a longstanding abscess. (Abscesses are seen as discrete, hypodense
areas that show an enhancing peripheral rim with use of intrave-
nous [IV] contrast material.) In general, most radiologists interpret
hypodense areas without ring enhancement to represent cellulitis
or edema. However, studies have shown that, when drained, ap-
proximately 45% of hypodense areas without ring enhancement
yield pus. In a study by Miller and associates, a hypodense area of
greater than 2 mL without ring enhancement yielded purulence at
the time of surgery. In the same study, CT scans were able to cor-
rectly differentiate cellulitis from an abscess in 85% of deep neck
space (lateral and retropharyngeal) infections.
Computed tomography also provides important information
regarding the details of adjacent anatomic structures, such as the
A integrity of the airway, tracheal deviation, and the proximity of
vascular structures (the carotid sheath). Airway deviation and the
risk of rupture of the pharyngeal abscess during intubation are
important factors in determining the choice of technique to se-
cure the airway.
Magnetic resonance imaging (MRI) is also a useful imaging
modality for soft tissue evaluation. Compared with CT, advan-
tages of MRI include superior anatomic multiplanar display, high
soft tissue contrast, fewer artifacts from dental amalgam, and lack
of ionizing radiation. However, MRI is more difficult and slower
to perform on an emergency basis and is more costly, and claus-
trophobia may preclude examination in some patients. MRI,
when possible, has been shown to be superior in the assessment of
deep neck infections.
Ultrasonography has shown some benefit in differentiating
cellulitis from an abscess in superficial locations, but the use of
B this modality as a sole imaging technique for deep neck infection
is in its infancy. Ultrasonography imaging can detect edema, sub-
• Fig. 25.1 A, Significant swelling of the left face and maximal interincisal cutaneous emphysema, and perifacial fluid collection. The ultra-
opening of 17 mm. B, Large, fluctuant swelling of the posterior orophar- sound probe can be placed intraorally, although in the setting of
ynx partially obstructing the airway. an acute infection and trismus, this can be difficult. An abscess is

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116 S E C TI O N Oral and Maxillofacial Infections

• BOX 25.1 Risk Factors for Contrast-Associated

Nephropathy
• Preexisting renal disease
• Diabetes
• Volume of contrast dye used
• Dehydration
• Congestive heart failure
• Advanced age
• Presence of nephrotoxic drugs (NSAIDs, ACEIs)
ACEI, Angiotensin-converting enzyme inhibitor; NSAID, nonsteroidal antiinflammatory drug.
From Soma VR: Contrast-associated nephropathy, Heart Dis 4:372-379, 2002.

monitored, and a baseline serum creatinine concentration should

be obtained before and within 48 to 72 hours after the procedure.
The WBC count for the current patient was 18,500 cells/mm3;
the differential diagnosis included 80% polymorphonucleocytes
with a shift to the left (indicative of an acute inflammatory process).
Serum chemistries showed a sodium level of 150 mEq/dL (hy-
povolemic hypernatremia caused by dehydration), BUN of 48 mg/
• Fig. 25.2 Axial cut, contrast-enhanced computed tomography scan, dem- dL, and creatinine of 1.1 mg/dL (prerenal azotemia consistent with
onstrating large areas of rim-enhanced hypodensities (loculations) both me- dehydration).
dial and lateral to the left mandible with significant deviation of the airway.
Assessment
seen as an echo-free cavity with an irregular, well-defined circum- Deep neck infection involving the anterior compartment of the left
ference. A recent study by Costa et al. presents an ultrasonogra- lateral pharyngeal space (LPS) with significant upper airway devia-
phy technique that uses a transcervical probe to evaluate deep tion and edema and left medial and lateral masticator space infec-
neck infections after drainage to determine the locations of the tions secondary to an impacted mandibular third molar, complicated
drains inside the collection area as well as adjacent edema. This by dehydration and potential onset of sepsis.
approach allows for more frequent bedside assessments of patient
infection resolution than CT or MRI. Treatment
In the current patient, the airway appeared clinically stable,
and a panoramic radiograph demonstrated a carious and partially Successful treatment of fascial space infections should include the
bony impacted left mandibular third molar. A CT scan with con- following:
trast demonstrated significant swelling of the lateral pharyngeal • Surgical drainage of an abscess or, in select cases, drainage of
area and deviation of the airway (Fig. 25.2). Large rim-enhancing cellulitis
hypodense areas consistent with pus are seen on the left lateral • Identification and removal of the source of infection (the
masticator and lateral pharyngeal (anterior compartment) spaces. tooth, in cases of odontogenic etiology)
• Administration of antibiotics (guided by culture and sensitiv-
Labs ity when possible)
• Optimization of host nutritional and immune status
A complete blood count and a basic metabolic panel should be Antimicrobial therapy can abort abscess formation if adminis-
obtained during the initial evaluation of deep neck space infec- tered at an early stage of infection. However, after an abscess has
tions. The white blood cell (WBC) count is an indicator of the formed, antimicrobial therapy is more effective in conjunction
severity of the systemic response to the infection and can be ob- with adequate surgical drainage.
tained periodically to monitor the progression of infection. (Cau- Impending airway obstruction may require immediate airway
tion should be exercised in interpretation of this value in a patient management (see discussions of Ludwig’s angina, earlier in this
who is at high risk for undiagnosed AIDS because the WBC chapter, and emergent surgical airway in Chapter 24). Maintain-
count may appear within the normal range secondary to the in- ing spontaneous ventilation and airway patency is critical in
ability to mount an adequate immune response.) patients with a compromised airway. Even a small dose of a respi-
The serum creatinine and blood urea nitrogen (BUN) levels ratory depressant may change an apparently controlled situation
should be obtained before contrast material is used for imaging. into an emergent one, especially in the presence of a fatiguing
Contrast material has been known to cause contrast-associated patient. Morbidity or death caused by the loss of an airway is still
nephropathy. The condition is defined as an increase in serum reported. Available options include endotracheal intubation
creatinine greater than 25% from baseline or an increase greater versus establishment of a surgical airway. The advantages and
than 0.5 mg/dL within 48 hours of contrast exposure in the disadvantages of these methods are summarized in Table 25.1.
absence of other causes. Risk factors for the development of Consideration should be given to endotracheal intubation using
contrast-associated nephropathy are summarized in Box 25.1. In an awake fiberoptic technique. This requires a skilled anesthesi-
the presence of risk factors, renal function should be carefully ologist and patient cooperation and can be time-consuming.

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 CHAPTER 25 Lateral Pharyngeal and Masticator Space Infection 117

TABLE Health & Science University) report that use of a nasal speculum
25.1 Intubation versus Surgical Airway can be beneficial for direct visualization of deep space neck infec-
tions. They have used this technique in more than 100 cases and
Procedure Advantages Disadvantages found significantly improved tissue visualization. After surgical
Intubation Potentially fast method Nonsecured airway drainage, a long nasal speculum can be passively inserted into the
Nonsurgical procedure Patient discomfort is required dissected tract, which is progressively dilated. This allows for di-
for extended periods rect visualization of important anatomic landmarks in each of the
Difficult to perform with up- deep spaces and for effective irrigation and unobstructed drain-
per airway edema age. Although this approach holds great potential benefit, it is not
Risk of rupture of abscess, currently widely used for deep space neck infections, and no
with subsequent aspiration randomized trials assessing its benefit have been performed.
Requires mechanical venti-
Supportive care to ensure adequate hydration, caloric intake,
lation during period of
intubation
and analgesia is also important. It is reported that minimum daily
Laryngotracheal stenosis fluid requirements increase by 300 mL per degree of fever (1°C)
per day. Caloric requirements also increase by approximately 5%
Tracheotomy Airway security Surgical procedure to 8% per degree of fever per day.
Patient comfort Bleeding Studies have shown that gram-positive cocci and gram-
Less need for ventilation Scarring
negative rods have the greatest growth percentage in cultures from
and sedation Pneumothorax
Earlier transfer from
deep neck space infections of odontogenic origin. It should be
unit to floor noted that some microbiologists estimate that only 50% of the
bacteria that make up oral flora can be cultured in a laboratory.
From Potter JK: Tracheotomy versus endotracheal intubation for airway management in Additionally, it is believed that the majority of human infections
deep neck space infections, J Oral Maxillofac Surg 60:349-354, 2002. are caused by bacteria in biofilms (a complex, usually multispe-
cies, highly communicative community of bacteria that is sur-
rounded by a polymer matrix). Bacteria present in biofilms are
difficult to culture with traditional methods. A cohort study was
Regardless of the airway technique used, caution should be conducted 2020 to evaluate the microbial composition in pediat-
exercised to prevent rupture of the abscess during intubation, ric and adult patients with deep neck space infections. They found
which can result in aspiration of purulent material and is associ- that pediatric infections were often the result of upper respiratory
ated with significant morbidity (aspiration pneumonitis, pneu- tract infections, and when able to culture, Staphylococcus aureus
monia, lung abscess, acute respiratory distress syndrome) and was the predominant organism. In contrast, adults had a wider
death. One useful technique is to aspirate the LPS before any variety of causes and far more severe infections. Most adults re-
intubation attempts. This can be done in the OR under local quired admission to the intensive care unit, and 19% died, largely
anesthesia. The abscess can be decompressed significantly, thereby because of sepsis. Concurrent HIV infection was observed in 67%
reducing the risk of aspiration during intubation. of the adult patients. The microbial composition observed in the
The anterior compartment can be approached intraorally via an adult cohort was more diverse with more aerobic than anaerobic
incision over the pterygomandibular raphe, with blunt dissection organisms. The aerobic organisms were Klebsiella spp., Enterobac-
around the medial side to enter the LPS. The extraoral approach is ter cloacae, Serratia marcescens, Citrobacter freundii, and Morgan-
accomplished by making a 1- to 2-cm incision approximately two ella morganii.
fingerbreadths inferior to the mandible; dissection is then carried Future trends indicate that rather than relying on traditional
through the platysma to the superficial layer of the deep cervical culture and sensitivity testing, DNA analysis may be used for
fascia. Sufficient fascia is exposed to identify the submandibular identification. Until strategies for the prevention of biofilm
gland and the posterior belly of the digastric muscle. Dissection is formation and disruption of existing biofilms are developed,
then carried just posterior to the posterior belly of the digastric surgical therapy is still necessary. Because of the rising incidence
muscle in a superior, medial, and posterior direction into the LPS. of penicillin resistance and failure of penicillin therapy, many
If finger dissection is also used, the surgeon will be able to palpate clinicians advocate the empiric use of clindamycin (in a penicil-
the endotracheal tube medially and the carotid sheath posterolater- lin-allergic patient) or a combination of a beta-lactam with peni-
ally. Through-and-through intraoral–extraoral drainage can be cillinase inhibitor (e.g., ampicillin–sulbactam) for deep neck
obtained by combining the intraoral approach with the extraoral space infections of odontogenic origin until an antibiogram is
approach. If old clots are found or if any signs of carotid sheath obtained. Clindamycin has the disadvantage of not covering
involvement are present, then vertical extension of the incision can Eikenella corrodens. If E. corrodens has been cultured, moxifloxa-
be made along the anterior border of the sternocleidomastoid cin is an excellent choice. A prospective cohort study found that
muscle. This extension allows the carotid artery to be pulled ante- initial management with a beta-lactam plus penicillinase inhibi-
riorly and controlled as necessary. tor (in this case, amoxicillin–clavulanate) plus metronidazole
The extraoral incision should parallel the lines of relaxed skin then transition to amoxicillin–clavulanate alone after drainage
tension and lie in a cosmetically acceptable site whenever possible. resulted in similar clinical outcomes to patients who stayed on
The incision should also be supported by healthy underlying dermis amoxicillin–clavulanate plus metronidazole. They conclude that
and subcutaneous tissue. Placement of drains should allow for in healthy patients, metronidazole is not necessary after drainage,
gravity-dependent drainage. A rigid drain should not be placed into and prescription should be based on clinical and laboratory as-
the LPS because of the potential for erosion into the carotid sheath. sessments of infection resolution.
Oral and maxillofacial surgeons in Portland, Oregon (Provi- The current patient was given a bolus of normal saline and was
dence Cancer Institute, Legacy Emanuel Medical Center, Oregon taken urgently to the OR. The anesthesiologist was informed about

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118 S E C TI O N Oral and Maxillofacial Infections

Complications
Complications of masticator space infections are partially de-
pendent on the severity of the presenting infection, the status
of the host immune system, the virulence and resistance pat-
terns of the infecting bacteria, and the time of presentation.
Complications can be major, ranging from unsightly scars from
incisions for drainage or tracheostomy to death from airway
embarrassment.
Infections that have gained entry into the LPS may erode into
the carotid sheath or impair any of the nerves found in the poste-
rior compartment. Signs that indicate possible carotid sheath in-
volvement include the following:
• Ipsilateral Horner’s syndrome (ptosis, miosis, anhidrosis)
• Fig. 25.3 Samples of the aspirate to be sent for Gram stain and aerobic • Unexplained palsies of cranial nerves IX through XII
and anaerobic culture and sensitivity studies. • Recurrent small hemorrhages from the nose, mouth, or ear
(herald bleeds)
• Hematoma in the surrounding tissue
• Persistent peritonsillar swelling despite adequate drainage
the parapharyngeal space involvement, and the anesthesiologist and • Protracted clinical course
surgeon agreed on a plan for airway management. Before any at- • Onset of shock
tempts at intubation, 6 mL of lidocaine was injected on the mucosa Any signs of carotid sheath involvement warrant immediate
of the oropharynx superficially; subsequently, 35 mL of purulent radiologic evaluation, CT, or CT angiography. Surgical explora-
material was evacuated, allowing decompression of the swelling tion and control of the great vessels may be required.
(Fig. 25.3). Subsequently, the patient was placed in the supine posi- Involvement of the cranial nerves (vagus and glossopharyngeal
tion, and anatomic landmarks were marked on the neck for a tra- nerves) can result in sudden death from bradycardia, asystole, and
cheotomy or cricothyroidotomy. The surgeon and OR personnel cardiac arrhythmia. Involvement of the retropharyngeal space can
were positioned and prepared for an emergent surgical airway in lead to descending infection involving the mediastinum. Ery-
case the need arose. The anesthesiologist successfully intubated the thema over the upper chest is suggestive of descending infection
patient using an awake fiberoptic nasal intubation technique. With and may require cardiothoracic consultation.
a large-bore needle, the LPS was further aspirated, and the material Of particular concern are infections that do not appropriately
was sent for culture and sensitivity. The left mandibular third molar respond to treatment. Consideration should be given to inade-
was extracted. The left medial and lateral masticator and the LPS quate drainage or resistant bacterial strains. Culture and sensitiv-
were explored and drained via an intraoral and extraoral approach. ity studies can be obtained on purulent aspirates to guide antimi-
A red rubber catheter was secured into the medial and lateral mas- crobial therapy.
ticator spaces, and a Penrose drain was secured in the LPS. (In pa- Major complications are more likely to develop with increased
tients with a latex allergy, a Foley catheter can be considered a viable length of stay for patients. Several studies have recently investi-
alternative to a red-rubber catheter and Penrose drain because they gated predictive biomarkers and clinical indicators that can be
both contain latex.) The patient was started on ampicillin–sulbactam used to predict length of stay (LOS). A retrospective cohort study
3 g intravenously every 6 hours. He remained intubated postopera- conducted by Gallagher et al. in 2021 investigated the benefit of
tively and was transferred to the intensive care unit (ICU). On the using the neutrophil-to-lymphocyte ration (NLR) as a biomarker
night of his surgery, he was weaned to minimal ventilator settings. He for deep neck space infections secondary to odontogenic infection
was awake and alert and in no apparent distress, with a Glasgow to predict patient LOS using data from a full blood count. NLR
Coma Scale score of 11T. is increased in patients with deep neck space infections because
The wound care regimen included meticulous irrigation of the neutrophils are the first line of defense in the innate immune re-
drains. On postoperative day 1, the patient’s WBC count de- sponse while lymphocytes are redistributed into the lymphatic
creased to 13,000 cells/mm3 (it is not uncommon for the WBC system. The researchers reviewed 161 patient charts from 2009 to
count to increase immediately after surgery because of demar- 2019 and found that NLR of 4.65 or more was statistically sig-
gination), and there was a notable decrease in pharyngeal and facial nificantly associated with patient LOS of 2 days or more with
edema (it is common for surgical edema and fluid resuscitation to 60.7% sensitivity. In addition, they found that patients with NLR
worsen the preexisting edema). A Gram stain revealed the presence of 11.75 or more should be carefully monitored for complications
of gram-positive cocci in pairs and chains (Streptococcus spp.) and that require ICU admissions. NLR can be a beneficial tool in the
gram-negative rods (mixed infection). On the second postopera- management and assessment of patients with odontogenic-in-
tive day, the WBC count decreased to 10,200 cells/mm3 with a duced deep space neck infections.
significant decrease in edema and return of the uvula to midline. A similar study was conducted by Stathopoulos, et al. in 2017
All sedative medications were discontinued, and the patient was investigated the role of C-reactive protein (CRP) as a predictive
extubated after passing a cuff leak test. He was subsequently trans- factor of LOS. They found that the concentration of CRP in pa-
ferred to the ward and discharged to home care with oral antibiot- tient serum was significantly associated with increased LOS. In
ics after 5 days of wound care and IV medications. At discharge, addition, they found a direct linear relationship between the LOS
there was no significant drainage, and all drains were removed. He and concentration of CRP. CRP testing can be very helpful at
was given instructions for jaw range of motion exercises and a predicting LOS but comes at an extra cost, but NLR can be cal-
follow-up appointment. culated directly from routine blood work.

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 CHAPTER 25 Lateral Pharyngeal and Masticator Space Infection 119

In addition, a study of deep space infections was conducted in also occur via spread through lymphatic vessels and subsequent
2022 to analyze the clinical features of patients with odontogenic rupture of a node. Lymphatic drainage from the nose and parana-
orofacial infection. Using multivariant logistic regression, they sal sinuses, ear, or oral cavity can involve this area. Infection can
found that diabetes mellitus and multiple space involvement were also spread from retropharyngeal, sublingual, submandibular, or
statistically significantly associated with a long ($5 days) LOS. masticator space infections. Peritonsillar abscesses that rupture
through the superior constrictor muscle can also cause entry and
Discussion infection of the LPS directly.
Symptoms of LPS involvement vary according to whether the
The LPS has the shape of an inverted pyramid or cone, the base anterior or posterior compartment is involved. The four most
of which is the sphenoid and the apex is the hyoid bone. The common signs of involvement of the anterior compartment are
boundaries of this space are summarized in Table 25.2. (1) trismus, (2) induration or swelling at the angle of the jaw, (3)
The LPS is divided by the styloid process and its muscles into an pharyngeal bulging with or without deviation of the uvula, and
anterior and a posterior compartment. The anterior compartment (4) fever.
contains only fat, muscle, connective tissue, and lymph nodes. The Deviation of the uvula with bulging of the pharyngeal wall can
posterior compartment contains the glossopharyngeal, spinal acces- also be seen with peritonsillar abscesses; however, trismus is usually
sory, and hypoglossal nerves. It also contains the carotid sheath (the absent. With LPS infections, trismus is seen secondary to involve-
carotid artery, internal jugular vein, and vagus nerve; the cervical ment of the adjacent medial pterygoid muscle. It can be difficult
sympathetic trunk lies posterior and medial to the carotid sheath). to differentiate a pterygomandibular space abscess from an LPS
A strong fascial plane, the stylopharyngeal aponeurosis of Zucker- infection, but this distinction may be of academic interest only
kandl and Testut, separates the anterior and posterior compart- because treatment would be similar. Involvement of the posterior
ments. It is a barrier that helps prevent the spread of infection from compartment may show posterior tonsillar deviation and retropha-
the anterior to the posterior compartment. ryngeal bulging. In this scenario, palsies of cranial nerves IX
Lateral pharyngeal infections can be caused by tonsillitis, otitis through XII may be seen, in addition to ipsilateral Horner’s syn-
media, mastoiditis, or parotitis; most commonly, they occur sec- drome (ipsilateral blepharoptosis, pupillary miosis, and facial anhi-
ondary to an odontogenic pathology. Involvement of the LPS can drosis). A common sign of LPS involvement is the presence of
swelling of the lateral neck just above the hyoid and just anterior
to the sternocleidomastoid muscle. This is the point where the LPS
is closest to the skin and where dependent edema or exudate is
TABLE constrained by binding of the fascial layers to the hyoid bone.
25.2 Boundaries of the Lateral Pharyngeal Space
Significant upper airway edema may require the patient to re-
Space Boundary
main in an upright position because assuming the supine position
may lead to airway obstruction. Also, depending on the severity
Anterior Pterygomandibular raphe (junction of buccinators and of the obstruction, patients may present with breathing with the
superior constrictor muscles) mouth open or in the “sniffing position,” with extension of the
Posterior Prevertebral fascia that communicates with the retro- neck, stridor, labored breathing, intercostal retractions, tracheal
pharyngeal space tug, sore throat, or globus. Changes in voice also provide a clue to
the location of airway involvement. A muffled, or “hot potato,”
Medial Buccopharyngeal fascia on lateral surface of the supe-
voice usually signifies a supraglottic process, whereas hoarseness is
rior constrictor muscle
a sign of vocal cord involvement.
Lateral Fascia over the medial masticator, the parotid gland,
and mandible ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 119.e1

Bibliography Miller WD, Furst IM, Sandor GK, et al: A prospective blinded com-
parison of clinical examination and computed tomography in deep
neck infections, Laryngoscope 109:1873-1879, 1999.
Adamson OO, Gbotolorun OM, Odeniyi O, et al: Assessment of predic- Mills C, Patel P: Adopting caries risk assessment in all practice environ-
tors of treatment outcome among patients with bacterial odontogenic ments, Gen Dent 64(4):66-72, 2016.
infection, Saudi Dent J 30(4):337, 2018. Munoz A: Acute neck infection: prospective comparison between CT
Bali R, Sharma P, Gaba S: Use of metronidazole as part of an empirical and MRI in 47 patients, J Comput Assist Tomogr 25:733-741, 2001.
antibiotic regimen after incision and drainage of infections of the O’Grady NP, Barie PS, Bartlett JG, et al: Guidelines for evaluation of
odontogenic spaces, Br J Oral Maxillofac Surg 53(1):18-22, 2015. new fever in critically ill adult patients: 2008 update from the
Brook I: Microbiology and management of peritonsillar, retropharyngeal and American College of Critical Care Medicine and the Infectious
parapharyngeal abscesses, J Oral Maxillofac Surg 62:1545-1550, 2004. Chow Diseases Society of America, Crit Care Med 36(4):1330-1349, 2008.
AW: Complications, diagnosis, and treatment of odontogenic Potter JK: Tracheotomy versus endotracheal intubation for airway man-
infections. In Post TW, editor: UpToDate, Waltham, MA, 2022, agement in deep neck space infections, J Oral Maxillofac Surg 60:349-
UpToDate Inc. doi:http://www.uptodate.com. 354, 2002.
Costa SM, Silveira RL, Amaral MBF: Ultrasonography on the early Ray JM, Triplett RG: What is the role of biofilms in severe head and neck
postoperative control of severe odontogenic infections, J Oral Maxil- infections? Oral Maxillofac Surg Clin North Am 23:497, 2011.
lofac Surg 79(3):608-610, 2021. Rega AJ: Microbiology and antibiotic sensitivities of deep neck space
Dzyak W, Zide MF: Diagnosis and treatment of lateral pharyngeal space infections, J Oral Maxillofac Surg 62:25-26, 2004.
infections, J Oral Maxillofac Surg 42:243-249, 1984. Sharma K, Das D, Joshi M, et al: Deep neck space infections-a study in
Flynn T: What are the antibiotics of choice for odontogenic infections diabetic population in a tertiary care centre, Indian J Otolaryngol Head
and how long should the treatment course last? Oral Maxillofacial Neck Surg 70(1):22-27, 2018.
Surg Clin North Am 23:519, 2011. Sittitrai P, Srivanitchapoom C, Reunmakkaew D: Deep neck infection in
Flynn TR, Shanti RM, Levi MH, et al: Severe odontogenic infections. Part patients with and without human immunodeficiency virus: a com-
1. Prospective report, J Oral Maxillofac Surg 64:1093-1103, 2006. Flynn parison of clinical features, complications, and outcomes, Br J Oral
TR: Surgical management of orofacial infection, Atlas Oral Maxil- Maxillofac Surg 56(10):962-967, 2018.
lofac Surg Clin North Am 8:77-99, 2000. Soma VR: Contrast-associated nephropathy, Heart Dis 4:372-379, 2002.
Gallagher N, Collyer J, Bowe CM: Neutrophil to lymphocyte ratio as a Stathopoulos P, Igoumenakis D, Shuttleworth J, et al: Predictive factors of
prognostic marker of deep neck space infections secondary to odon- hospital stay in patients with odontogenic maxillofacial infections: the
togenic infection, Br J Oral Maxillofac Surg 59(2):228-232, 2021. role of C-reactive protein, Br J Oral Maxillofac Surg 55(4):367-370, 2017.
Hawkins A, Ponnusamy S, Markiewicz MR, et al: Use of a Foley catheter Storoe W: The changing face of odontogenic infections, J Oral Maxillofac
in the drainage of deep space neck infections, Br J Oral Maxillofac Surg 59:739-748, 2001.
Surg 57(9):942-943, 2019. Styer TE: Peritonsillar abscess: diagnosis and treatment, AhymsicFian P
Hollinshead W: The head and neck. In Anatomy for Surgeons, Vol 1, 65:95, 2002.
Philadelphia, 1982, Lippincott-Raven. Udaka T, Hiraki N, Shiomori T, Miyamoto H, Fujimura T, Inaba T,
Jelmini J, Patel A: Utilizing a nasal speculum in maxillofacial trauma and Suzuki H: Eikenella corrodens in head and neck infections, J Infect
deep space neck infections: a technical note, J Oral Maxillofac Surg 54(4):343-348, 2007.
80(9):1518-1521, 2022. Yew CC, Ng MP, Khoo SE, et al: Multivariate analysis on orofacial odon-
Maharaj S, Mungul S, Ahmed S: Deep neck space infections: changing togenic infection in Northern Peninsular Malaysia, J Oral Maxillofac
trends in pediatric versus adult patients, J Oral Maxillofac Surg Surg 80(4):736-743, 2022.
78(3):394-399, 2020.

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26
Osteomyelitis
L A N C E T H OMP S O N

CC
A 62-year-old female presents to your clinic with ongoing pain
and swelling of 4 weeks’ duration after incision and drainage of a
multispacer submental–submandibular abscess.

HPI
One month before today’s visit, the patient was treated at the
hospital for an acute submental–submandibular abscess. She
underwent root canal treatment of tooth #19 and subsequently
developed pain and swelling below her jaw 14 days after the
procedure. She presented to the hospital with a leukocytosis
of 18,000 cells/mm3 and submental and submandibular edema
and pain. Maxillofacial computed tomography (CT) with con-
trast showed multifocal low-attenuation collections with fat
stranding in the ventral submental region and right submandibu-
lar space most consistent with an early abscess (Fig. 26.1).
Additionally, osseous dehiscence was noted on the lingual man-
dible adjacent to the root apices of tooth #19 (Fig. 26.2). No
osteolysis was noted anywhere other than the lingual cortex. • Fig. 26.1 Initial computed tomography scan with contrast showing sub-
1. Multifocal low-attenuation collections with fat stranding in mental abscess.
the ventral submental region and right submandibular space as
detailed earlier. Overall, this most likely represents right sub-
mandibular and submental phlegmon or early abscesses. There
is osseous dehiscence medial to the root of the left mandibular
molar (tooth #19) (best seen axial image 52, series 2). Findings
raises suspicion for a spread of infection or abscess from left
mandibular molar along the buccal mandibular gingiva. Oth-
erwise, suggest correlation with caries of the mandibular inci-
sors or right mandibular canine.
Initial axial CT scan (Fig. 26.3) shows normal bone architec-
ture of the mandible.
The patient was taken to the operating room (OR) for incision
and drainage (I&D) of the submental and sublingual space ab-
scess along with extraction of tooth #19. She had an uncompli-
cated hospital course and was discharged on postoperative day 4
on oral antibiotics (7-day course of amoxicillin-clavulanate
875/125) after removal of submental and submandibular drains.
She presented to clinic 1 week after discharge from the hospital
with ongoing pain from the anterior mandible–submental region
with edema. An additional course of antibiotics was prescribed,
and the patient followed up weekly with slow improvement. At
the 1-month follow-up visit, she complained of persistent swell-
ing and pain. A cone-beam CT (CBCT) scan was performed with • Fig. 26.2 Sagittal slice showing lingual cortical perforation adjacent to
significant mandibular osteolysis with mottled-appearing bone recently root canal treated tooth #19.

120
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 CHAPTER 26 Osteomyelitis 121

Edentulous space #19 is well healed. Occlusion is stable and repro-

ducible without signs of stepoffs. No mandibular exposed bone,
mobility, or pathologic fracture. Floor of the mouth is soft and
nonelevated.
Neck. Trachea midline, thyroid soft, and nonenlarged. Subtle
submental edema is noted. This area is mildly tender to palpation.
Surgical drain wounds from the submental and submandibular
space are healed without any purulent exudate. There is mild
lymphadenopathy present in the left submandibular nodes.

Imaging
The initial imaging study included a medical grade CT with con-
trast, which showed soft tissue rim-enhanced hypodense regions
consistent with a submental and submandibular space abscess (see
Fig. 26.1). Also evident on the scan is lingual cortical perforation
adjacent to the roots of tooth #19 (see Fig. 26.2).
As the course of the process continued, mandibular osteolysis
• Fig. 26.3 Initial axial computed tomography scan showing normal bone became apparent. These areas of osteolysis eventually were re-
architecture of the mandible. placed with dense bone with increased cortical width.
At the 1-month follow-up visit, a CBCT scan was obtained
that shows increased medullary spread of osteolysis and cortical
along the mandibular symphysis. Compared with the initial CT, mottling extending from the left body of the mandible to the
there is noted increased density of the left mandibular body. symphysis (eFig. 26.4).
eFig. 26.5 shows a panoramic view of the mottled-appearing
PMHX/Medications/Allergies/SH/FH left mandibular body and symphysis also taken on the 1-month
follow-up visit.
• Asthma–chronic obstructive pulmonary disease overlap syn- eFig. 26.6 shows new mottled areas with increased sclerotic-
drome appearing bone demonstrated as increased density in the left
• Chronic cough mandibular body and symphysis.
• Chronic kidney disease eFig. 26.7 and Fig. 26.8 are the three-dimensional reconstruc-
• Hypertension tions from the CBCT demonstrating the evolving osseous de-
• Medications: albuterol inhaler, amlodipine struction and progressing sclerotic or cortical thickened areas at
• Allergies: no known drug allergies the 1- and 3-month timeframe.
Surgical history and family history are noncontributory. Axial view of the CBCT from the 3-month appointment
This patient denies any history of head and neck radiation or shows extensive increased radiopacity of the medullary bone with
use of bisphosphonates. These are important factors to rule out to thickened cortex and minimal density difference between cortex
help differentiate between osteomyelitis and bisphosphonate-in- and marrow (Fig. 26.9). Also noted in this image is a lingual
duced osteonecrosis and osteoradionecrosis. The patient is medi- sequestrum.
cated for asthma, and her renal issues are stable and do not require
dialysis or renal dosing adjustment. Other pertinent negatives Assessment
include the absence of diabetes mellitus, no acquired viral or
medication-induced immunocompromised state, nonsmoker, and Acute submental–submandibular space abscess progressing to diffuse
no history of splenectomy. sclerosing osteomyelitis or chronic sclerosing osteomyelitis. This diagno-
sis is based on the demonstrated acute infection with abscess formation
Examination followed by the chronic prolonged symptoms and sclerotic changes to
the bone.
Vital signs. Blood pressure is 126/84 mm Hg, heart rate is 74 bpm, The patient underwent routine root canal treatment of tooth
respirations are 16 breaths per minute, and temperature is 37.4°C. #19. Two weeks after the procedure, she developed submandibu-
General. Well-appearing, well-nourished 62-year-old female lar and submental swelling. Clinical and radiographic findings
who appears her stated age. Oriented 33 in no acute distress. suggesting submental and submandibular space abscess were pres-
Head and maxillofacial. Normocephalic, no notable facial ent. There was cortical dehiscence on the lingual surface of the
asymmetry. Pupils equal, round, and reactive to light and accom- mandible adjacent to the root apices of tooth #19. Transcervical
modation. Extraocular movements are intact bilaterally, external I&D was performed along with extraction of tooth #19. She was
ears are normal in appearance, external audial canal is clear, tym- treated with appropriate perioperative antibiotics and discharged
panic membrane is intact, septum is midline without deviation. with 10 days of amoxicillin–clavulanate. Outpatient follow-up
Facial skin is free of lesions or masses. No trismus. Maximal in- revealed ongoing pain and swelling. One month after I&D, a CT
terincisal movement is 40 mm. No sensory disturbances. Bilateral MaxFace was obtained and showed osteolysis of the mandible
V3 sensation intact and normal. consistent with osteomyelitis. The patient was maintained on
Oral cavity. No lesions noted on the oral mucosa. Dentition is antibiotics and scheduled for surgery. On the day of the opera-
in good repair with restorations showing no signs of recurrent de- tion, in the preoperative check-in examination, she endorsed im-
cay. No evidence of severe periodontal disease or dental mobility. proved symptoms of pain and swelling. This is an important point

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 CHAPTER 26 Osteomyelitis 121.e1

• eFig. 26.6 Progression to chronic sclerosing osteomyelitis shown on the

final cone-beam computed tomography reconstructed as a panoramic
radiograph 3 months after initial presentation to the hospital.

B
• eFig. 26.4 A and B, One-month postoperative image after incision and
drainage and extraction of tooth #19.

B
• eFig. 26.7 Three-dimensional reconstruction from the cone-beam com-
puted tomography scan demonstrating the evolving osseous destruction
and progressing sclerotic or cortical thickened areas at the 1- (A) and
3-month (B) timeframes.

• eFig. 26.5 Progression and diagnosis of osteomyelitis. Panoramic radio-

graph from 1 month after incision and drainage and extraction of tooth #19.

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122 S E C TI O N Oral and Maxillofacial Infections

because of the effect it may have on influencing treatment. Even

though the patient showed improvement, it was necessary to go
forward with the planned procedure to obtain culture data and a
biopsy of bone to diagnose this as osteomyelitis. The patient was
taken to the OR for debridement and decortication, and bone
biopsy revealed generally healthy-appearing bone. Specimens of
bone were taken from the most representative site and sent for
pathology and culture. Of note, no purulence, granulation tissue,
or reactive periosteum were noted on exploration of the mandible.
Culture and pathology data are included here. The pathology
report showed the following diagnosis after microscopic examina-
tion: left mandible, biopsy:
• Fragments of benign bone with mild reactive reparative changes
• Negative for definitive features of acute or chronic osteomyelitis

Culture Data
Culture data showed:
A • Streptococcus sanguinis isolated from thioglycollate broth only
• No Staphylococcus aureus isolated
• No beta-hemolytic streptococci isolated
• No anaerobic organisms isolated
The pathology showed no definitive features of osteomyelitis,
and the cultures showed minimal growth of S. sanguinis. A con-
sultation by infectious disease specialists was limited because of
the lack of conclusive histopathology and culture data. The deci-
sion was made to continue amoxicillin–clavulanate for 4 weeks.
The patient continued to improve after surgery. The impression
was that the patient was improving and that the osteolysis seen on
B preoperative imaging had already begun to recorticate. At 1
• Fig. 26.8 Three dimensioanl CBCT images showing loss of cortical month after the second procedure, she was significantly improved
bone and destructive lesion of the anterior lingual mandible. clinically. Her pain and swelling had almost entirely resolved.
The most recent imaging CBCT showed lingual sequestrum
and mixed osteolysis and sclerotic bone. Infectious disease was
reconsulted, and antibiotics were resumed. The final diagnosis of
diffuse sclerotic osteomyelitis was made, and additional surgical
debridement was discussed.

Etiology
This is a rare presentation for sclerotic osteomyelitis because there
is traditionally no acute stage. Acute and chronic suppurative
forms of osteomyelitis are defined by formation of purulence. Dif-
fuse sclerosing osteomyelitis typically has a more insidious onset
that can prolong the time to diagnosis and treatment. The classic
description includes pain and swelling that occur with acute exac-
erbations without any purulent drainage or abscess formation.
Diffuse sclerosing osteomyelitis is a rare infectious disease
characterized by chronic mandibular pain and osseous changes
with classic radiographic findings. There are active exacerbations
of pain and soft tissue swelling that are transient. As the course of
the disease process progresses, the bone becomes sclerotic with
increased radiopacity. The mandibular body is the most common
area of occurrence. Several organisms have been implicated with
the Actinomyces species mutualistic relationship, with Eikenella
corrodens being the most commonly described bacteria involved.
• Fig. 26.9 Axial view of the cone-beam computed tomography scan from The presence of skin and oral flora contributing to contamination
the 3-month appointment showing extensive increased radiopacity of the of the specimen can potentially lead to erroneous culture data.
medullary bone with thickened cortex and minimal density difference The defining feature of this form of osteomyelitis is the lack of any
between the cortex and marrow. Also noted in this image is a lingual suppurative drainage. The absence of this hallmark sign of infec-
sequestrum. tion makes sclerosing osteomyelitis a diagnostic challenge.

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 CHAPTER 26 Osteomyelitis 123

Diagnosis
The diagnosis of nonsuppurative osteomyelitis can be a challenge
because of fewer outward signs of infection. The classic presentation
of chronic sclerosing osteomyelitis involves intermittent episodes of
pain and swelling without any abscess. Clinically, patients exhibit
subtle swelling and possibly warm erythematous soft tissue overlying
the area of infection. This condition almost always involves the man-
dible and historically is most common in young females. Several de-
scribed possible pathways for bacterial invasion have been described,
but there are no hard data to suggest a typical route. Chronic peri-
odontal disease and root canal treatments are both commonly cited
as potential mechanisms of bacterial ingress. The classic description
of the disease process is a slow onset with severe pain in the mandible.
These episodes of pain can be constant or episodic.

Radiologic Findings • Fig. 26.11 Sagiattal view of the anterior manible, showing mixed radio-
The main differentiating factors between chronic sclerosing osteo- lucent and radiopaque lesion with cortical destruction.
myelitis (CSO) and the other forms of this disease are the pro-
found sclerosis with increased density of the bone. In standard slightly reossified (Fig. 26.11). The sclerotic-appearing bone can
osteomyelitis, it is typical to find a radiolucency that represents take on the same density as the cortical bone. Magnetic resonance
osteolysis spreading throughout cancellous bone. This is often imaging and Tc-scintigraphy can also be used but are much less
seen in conjunction with cortical perforations and a lamellated common methods of diagnosis or monitoring.
periosteal reaction. In CSO, there is osteolysis, but the defining
feature is the increased endosteal radiopacity. It is possible to see Histopathologic Findings
bone apposition and cortical expansion, but these are usually late
signs. Panoramic radiography shows these changes as course tra- Sclerotic changes of the bone with coarse trabeculae are routinely
becular patterns with a ground-glass increased radiopacity. CT seen on microscopic evaluation. The other findings can be similar
(medical-grade or office CBCT) scans have the advantage of to fibrous dysplasia. These include necrotic foci and partial calci-
showing areas of sequestrum in greater detail. There are often fication of atrophic trabeculae. Chronic inflammatory changes are
areas of osteolysis within the cancellous bone that track to the also common.
cortex, where a perforation can be seen. There can be widening
of the lamina dura that mimics periapical abscess. The teeth Laboratory Markers
should be assessed for vitality to confirm that pulpal necrosis is
not present. The recommendation is to avoid extraction of these A complete blood count is a standard laboratory test to evaluate
teeth because the areas of osteolysis often improve given time. the white blood cell (WBC) count for leukocytosis. This value can
The widened lamina dura can be visualized first (Fig. 26.10) and be used to trend the infection and monitor the response to surgery
and antibiotics. Depending on the laboratory, a WBC count
above 10,000 cells/mm3 is considered elevated. C-reactive protein
and the erythrocyte sedimentation rate are nonspecific inflamma-
tory markers that can also help trend the response of infections to
treatment. There is no specific laboratory marker to diagnose,
stage, or track the disease progress of CSO.

Treatment
The treatment for any infection is source control. This is difficult
in CSO because the medullary spread and diffuse nature of the
entity make clearing the entire infection impossible in most cases.
Additionally, several signs point to the transition from a bacterial
to an inflammatory or metabolically driven disease process in the
late stages. For these reasons, CSO can often become chronic with
no surgical cure. The goals of treatment are to remove all areas of
necrotic or sequestered bone and to obtain culture and pathology
samples of excellent quality to aid the diagnosis and treatment.
Decortication of the infected bone is also commonly used to at-
tempt increasing penetration and neovascularization to the can-
cellous bone sites of infection. Aggressive decortication with re-
moval of the buccal plate via a transoral or transcervical approach
• Fig. 26.10 Cone-beam computed tomography scan taken 1 month after may be used for recalcitrant disease. Long-term oral or intrave-
incision and drainage. nous (IV) antibiotics are the gold standard treatment in addition

t.me/Dr_Mouayyad_AlbtousH
124 S E C TI O N Oral and Maxillofacial Infections

to the initial surgical phase of treatment. Most patients require Discussion

long-term IV antibiotics and an infectious disease medical consulta-
tion. Some surgeons recommend hyperbaric oxygen treatments be- Osteomyelitis in general is more common in the mandible, and
fore and after surgery to aid in perfusion and improved tissue regen- this is commonly blamed on less blood supply and increased bone
eration. Other adjuncts to treatment are available with the most density relative to the maxilla. CSO almost invariably occurs in
promising being the antiresorptives. Bisphosphonates have been the mandible with only a few cases reported of maxillary manifes-
described in the treatment of patients with refractory CSO. The tation. The classic demographic for this disease process is in young
main benefit is improved pain. Newer studies have shown that de- females. Although medical and surgical treatment options are
nosumab at 60 or 120 mg has notable improvement in symptoms. available and have reasonable outcomes, there is no agreed-upon
The benefits to using denosumab over traditional bisphosphonates cure for the process. Initial treatment after the diagnosis is made
are the shorter half-life of the drug and secondarily the decreased includes antibiotics and surgical debridement, which typically
long-term risk of medication-related osteonecrosis of the jaw becomes increasing aggressive as the process continues on. Decor-
(MRONJ). The exact mechanism that allows these medications to tication and removal of sequestra are often included in the surgi-
treat the symptoms is unclear but appears to involve targeting the cal phase. Long-term IV antibiotics are typically used based on
receptor activator of nuclear factor-kB (RANK), receptor activator culture data and discussion with an infectious disease specialist. If
of nuclear factor-kB ligand (RANKL), and osteoprotegerin system the disease is not responsive and the patient continues to have
that is dysregulated in CSO. The main drawback to the use of anti- episodic pain, treatment with antiresorptives has shown good ef-
resorptive medications is the risk of MRONJ. For this reason, these ficacy. Denosumab 60-mg subcutaneous injection has shown to
medications are reserved for the most symptomatic and refractory be effective while minimizing the risks of MRONJ and having a
cases. A thorough conversation with the patient regarding the risks short half-life. As with any infectious disease, early diagnosis and
of the medication is important. Patients who are at high risk for proper treatment are critical to mitigation of complications and
MRONJ, including those with severe periodontal disease, nonre- tissue destruction.
storable teeth, or impacted third molars, should be treated surgically
before starting these medications. Additionally, corticosteroids have ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
been used with some subjective improvement in pain. complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 124.e1

Bibliography Marx RE, Carlson EC, Smith BR, et al: Isolation of Actinomyces species
and Eikenella corrodens from patients with chronic diffuse sclerosing
osteomyelitis, J Oral Maxillofac Surg 52:26-33, 1994.
Adekeye EO, Cornah J: Osteomyelitis of the jaws: a review of 141 cases, Montonen M, Li TF, Lukinmaa PL, et al: RANKL and cathepsin K in
Br J Oral Maxillofac Surg 23:24-35, 1985. diffuse sclerosing osteomyelitis of the mandible, J Oral Pathol Med
Antao CJ, Dinkar AD, Khorate MM, et al: Chronic diffuse sclerosing 35(10):620-625, 2006.
osteomyelitis of the mandible, Ann Maxillofac Surg 9(1):188-191, Montonen M, Lindqvist C: Diagnosis and treatment of diffuse sclerosing
2019. doi:10.4103/ams.ams_257_18. osteomyelitis of the jaws, Oral Maxillofacial Surg Clin North Am 15:
Antao C, Dinkar A, Khorate M, Dessai S: Diffuse sclerosing osteomyeli- 69-78, 2003.
tis of the mandible. Otto S, Burian E, Troeltzsch M, et al: Denosumab as a potential treatment
Hallmer F, Korduner M, Møystad A, et al: Treatment of diffuse sclerosing alternative for patients suffering from diffuse sclerosing osteomyelitis
osteomyelitis of the jaw with denosumab shows remarkable results—a of the mandible—a rapid communication, J Craniomaxillofac Surg
report of two cases, Clin Case Rep 6(12):2434-2437, 2018. doi:10. 46(4):534-537, 2018.
1002/ccr3.1894. Peterson LJ: Microbiology of head and neck infections, Oral Maxillofac
Marx RE: Chronic osteomyelitis of the jaws, Oral Maxillofac Clin North Surg Clin North Am 3:247, 1991.
Am 3:367-381, 1991. Previous Edition of Clinics

t.me/Dr_Mouayyad_AlbtousH
27
Third Molar Odontectomy
S H A H R O K H C . B AG H ER I a n d S A N D E E P V. PAT H A K

CC holding certain medicines (i.e., bisphosphonates) to accomplish a

procedure or considering prophylactic removal of compromised
The patient states, “My lower wisdom teeth are hurting.” teeth before the start of radiation to the head and neck or closely
monitoring wound healing from an oral surgery procedure in an
HPI irradiated field. The patient’s fitness for surgery and anesthesia
may be assessed in metabolic equivalents as a functional assess-
A 27-year-old female is referred to your clinic for consultation ment. One may also inquire about prior cardiac history (i.e.,
regarding her third molars. The patient completed her orthodon- stents, cardiac surgery, peripheral artery disease) and exercise tol-
tic therapy in her teen years. For the past few weeks, she had ex- erance to help determine the need for perioperative cardiac diag-
perienced increasing discomfort in the posterior mandible. She nostics (i.e., electrocardiography [ECG], echocardiography, stress
was subsequently referred by her dentist for evaluation. She denies testing, or perfusion imaging). As a result, the patient may require
any fever, swelling, drainage, or trismus as a result. “medical optimization” or perhaps more invasive cardiac proce-
dure to minimize the risk of cardiac event in the perioperative
PMHX/PDHX/Medications/Allergies/SH/FH phase of oral surgical care.
The patient does report intermittent symptoms suggestive of
The patient reports no significant medical problems and takes temporomandibular joint dysfunction (TMD). She does have
birth control medicine regularly. She recalls having had tonsillec- intermittent clicking noises on function but no history of locking.
tomy and ear tubes as a child. Thorough past medical and dental TMD may be aggravated in rare cases as a result of anatomic
histories are important to determine any potential concerns with predisposition of the temporomandibular joint (TMJ) (i.e., discal
general health, fitness for anesthesia, and any possible anesthetic dislocation, condylar pathologies) or surgical techniques (i.e.,
or surgical risks. Although this patient does not report any medi- mouth opening position, length of time for surgery, use of mallet
cal problems regarding these concerns, the surgeon must consider and chisel). She has been taking ibuprofen for her dental pain and
an appropriate plan to contend with the following: bleeding from no other medicines on a regular basis. The patient smokes ap-
coagulopathies (secondary to derangement of hemostasis or med- proximately a half pack of cigarettes per day for the past 6 years
ication induced); wound healing affected by medications (i.e., (risk factor for the development of dry sockets). Al-Belasy (2004)
immunosuppressants) or underlying medical concerns (i.e., dia- has reported the incidence of dry sockets to be reduced with
betes or autoimmune diseases or radiation to a surgical site); fit- smoking cessation. The patient may be counseled on smoking
ness for anesthesia and surgery with regard to cardiac, circulatory, cessation for general health as well as its effect on wound healing.
and respiratory status; and mental status with regard to the pa-
tient’s ability to understand the procedure or be able to cooperate Examination
with a surgical plan. Although bleeding disorders (i.e., coagulopa-
thies) may be of concern, the surgeon more commonly encoun- General. The patient is a well-developed and well-nourished fe-
ters bleeding problems as a result of anticoagulant medicines, male in no apparent distress. Patients exhibiting higher levels of
such as warfarin or newer antiplatelet drugs or over-the-counter anxiety may require a deeper level of sedation and anesthesia.
nonsteroidal antiinflammatory drugs (NSAIDs) or herbal medi- Maxillofacial. There is no soft tissue abnormality or lymph-
cines. Countermeasures are considered based on the mechanism adenopathy. The patient has a good range of mandibular motion
of action of these specific drugs and may include simply stopping with a maximal interincisal opening (MIO) of 45 mm. Examina-
the medicine versus a counter drug. The patient may be taking tion of the TMJ reveals no clicks or pain on palpation nor any
anticoagulant therapy to prevent a thromboembolic event. The deviation on range of motion. The muscles of mastication are
surgeon must stratify the patient’s risk as low, moderate, or high nontender to palpation. It is important to detect preexisting
for a perioperative thromboembolic event as a result of stopping symptoms of TMD. The range of motion of the mandible and of
or modifying anticoagulant therapy. The surgeon may coordinate the neck and classification of the airway may indicate the diffi-
care with the patient’s cardiologist and consider the urgency and culty of intubation if needed.
nature of the planned surgical intervention. Wound healing is also Intraoral. Oral soft tissue is free of lesions, and there is no
of paramount concern and may require optimizing medical ther- evidence of acute infection. The mandibular third molars are im-
apy for an underlying medical condition (i.e., diabetes) or perhaps pacted and hypoerupted, with approximately 20% of the crown

126
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 CHAPTER 27 Third Molar Odontectomy 127

visible in the oral cavity with insufficient space for functional • BOX 27.1 Rood’s Radiographic Predictors of
eruption. The overlying operculum appears slightly inflamed, Potential Tooth Proximity to the
with evidence of plaque and periodontal pockets of 6 mm on the
Inferior Alveolar Canal
distal of the left and right mandibular second molars. The right
and left maxillary third molars are hypoerupted and buccally • Darkening of the root
malposed with occlusal caries. Oral hygiene is fair. An examina- • Deflection of the root
tion of the oropharynx is without tonsillar hypertrophy, and the • Narrowing of the root
patient has a Mallampati score of 1. • Dark and bifid root apex
Obvious indications for the removal of third molars include • Interruption of the white line of the canal
pain, infection, dental and periodontal disease (of the third molar • Diversion of the canal
• Narrowing of the canal
or adjacent teeth), nonrestorable status of the tooth, malposition,
and lack of space leading to such conditions. However, other Modified from Rood JP, Shehab BA: The radiological prediction of inferior alveolar nerve injury during
indications according to the parameters of care of the American third molar surgery, Br J Oral Maxillofac Surg 28(1):20-25, 1990.

Association of Oral and Maxillofacial Surgeons (AAOMS) include

abnormality of size or shape not allowing appropriate function,
facilitation of prosthetic rehabilitation, facilitation of orthodontic
positioning of teeth, tooth interfering with mandible fracture re- adjunct for identification of an increased risk for IAN injury, the
pair or orthognathic surgery, teeth with associated pathology use of CBCT does not translate into a reduction of IAN injury
(odontogenic tumors), prophylactic removal in the face of pending and other postoperative complications, after removal of the com-
medical or surgical care (e.g., transplant surgery, bisphosphonate, plete mandibular third molar” (Fee et al.). Tofangchiha et al.
chemo- or radiation therapy), tooth fracture, pathologic resorption found the root apex darkening of impacted third molars and in-
of tooth, malposed third molars adversely influencing the eruption terference with the white line of the inferior alveolar canal on
of adjacent teeth, and third molar as a donor tooth for autotran- panoramic radiographs had a high positive predictive value for
plantation, The decision to remove symptomatic third molars may determination of the contact of impacted mandibular third mo-
be more straightforward on complete discussion of the informed lars with the inferior alveolar canal.
consent process with the patient or their family. However, the deci- Slavos et al. assessed the degree of compression of the IAN
sion to remove asymptomatic third molars (impacted or otherwise) canal with outcomes of the mandibular third molar removal sur-
or to monitor them has been the subject of some controversy over gery and found that a greater degree of compression may predict
the years. Unfortunately, there is no clear guidance from multiple an increased risk of IAN injury postoperatively. Multiple studies
studies for either decision. Despite the lack of clear evidence, the have identified the buccolingual IAN position and decorticaliza-
decision for removal or monitoring the third molars is one that tion of the IAN canal with lingual position of the nerve are associ-
should be best undertaken with the patient based on their clinical ated with high risk of nerve damage. Direct contact with the root
and radiographic examination and discussion of the pros and cons of third molars and IAN canal or nerve and appearance of a
of both possible choices and the various rationales for removal. As teardrop or dumbbell shape of the canal or nerve in cross-section
indicated by Pogrel, it is clear younger patients (younger than 25 on a CT are indicative of anatomic risk factors.
years old) do fairly better in the recovery process. Conversely, the Given the risk of postoperative IAN injury, partial odontectomy
risk of complications and recovery do increase with increasing age. (coronectomy) may at times be an alternative treatment in patients
The decision to remove asymptomatic third molars should be requiring removal of a third molar that is in close proximity to the
driven by evidence-based decision making; the predominant guid- IAN. However, this procedure does not eliminate the risk of IAN
ing principle should be the patient’s preference. injury and possible future infectious complications because of re-
tention of root fragments. More recent studies support coronec-
Imaging tomy as an alternative to minimize the risk to the IAN. However,
the decision to perform coronectomy versus total odontectomy
A panoramic radiograph is the minimum imaging modality nec- should be discussed thoroughly with the patient, weighing the pros
essary for the evaluation and treatment of impacted third molars. and cons of each procedure and the patient’s risk tolerance.
This imaging affords an overall view of the position of the third In the current patient, the panoramic radiograph (Fig. 27.1) reveals
molars in a two-dimensional representation. Most important, it a lack of space to accommodate the eruption of the distoangularly
can indicate the proximity of the roots of the third molars to the
inferior alveolar nerve (IAN) canal. The radiographic markers of
possible IAN proximity and subsequent possible adverse out-
comes are well-known for panoramic imaging, such as deflection
of the canal, narrowing of the canal, darkened appearance over the
roots of these teeth, or loss of cortical borders of the canal (Rood’s
predictors: Box 27.1). As a result, the surgeon may recommend
three-dimensional (3D) imaging to better visualize the relation-
ship of these vital structures and better predict the risk of removal
of these teeth. Cone-beam computed tomography (CBCT) is
becoming more common place in practice. Computed tomogra-
phy (CT) scans are not always necessary for routine evaluation,
but they may be used in select cases of suspected maxillofacial
pathology or for accurate determination of the IAN anatomy. • Fig. 27.1 Panoramic radiograph demonstrating the position of the im-
Multiple studies suggest that the CBCT is “a valuable diagnostic pacted third molars.

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128 S E C TI O N Dentoalveolar Surgery

• Fig. 27.2 Cone beam computed tomography reconstruction with outline of the mandibular canal with
transverse and coronal analysis as different angles.

impacted mandibular third molars with 100% root develop- Assessment

ment. The roots are completed in development and extend infe-
rior to the level of the neurovascular bundle. The outlines of A 27-year-old female in good health with partial bony impaction of
mandibular canals are easily discerned on the radiograph. There the right and left maxillary and mandibular third molars with insuf-
is no diversion of the inferior alveolar canal, but there is interrup- ficient space for functional eruption; carious malposed maxillary third
tion of the cortical white line, and there is darkening of the third molars, localized gingivitis, and periodontal pocketing are noted
molar root (risk factors associated with IAN injury). The maxil- around the left and right mandibular third molars.
lary third molars are buccally malposed and hypoerupted. The
maxillary sinuses and the remainder of the radiograph are within Treatment
normal limits. The primary risks associated with the maxillary
third molars, depending on their degree of impaction, are dis- The patient was seen in the clinic for extraction of teeth #1 and
placement to the maxillary sinus or to the infratemporal or #16 and coronectomy of #17 and #32 under intravenous seda-
pterygoid spaces or perhaps iatrogenic creation of oroantral com- tion. The patient has taken preoperative antibiotics (amoxicillin 1
munication. For this patient’s case, given the panoramic image g orally). Monitors (pulse oximetry, capnography, blood pressure,
findings of the mandibular third molar teeth position relative to and three-lead ECG) were placed, and oxygen was delivered via a
the inferior alveolar canal, a 3D CBCT was ordered to better nasal mask at 4 L/min followed by nitrous oxide. Midazolam,
evaluate the relationship of these structures (Fig. 27.2 and fentanyl, and propofol were slowly titrated until a comfortable
eFig. 27.3). In the 3D imaging, it was evident that there was loss state of conscious sedation was achieved. A local anesthetic with
of cortical bone around the inferior alveolar canal in relation to epinephrine was injected, and adequate time was allowed for the
the root position. eFigs. 27.4 and 27.5 show the IAN canal in local anesthetic block. A bite block was placed for TMJ stabiliza-
orange highlight. tion. An oral screen with loosely packed, moist gauze was placed
to protect the airway from accidental aspiration. A full mucoperi-
Labs osteal flap was elevated using a buccal envelope incision with a
distal hockey-stick extension for the mandibular third molars.
No routine laboratory tests are indicated for the routine evalua- Special consideration was given to preventing trauma to the lin-
tion of impacted third molars unless dictated by underlying gual tissue. A buccal trough was made using a high-speed instru-
medical conditions. Female patients in their childbearing years ment (impaction drill and burr with irrigation), and the crown of
should be questioned as to pregnancy because pregnancy has im- the impacted tooth was exposed. The crown was sectioned from
plications on the choice of anesthetics and perioperative analgesic the roots with careful attention paid to avoid violation of the
medications (e.g., NSAIDs are contraindicated in pregnancy). lingual cortex (although at times, disrupting the lingual cortex is
Depending on the patient’s medication list or medical problems, unavoidable).
the surgeon may require results of an international normalized The position of the lingual nerve is found to be very variable
ratio or coagulation studies, a complete blood count and chemis- by multiple studies. In the largest cadaveric study of lingual nerve
try panel, and perhaps cardiac evaluation with ECG or stress anatomy by Behnia and associates, 669 nerves from 430 fresh
testing and may consult with the patient’s medical doctor for any cadavers were examined. In 94 cases (14%), the nerve was above
specific questions that may arise. the lingual crest, and in 1 case, the nerve was in the retromolar

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128.e1 S EC TI O N Dentoalveolar Surgery

• eFig. 27.3 Cone beam computed tomography reconstruction with outline of the mandibular canal with
transverse and coronal analysis as different angles.

• eFig. 27.4 Cone beam computed tomography reconstruction with outline of the mandibular canal with
transverse and coronal analysis as different angles.

• eFig. 27.5 Cone beam computed tomography reconstruction with outline of the mandibular canal with
transverse and coronal analysis as different angles.

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 27 Third Molar Odontectomy 129

pad region. In the remaining 574 cases (86%), the mean horizon- there is also no expected regimen to follow because there is no clear
tal and vertical distances of the nerve to the lingual plate and the evidence as to any one antibiotic choice or regimen. In general,
lingual crest were 2.1 mm and 3 mm, respectively. In 149 cases however, the outcomes from various studies indicate equivocal
(22%), the nerve was in direct contact with the lingual plate of the outcomes for those given antibiotics and those not. The one guid-
alveolar process. The unpredictable anatomy of the lingual nerve in ing principle for an antibiotic choice would be to cover the ap-
relation to the mandibular third molar increases this nerve’s sus- propriate oral flora. If one is not allergic, then penicillin is still the
ceptibility to injury. More recent studies confirm the lingual nerve most recommended choice. There is also no clear guidance as to
ranges in horizontal position from direct contact with the lingual the technique of tooth removal; it essentially comes down to “sur-
cortical plate to up to 4 mm, and the vertical range varies from the geon preference.” It will commonly be suggested for a surgeon to
alveolar crest to up to 16.8 mm (Mendes et al.). develop his or her own protocol based on the survey of the litera-
The remainder of the coronal aspect of the root was trimmed ture to guide evidence-based practices and to follow sound surgical
to eliminate any remnants of the enamel of the crown. The root principles. Although the majority of patients undergoing third
remnant was smoothed to ensure it remained at least 3 to 4 mm molar surgeries have excellent outcomes, the surgeon should be
apical to the bony margin. The neurovascular bundle was not vi- prepared to manage all variety of complications that may arise.
sualized, and there was no excessive hemorrhage from the socket. Although many are trained to remove teeth, oral and maxillofacial
(Visualization of the neurovascular bundle, on total odontectomy, surgeons are in the unique position to manage oral and maxillofa-
and excessive hemorrhage from the socket are associated with an cial wounds and complications arising from the removal of third
increased risk of IAN injury.) The wound was irrigated with nor- molars or any other tooth. A variety of complications may arise in
mal saline, Platelet-rich fibrin (PRF) plugs were placed into the the perioperative management of third molars, including pain,
sockets, and the flaps were closed primarily with chromic suture, swelling, bleeding, fracture of the tooth in question and having to
with careful attention paid to suturing only the superficial lingual leave a root fragment, displacement of root fragment to an adja-
mucosa and thus preventing lingual nerve injury. Recent system- cent fascial space or to the maxillary sinus or mandibular canal,
atic reviews and meta-analyses have shown that L-PRF may fa- local or fascial space infection and possible hospitalization and
cilitate soft tissue healing. The variety of PRF may be fabricated emergent airway procedures, injury to adjacent teeth, alveolar os-
based on specific spin protocols using a centrifuge. teitis, periodontal defects, trismus, jaw fracture, oroantral com-
The maxillary third molars were removed through an envelope munication, dentoalveolar fracture, injury to the IAN or lingual
mucoperiosteal flap, and the teeth were elevated and extracted nerve resulting in hypoesthesia, and instrument fracture. More
with forceps. Care was taken to avoid the roots of the maxillary extreme complications include hematoma formation tracking to
second molars (a possible complication). There was no evidence the airway resulting in death, aspiration of tooth fragment, medi-
of oral antral communication. The tooth follicular remnants were astinitis from fascial space infection, hemorrhage, or infection via
removed, and the sites were irrigated. Gauze was placed between the inferior orbital fissure leading to periorbital infection or com-
the sites to promote hemostasis, and the patient was monitored in pression and vision changes.
the recovery room until she was fully awake and alert. A postop- Coronectomy may be considered as a surgical approach in
erative Panorex was taken indicating the results of the recent patients with high-risk third molar teeth with IAN proximity and
procedure and to document the coronectomy and position of the coronal pathology or symptoms from their impacted position. A
remaining roots (Fig. 27.6). The patient may be discharged home systematic review of the complications of high-risk third molar
with her family upon meeting the Aldrete scoring system for removal surgery was evaluated by Pitros et al. indicating that
postoperative recovery. coronectomy “reduced the risk of nerve injury in high risk third
The safe removal of third molars is one of the most common molars.” However, they caution that “outcomes such as the need
surgical procedures in the skill set of oral and maxillofacial sur- for re-operation . . . may alter the cost ratio of coronectomy:extraction”
geons. As mentioned previously, the decision to monitor or treat and suggested that “higher quality studies with longer follow up
the third molars should be a patient-driven decision because there are needed.” Monaco et al. also found that a coronectomy may be
is limited clear guidance for practitioners. The decision to provide recommended for treatment of third molars in close proximity to
perioperative antibiotics is also somewhat controversial in terms of the IAN or inferior alveolar canal because of their findings of low
whether to provide a prophylactic antibiotic to an otherwise postoperative complications and no cases of neurologic lesions
healthy individual patient. If one does decide to provide antibiotic, nor any cases of late infections with the retained root in their
prospective study with 5-year follow-up. Vignudelli et al. found
“restoration of a clinical healthy periodontium distal to the sec-
ond molar was observed” after third molar coronectomy.
For the sake of completeness, another alternative treatment op-
tion with high-risk third molars is orthodontic extrusion using
various orthodontic traction methods, resulting in an improved
position of the impacted tooth relative to the inferior alveolar canal.

Complications
Third molar extraction is the surgical procedure that oral and
maxillofacial surgeons perform most often. A well-planned surgi-
cal approach, with the goal of prevention, is the best way to
minimize complications. But despite our best efforts, complica-
• Fig. 27.6 Postoperative panoramic radiograph showing coronectomy of tions are expected, and it is best to counsel patients preoperatively
teeth #17 and #32 and extraction of teeth #1 and #16. for potential risks. Clinicians need to be aware of the risk factors

t.me/Dr_Mouayyad_AlbtousH
130 S E C TI O N Dentoalveolar Surgery

associated with an increased risk of complications for this com- compared with placebo. The decision on whether to prescribe
monly performed procedure. antibiotics is multifactorial, and generally left to the clinical deci-
Pogrel concluded, “The age of 25 years appears in many studies sion of the practitioner.
to be a critical time after which complications increase more rap- In the event of coronectomy procedures, Pitros et al. found the
idly.” No studies indicate that complications decrease as age in- risk of root migration to be variable (13%–85%) and the average
creases. In fact, the older a patient is, the more likely it is that the incidence of reoperation to be 2.2%, low rates of infection, and
recovery from complications will be prolonged, less predictable, reduced IAN injury by 84%. Leung studied factors such as age,
and less complete. sex, type and pattern of impaction, and root form with regard to
Sensory nerve injury is well documented. The anatomy of the root migration rate and found that 91% of root migrations oc-
IAN is variable, but the canal is usually located inferior and buccal curred within the first 6 months, decreased thereafter, and
to the impacted mandibular third molars. A lingual position of dropped to less than 5% after 24 months. They also found that
the canal in contact with the roots of the mandibular third molars “migration decreased with increasing age” and other factors unre-
increases the risk of injury. Injury to the IAN can lead to a range lated to migration. A younger patient is more likely to have root
of symptoms along its distribution (anesthesia, hypoesthesia, migration in their lifetime and should be counseled as such.
dysesthesia, or paresthesia). A review of the literature demon- Localized osteitis (dry socket) is a well-known complication of
strates an incidence of nerve injury between 0.4% and 7%. In one tooth extractions. Although the cause of dry socket is still not
large study with 367,170 patients, the incidence of nerve injury completely understood, it is believed to be the result of disintegra-
was 0.4% (22% of whom had symptoms lasting longer than tion of the clot by localized fibrinolysis via the activation of the
12 months). The risk of nerve injury is greater with increasing plasminogen pathway by direct and indirect substances. The inci-
patient age, degree of root development, degree of impaction, and dence widely ranges from 1% to 37% for mandibular third molar
the radiographic relationship of the roots to the inferior alveolar removal sites. The most plausibly identified risk factors of dry
canal. The incidence of injury to the IAN is slightly higher than socket development may be related to surgical trauma or difficulty
that for the lingual nerve, but the IAN has a higher incidence of in removing a third molar (i.e., level of impaction, local bony
spontaneous recovery (because of its position in the bony canal, conditions, length of time) surgeon experience, oral contraceptive
which allows a greater possibility that the nerve endings will reap- use, female gender, smoking history (amount and length of time),
proximate); however, older patients are more likely to have in- localized bacteria, prior history of localized pericoronitis, and in-
complete recovery. Injury to the long buccal nerve is also possible, creased age. Known beneficial methods of prevention include
but it is less of a concern, causing minimal to no subjective dis- systemic antibiotic use to reduce postoperative inflammatory
ability. Patients with severe IAN or lingual nerve injury should be complications and use of topical chlorhexidine 0.12% oral rinse.
referred to a microneurosurgeon for prompt evaluation and po- There is no consensus for treatment other than pain management.
tential surgical intervention (decompression, neurolysis, or neu- Recent studies have suggested application of PRF. Some studies
rorrhaphy). Suhaym and Milono reported: “A trend towards early have demonstrated improved outcomes of pain score and reduc-
repair achieving better functional sensory recovery outcomes was tion of dry socket development with the application of PRF to the
observed, but the specific time period is unknown.” Complica- socket or wounds.
tions from local anesthesia also have been reported, probably Other complications associated with third molar surgery in-
caused by direct needle trauma to the IAN. The reported inci- clude periodontal complications, maxillary sinus involvement
dence ranges from 1 in 400,000 to 1 in 750,000 patients. (oral antral communications, displacement of a fragment into the
As with any other procedure, infections are commonly associ- sinus), displacement of a tooth into adjacent fascial spaces, break-
ated with third molar removal, both preoperatively and postop- age of instruments, aspiration or swallowing of foreign objects,
eratively. This appears to be more common after removal of partial TMJ pain, maxillary tuberosity fractures, root fracture, injury to
and full bony impactions. Infections can occur as early as several adjacent teeth, hemorrhage/hematoma, wound dehiscence, man-
days after the procedure, or they may present late (within several dible fracture, and soft tissue emphysema. The displacement of a
weeks). They can be localized to the area of the third molar or tooth or root fragment to the maxillary sinus may be managed by
occasionally can spread to adjacent fascial spaces to cause life- attempted retrieval from the site of perforation. If this unsuccess-
threatening conditions. Most infections are easily managed with ful, then consideration for Caldwell Luc access to retrieve a frag-
local measures and the use of antibiotics. The incidence of post- ment and concurrent use of antibiotic therapy to minimize risk of
operative infection is approximately 3%. There is increasing evi- sinus infection. The oroantral communication may be addressed
dence to challenge prophylactic use of perioperative antibiotics in by a variety of localized pedicled flaps based on branches of the
otherwise healthy patients undergoing removal of wisdom teeth maxillary artery (from rotational flap to advancement flap to buc-
(impacted or otherwise). Lodi et al. performed a meta-analysis cal fat advancement flap and primary closure). The surgeon will
including 23 trials randomizing 3206 participants to prophylactic be adept in the management of these complications.
antibiotics or placebo and found that the vast majority of studies
(21 of 23) included mostly healthy individuals. “On average, Discussion
treating 19 healthy patients with prophylactic antibiotics may
stop one person from getting an infection.” As a result, these re- Two major professional organizations have made contradictory
sults are not generalizable to overall population. Immunocompro- recommendations on the prophylactic removal of impacted third
mised patients or patients with medical problems should be molars. The researchers for AAOMS Third Molar Clinical Trials
treated on an individual basis and their susceptibility to infection published several scientific articles that linked third molars to fu-
as a result of a procedure. Morrow et al. found postoperative an- ture health problems in adults. In light of these findings, in 2005,
tibiotic use to decrease inflammatory complications compared the AAOMS suggested that removal of the third molars during
with no antibiotic use. Mariscal-Cazalla also found that periop- young adulthood may be the most prudent option. In contrast,
erative antibiotic decrease postoperative pain and inflammation the National Health Service (NHS) of Great Britain and an

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 27 Third Molar Odontectomy 131

associated agency, the National Institute of Clinical Excellence soft tissues and teeth. The increased difficulty and risks of third
(NICE), published a series of guidelines recommending that “the molar removal with increasing age, inadequate oral hygiene, and
practice of prophylactic removal of pathology-free impacted third tooth position, in addition to periodontal health and orthodontic
molars should be discontinued in the NHS.” These guidelines, considerations, should be taken into account. Erupted or partially
made public in 2000, did acknowledge the ongoing AAOMS erupted third molars have been shown to have a negative impact
Third Molar Clinical Trials. In 2012 Renton and colleagues pub- on periodontal health. In a study by Dodson, attachment levels
lished an article chronicling the United Kingdom’s experience and probing depths improved after third molar removal. Pogrel
with retention of third molars. They concluded that “admissions reported that a periodontal condition may persist or may be cre-
for M3 [third molar] surgery activity under the NHS have de- ated on the distal aspect of the second molar after third molar
creased from the mid-1990s and into the 2000s, in association removal, especially in some older patients. Dodson has suggested
with professional and policy guidelines.” They subsequently found that in this subgroup of patients, immediate reconstruction may
that the average age for third molar surgery had risen, and the be beneficial in the long term. However, the relationship between
indications for the surgery were “increasingly associated with third molars and periodontal disease pathogenesis requires further
other pathologic features such as dental caries or pericoronitis, in study. There is no clear consensus on the ability of mandibular
line with NICE guidelines.” Although NICE lead to a drop in the third molars to cause crowding of the anterior teeth. Although
number of patients obtaining third molar removal surgery shortly some investigators have shown a statistical association of third
after its implementation, it did not actually lead to a drop in the molars and late anterior crowding, this association is not strong.
number of patients requiring third molar removal later. Now the The majority of the literature does not support this hypothesis.
number of patients requiring third molar removal surgery had Offenbacher and colleagues published a study on periodontal
returned to preimplementation levels, but the patients are older. disease and the risk of preterm delivery. The study involved 1020
In some regions of the world, socioeconomic and available pregnant female patients who received antepartum and postpartum
resources play a major role in the determination of guidelines for periodontal examinations. The findings clearly demonstrated that
third molar extractions, and current scientific evidence remains maternal periodontal disease increases the relative risk of preterm or
unchanged. The cumulative financial costs of treating the health spontaneous preterm birth. The mothers with third molar peri-
complications of retained third molars in the older population odontal pathology had elevated serum markers of systemic inflam-
should be considered. Although there is cost associated with the mation (C-reactive protein, isoprostanes). Periodontal disease was
procedure to remove third molars, there is also the cost of moni- also a predictor of more severe adverse pregnancy outcomes.
toring retained third molars. Subsequent removal at an older age For extraction of third molars, there is a wide range of choices
may also be associated with the cost of lost income in recupera- of anesthetic and surgical techniques related to the surgeon’s train-
tion time in addition to the greater risks of removal at an older ing and experience. As the common dictum proclaims, “There is
age. In a systematic review and economic evaluation of the pro- more than one way to do it.” Many different surgical flaps and
phylactic removal of mandibular third molars, Hounsome et al. instruments have been developed over the years. A variation of the
developed an exploratory model based on evidence of symptom buccal hockey stick incision appears to be the most commonly
development and the rates of extraction of retained impacted used and has the lowest incidence of permanent neurosensory
mandibular third molars and suggest that “prophylactic removal injury. Similarly, the choice of anesthesia can vary from local an-
may be the more cost-effective strategy.” esthesia, to intravenous sedation using a variety of medications, to
It is clear that the extraction of third molars poses some risks general anesthesia with endotracheal intubation. This choice is
to the patient. However, the determination of extraction versus influenced by many factors, including the patient’s preference,
nonextraction of asymptomatic third molars must compare the available resources, surgeon’s training, and practice patterns in the
cost and risks of surgical extraction with the lifetime health and region. Various regimens of perioperative care are also followed.
cost benefits of preventing and eliminating any pathologic pro- Common practices include the use of a long-acting local anes-
cesses associated with retention of the third molars. More recent thetic (e.g., 0.5% bupivacaine or 1.3% bupivacaine), corticoste-
studies continue to bolster these concepts. roids, and NSAIDs to improve postoperative pain management.
The effectiveness, safety, and relatively minimal cost of extrac- Bailey et al. performed a meta-analysis of the various databases
tion of third molars using outpatient, office-based anesthesia, comparing various surgical techniques for the removal of man-
along with the currently available scientific evidence linking as- dibular third molars teeth in randomized controlled trials and
ymptomatic third molars to multiple health hazards, generally found no meaningful conclusive recommendations to guide sur-
support the extraction of asymptomatic third molars in young geons in their technique for this removal surgery. The surgeon
adults; however, as mentioned, the patient’s preference and an should be guided by their training, use of sound surgical princi-
informed decision arrived at by the surgeon and patient are the ples, and evidence that best supports their chosen technique of
most important deciding factors. care and, of course, the patient’s preference of care having been
Indications for the removal of third molars are variable and explained the risks and benefits.
influenced by many factors, as previously outlined. Insufficient
room for adequate eruption of the teeth can create difficulty with ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
maintenance of oral hygiene in these areas, affecting the adjacent complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 131.e1

Dodson TB: Management of mandibular third molar extraction sites to

Bibliography prevent periodontal defects, J Oral Maxillofac Surg 62(10):1213-
1224, 2004.
Al-Belasy FA: The relationship of “Shisha” (water pipe) smoking to Dodson TB: Surveillance as a management strategy for retained third
postextraction dry socket, J Oral Maxillofac Surg 62:10, 2004. molars: is it desirable? J Oral Maxillofac Surg 70(9):S20-S24, 2012.
Ali AS, Benton JA, Yates JM: Risk of inferior alveolar nerve injury with Donoff RB, Fagin AP: Lingual and inferior alveolar nerve injuries after
coronectomy vs surgical extraction of mandibular third molars—A third molar removal, Alpha Omegan 106(3-4):91-95, 2013.
comparison of two techniques and review of the literature, J Oral Dos Santos Ferreira L, Abreu LG, Calderipe CB, et al: Is teriparatide therapy
Rehabil 45(3):250-257, 2018. effective for medication-related osteonecrosis of the jaw? A systematic
Alling C, Helfrick J, Alling R: Impacted Teeth, Philadelphia, 1993, Saunders. review and meta-analysis, Osteoporos Int 32(12):2449-2459, 2021.
Alling CC: Dysesthesia of the lingual and inferior alveolar nerves follow- Duvall NB, Fisher TD, Hensley D, et al: The comparative efficacy of
ing third molar surgery, J Oral Maxillofac Surg 44:454, 1986. 0.12% chlorhexidine and amoxicillin to reduce the incidence and
American Association of Oral and Maxillofacial Surgeons: Research study magnitude of bacteremia during third molar extractions: a prospec-
links wisdom teeth to health problems in young adults, September 20, tive, blind, randomized clinical trial, Oral Surg Oral Med Oral Pathol
2005 (news release). Oral Radiol 115(6):752-763, 2013.
Bagheri SB, Bell RB, Khan HA (eds): Current Therapy in Oral and Max- Elter JR, Cuomo CJ, Offenbacher S, et al: Third molars associated
illofacial Surgery, Philadelphia, 2011, Elsevier/Saunders, pp 122-126. with periodontal pathology in the Third National Health and Nu-
Bagheri SC, Khan HA: Extraction versus non-extraction management of trition Examination Survey, J Oral Maxillofac Surg 62(4):440-445,
third molars, Oral Maxillofac Surg Clin North Am 19(1):15-21, 2007. 2004.
Bagheri SC, Meyer RA, Cho SH, et al: Microsurgical repair of the infe- Fee PA, Wright A, Cunningham C: Cone beam computed tomography
rior alveolar nerve: success rate and factors that adversely affect out- in pre-surgical assessment of mandibular third molars, Evid Based
come, J Oral Maxillofac Surg 70(8):1978-1990, 2012. Dent 17(4):117-118, 2016.
Bailey E, Kashbour W, Shah N, et al: Surgical techniques for the removal Freire BB, Nascimento EHL, Vasconcelos KF, et al: Radiologic assess-
of mandibular wisdom teeth, Cochrane Database Syst Rev 7(7): ment of mandibular third molars: an ex vivo comparative study of
CD004345, 2020. panoramic radiography, extraoral bitewing radiography, and cone
Bao M, Du G, Zhang Y, et al: Application of platelet-rich fibrin deriva- beam computed tomography, Oral Surg Oral Med Oral Pathol Oral
tives for mandibular third molar extraction related post-operative se- Radiol 128(2):166-175, 2019.
quelae: a systematic review and network meta-analysis, J Oral Maxil- Frenkel B, Givol N, Shoshani Y: Coronectomy of the mandibular third
lofac Surg 79(12):2421-2432, 2021. molar: a retrospective study of 185 procedures and the decision to
Bao MZ, Liu W, Yu SR, et al: Application of platelet-rich fibrin on man- repeat the coronectomy in cases of failure, J Oral Maxillofac Surg
dibular third molar extraction: systematic review and meta-analysis, Hua 73(4):587-594, 2015.
Xi Kou Qiang Yi Xue Za Zhi 39(5):605-611. English, Chinese, 2021. Ghaeminia H, Nienhuijs ME, Toedtling V, et al: Surgical removal versus
Baqain ZH, AlHadidi A, AbuKaraky A, et al: Does the use of cone-beam retention for the management of asymptomatic disease-free impacted
computed tomography before mandibular third molar surgery impact wisdom teeth, Cochrane Database Syst Rev 5(5):CD003879, 2020.
treatment planning? J Oral Maxillofac Surg 78(7):1071-1077, 2020. González-Martínez R, Jovani-Sancho MD, Cortell-Ballester I: Does psy-
Barcellos BM, Velasques BD, Moura LB, et al: What are the parameters chological profile influence third molar extraction and postoperative
for reoperation in mandibular third molars submitted to coronectomy? pain? J Oral Maxillofac Surg 75(3):484-490, 2017.
A systematic review, J Oral Maxillofac Surg 77(6):1108-1115, 2019. Halabi D, Escobar J, Alvarado C, et al: Chlorhexidine for prevention of
Behnia H, Kheradvar A, Shahrokhi M: An anatomic study of the lingual alveolar osteitis: a randomised clinical trial, J Appl Oral Sci
nerve in the third molar region, J Oral Maxillofac Surg 58(6):649-651, 26:e20170245, 2018.
2000, discussion 652-653. Halabí D, Escobar J, Muñoz C, et al: Logistic regression analysis of risk
Blaeser BF, August MA, Donoff RB, et al: Panoramic radiographic risk factors for the development of alveolar osteitis, J Oral Maxillofac Surg
factors for inferior alveolar nerve injury after third molar extraction, 70(5):1040-1044, 2012.
J Oral Maxillofac Surg 61(4):417-421, 2003. Hall HD, Bildman BS, Hand CD: Prevention of dry socket with local
Blakey GH, Jacks MT, Offenbacher S, et al: Progression of periodontal application of tetracycline, J Oral Surg 29:35, 1971.
disease in the second/third molar region in subjects with asymptom- Hasani A, Ahmadi Moshtaghin F, Roohi P, et al: Diagnostic value of cone
atic third molars, J Oral Maxillofac Surg 64(2):189-193, 2006. beam computed tomography and panoramic radiography in predict-
Blakey GH, Marciani RD, Haug RH, et al: Periodontal pathology associ- ing mandibular nerve exposure during third molar surgery, Int J Oral
ated with asymptomatic third molars, J Oral Maxillofac Surg 60(11): Maxillofac Surg 46(2):230-235, 2017.
1227-1233, 2002. Hasegawa T, Ri S, Shigeta T, et al: Risk factors associated with inferior
Bouloux GF, Steed MB, Perciaccante VJ: Complications of third molar alveolar nerve injury after extraction of the mandibular third molar—
surgery, Oral Maxillofac Surg Clin North Am 19(1):117-128, 2007. a comparative study of preoperative images by panoramic radiography
Brasil DM, Nascimento EHL, Gaêta-Araujo H, et al: Is panoramic imag- and computed tomography, Int J Oral Maxillofac Surg 42(7):843-851,
ing equivalent to cone-beam computed tomography for classifying 2013.
impacted lower third molars? J Oral Maxillofac Surg 77(10):1968- Haug RH, Abdul-Majid J, Blakey GH, et al: Evidenced-based decision
1974, 2019. making: the third molar, Dent Clin North Am 53(1):77-96, 2009.
Cilasun U, Yildirim T, Guzeldemir E, et al: Coronectomy in patients Herpy AK, Goupil MT: A monitoring and evaluation study of third
with high risk of inferior alveolar nerve injury diagnosed by computed molar surgery complications at a major medical center, Mil Med
tomography, J Oral Maxillofac Surg 69:1557-1561, 2011. 156(1):10-12, 1991.
Clé-Ovejero A, Sánchez-Torres A, Camps-Font O, et al: Does 3-dimen- Hounsome J, Pilkington G, Mahon J, et al: Prophylactic removal of
sional imaging of the third molar reduce the risk of experiencing in- impacted mandibular third molars: a systematic review and economic
ferior alveolar nerve injury owing to extraction? A meta-analysis, J Am evaluation, Health Technol Assess 24(30):1-116, 2020.
Dent Assoc 148(8):575-583, 2017. Inokoshi M, Kubota K, Yamaga E, et al: Postoperative bleeding after
Dodson TB, Gonzalez ML: American Association of Oral and Maxillo- dental extraction among elderly patients under anticoagulant therapy,
facial Surgeons’ Anesthesia and Third Molar Extraction Benchmark Clin Oral Investig 25(4):2363-2371, 2021.
Study: rationale, methods, and initial findings, J Oral Maxillofac Surg Isiordia-Espinoza MA, Aragon-Martinez OH, Martínez-Morales JF, et al:
74(5):903-910, 2016. Risk of wound infection and safety profile of amoxicillin in healthy
Dodson TB: Management of asymptomatic wisdom teeth: an evidence- patients which required third molar surgery: a systematic review and
based approach, J Mass Dent Soc 55(4):30-32, 2007. meta-analysis, Br J Oral Maxillofac Surg 53(9):796-804, 2015.

t.me/Dr_Mouayyad_AlbtousH
131.e2

Issrani R, Prabhu N, Sghaireen M, et al: Comparison of Digital OPG Miloro M, Halkias LE, Slone HW, et al: Assessment of the lingual nerve
and CBCT in assessment of risk factors associated with inferior nerve in the third molar region using magnetic resonance imaging, J Oral
injury during mandibular third molar surgery, Diagnostics (Basel) Maxillofacial Surg 55(2):134-137, 1997.
11(12):2282, 2021. Monaco G, Vignudelli E, Diazzi M, et al: Coronectomy of mandibular
Jung S, Lee JH, Huh J, et al: Orthodontic extrusion of mandibular third third molars: a clinical protocol to avoid inferior alveolar nerve injury,
molar with a miniscrew and cross-arch elastic, J Oral Maxillofac Surg J Craniomaxillofac Surg 43(8):1694-1699, 2015.
79(7):1422.e1-1422.e8, 2021. Monaco G, D’Ambrosio M, De Santis G, et al: Coronectomy: a surgical
Kalantar Motamedi MR, Heidarpour M, Siadat S, et al: Orthodontic option for impacted third molars in close proximity to the inferior
extraction of high-risk impacted mandibular third molars in close alveolar nerve—a 5-year follow-up study, J Oral Maxillofac Surg
proximity to the mandibular canal: a systematic review, J Oral Maxil- 77(6):1116-1124, 2019.
lofac Surg 73(9):1672-1685, 2015. Monaco G, De Santis G, Pulpito G, et al: What are the types and fre-
Kiesselbach JE, Chamberlain JG: Clinical and anatomic observations on quencies of complications associated with mandibular third molar
the relationship of the lingual nerve to the mandibular third molar coronectomy? A follow-up study, J Oral Maxillofac Surg 73(7):1246-
region, J Oral Surg 42:565, 1984. 1253, 2015.
Kindler S, Mksoud M, Holtfreter B, et al: Do molars contribute to sys- Montevecchi M, Incerti Parenti S, Checchi V, et al: Periodontal healing
temic inflammation? results from a population-based study from after “orthodontic extraction” of mandibular third molars: a retrospec-
northeast Germany, J Oral Maxillofac Surg 77(8):1541-1547, 2019. tive cohort study, Int J Oral Maxillofac Surg 43(9):1137-1141, 2014.
Kirnbauer B, Jakse N, Truschnegg A, et al: Is perioperative antibiotic Morrow AJ, Dodson TB, Gonzalez ML, et al: Do postoperative antibiot-
prophylaxis in the case of routine surgical removal of the third molar ics decrease the frequency of inflammatory complications following
still justified? A randomized, double-blind, placebo-controlled clinical third molar removal? J Oral Maxillofac Surg 76(4):700-708, 2018.
trial with a split-mouth design, Clin Oral Investig 26(10):6409-6421, Nakamori K, Fujiwara K, Miyazaki A, et al: Clinical assessment of the
2022. relationship between the third molar and the inferior alveolar canal
Kolokythas A, Olech E, Miloro M: Alveolar osteitis: a comprehensive using panoramic images and computed tomography, J Oral Maxillofac
review of concepts and controversies, Int J Dent 2010:249073, 2010. Surg 66:2308-2313, 2008.
Koumaras GM: What costs are associated with the management of third Nakayama K, Nonoyama M, Takaki Y, et al: Assessment of the relation-
molars? J Oral Maxillofac Surg 70(9):S8-S10, 2012. ship between impacted mandibular third molars and inferior alveolar
Kuśnierek W, Brzezińska K, Nijakowski K, et al: Smoking as a risk factor nerve with dental 3-dimensional computed tomography, J Oral Max-
for dry socket: a systematic review, Dent J (Basel) 10(7):121, 2022. illofac Surg 67:2587-2591, 2009.
Lau AAL, De Silva RK, Thomson M, et al: Third molar surgery out- National Institute for Clinical Excellence: Guidance on the extraction of
comes: a randomized clinical trial comparing submucosal and intrave- wisdom teeth. Available at: www.nice.org.uk/pdf/wisdomteethguid-
nous dexamethasone, J Oral Maxillofac Surg 79(2):295-304, 2021. ance.pdf. Accessed February 5, 2013.
Lee NJ, Jung SY, Park KM, et al: Factors affecting root migration after Nishimoto RN, Moshman AT, Dodson TB, et al: Why is mandibular
coronectomy of the mandibular third molar, Medicine (Baltimore) third molar coronectomy successful without concurrent root canal
100(20):e25974, 2021. treatment? J Oral Maxillofac Surg 78(11):1886-1891, 2020.
Leung YY, Cheung LK: Long-term morbidities of coronectomy on lower Offenbacher S, Beck JD, Moss KL, et al: What are the local and systemic
third molar, Oral Surg Oral Med Oral Pathol Oral Radiol 121(1):5-11, implications of third molar retention? J Oral Maxillofac Surg 70(9):
2016. S58-S65, 2012.
Leung YY, Cheung KY: Root migration pattern after third molar coro- Offenbacher S, Boggess KA, Murtha AP, et al: Progressive periodontal
nectomy: a long-term analysis, Int J Oral Maxillofac Surg 47(6):802- disease and risk of very preterm delivery, Obstet Gynecol 107(1):29-36,
808, 2018. 2006.
Lodi G, Azzi L, Varoni EM, et al: Antibiotics to prevent complications Osborn TP, Frederickson G, Small IA, et al: A prospective study of com-
following tooth extractions, Cochrane Database Syst Rev 2(2):CD003811, plications related to mandibular third molar surgery, J Oral Maxillofac
2021. Surg 43:767-771, 1985.
Long H, Zhou Y, Liao L, et al: Coronectomy vs total removal for third Pasupathy S, Alexander M: Antibiotic prophylaxis in third molar surgery,
molar extraction: a systematic review, J Dent Res 91(7):659-665, 2012. J Craniofac Surg 22(2):551-553, 2011.
Marciani RD: Third molar removal: an overview of indications, imaging, Patel V, Gleeson CF, Kwok J, et al: Coronectomy practice. Paper 2. Com-
evaluation, and assessment of risk, Oral Maxillofac Surg Clin North plications and long term management, Br J Oral Maxillofac Surg
Am 19(1):1-13, 2007. 50(8):739-744, 2012.
Mariscal-Cazalla MDM, Manzano-Moreno FJ, García-Vázquez M, et al: Pedersen MH, Bak J, Matzen LH, et al: Coronectomy of mandibular
Do perioperative antibiotics reduce complications of mandibular third third molars: a clinical and radiological study of 231 cases with a
molar removal? A double-blind randomized controlled clinical trial, mean follow-up period of 5.7 years, Int J Oral Maxillofac Surg
Oral Surg Oral Med Oral Pathol Oral Radiol 131(3):286-294, 2021. 47(12):1596-1603, 2018.
Martin A, Perinetti G, Costantinides F, et al: Coronectomy as a surgical Piecuch JF: What strategies are helpful in the operative management of
approach to impacted mandibular third molars: a systematic review, third molars? J Oral Maxillofac Surg 70(9):S25-S32, 2012.
Head Face Med 11:9, 2015. Pippi R, Spota A, Santoro M: Prevention of lingual nerve injury in third
Martin MV, Kanatas AN, Hardy P: Antibiotic prophylaxis and third molar surgery: literature review, J Oral Maxillofac Surg 75(5):890-
molar surgery, Br Dent J 198(6):327-330, 2005. 900, 2017.
McArdle LW, Renton T: The effects of NICE guidelines on the manage- Pitros P, O’Connor N, Tryfonos A, et al: A systematic review of the com-
ment of third molar teeth, Br Dent J 213(5):E8, 2012. plications of high-risk third molar removal and coronectomy: devel-
Mendes MB, de Carvalho Leite Leal Nunes CM, de Almeida Lopes MC: opment of a decision tree model and preliminary health economic
Anatomical relationship of lingual nerve to the region of mandibular analysis to assist in treatment planning, Br J Oral Maxillofac Surg
third molar, J Oral Maxillofac Res 4(4):e2, 2014. 58(9):e16-e24, 2020.
Mercier P, Precious D: Risks and benefits of removal of impacted 3rd Poeschl PW, Eckel D, Poeschl E: Postoperative prophylactic antibiotic
molars. A critical review of the literature, Int J Oral Maxillofac Surg treatment in third molar surgery—a necessity? J Oral Maxillofac Surg
21(1):17-27, 1992. 62(1):3-8; discussion 9, 2004.
Milic T, Raidoo P, Gebauer D: Antibiotic prophylaxis in oral and maxil- Pogrel MA: Complications of third molar surgery. In Kaban LB, Pogrel
lofacial surgery: a systematic review, Br J Oral Maxillofac Surg MA, Perrott DH (eds): Complications of Oral and Maxillofacial
59(6):633-642, 2021. Surgery, Philadelphia, 1997, Saunders.

t.me/Dr_Mouayyad_AlbtousH
 131.e3

Pogrel MA, Renaut A, Schmidt B, et al: The relationship of the lingual Srivastava A, Nogueras Gonzalez GM, Geng Y, et al: Prevalence of
nerve to the mandibular third molar region: an anatomic study, J Oral medication related osteonecrosis of the jaw in patients treated with
Maxillofac Surg 53(10):1178-1181, 1995. sequential antiresorptive drugs: systematic review and meta-analysis,
Pogrel MA: What is the effect of timing of removal on the incidence and Support Care Cancer 29(5):2305-2317, 2021.
severity of complications? J Oral Maxillofac Surg 70(9):S33-S36, 2012. Steel BJ, Surendran KSB, Braithwaite C, et al: Current thinking in lower
Pogrel MA: What is the effect of timing of removal on the incidence and third molar surgery, Br J Oral Maxillofac Surg 60(3):257-265, 2022.
severity of complications? J Oral Maxillofac Surg 70(9):S37-S40, 2012. Suhaym O, Miloro M: Does early repair of trigeminal nerve injuries in-
Qi W, Lei J, Liu YN, et al: Evaluating the risk of post-extraction inferior fluence neurosensory recovery? A systematic review and meta-analysis,
alveolar nerve injury through the relative position of the lower third Int J Oral Maxillofac Surg 50(6):820-829, 2021.
molar root and inferior alveolar canal, Int J Oral Maxillofac Surg Sweet JB, Butler DP: Predisposing and operative factors: effect on the
48(12):1577-1583, 2019. incidence of localized osteitis in mandibular third molar surgery, J
Quirino de Almeida Barros R, Bezerra de Melo N, de Macedo Ber- Oral Surg 46:206, 1978.
nardino Í, et al: Association between impacted third molars and posi- Task Force for Third Molar Summary: Summary of the Third Molar
tion of the mandibular canal: a morphological analysis using cone- Clinical Trials: report of the AAOMS Task Force for Third Molar
beam computed tomography, Br J Oral Maxillofac Surg 56(10): Summary, J Oral Maxillofac Surg 70(9):2238-2248, 2012.
952-955, 2018. Tofangchiha M, Koushaei S, Mortazavi M, et al: Positive predictive value
Reiland MD, Ettinger KS, Lohse CM, et al: Does administration of oral of panoramic radiography for assessment of the relationship of im-
versus intravenous antibiotics for third molar removal have an effect pacted mandibular third molars with the mandibular canal based on
on the incidence of alveolar osteitis or postoperative surgical site infec- cone-beam computed tomography: a cross-sectional study, Diagnostics
tions? J Oral Maxillofac Surg 75(9):1801-1808, 2017. (Basel) 11(9):1578, 2021.
Renton T, Al-Haboubi M, Pau A, et al: What has been the United King- Vignudelli E, Monaco G, Gatto MR, et al: Periodontal healing distally to
dom’s experience with retention of third molars? J Oral Maxillofac second mandibular molar after third molar coronectomy, J Oral Max-
Surg 70(9):S48-S57, 2012. illofac Surg 75(1):21-27, 2017.
Rood JP, Shehab BA: The radiological predictors of inferior alveolar nerve White RP Jr, Madianos PN, Offenbacher S, et al: Microbial complexes
injury during third molar surgery, Br J Oral Maxillofac Surg 28:20, 1990. detected in the second/third molar region in patients with asymptom-
Ruggiero SL, Dodson TB, Aghaloo T, et al: American Association of Oral and atic third molars, J Oral Maxillofac Surg 60(11):1234-1240, 2002.
Maxillofacial Surgeons’ position paper on medication-related osteonecrosis Yamashiro M: Effectiveness of conscious sedation with a single benzodi-
of the jaws—2022 update, J Oral Maxillofac Surg 80(5):920-943, 2022. azepine compared with a combination of drugs, Anesth Prog 42
Sanmartí-Garcia G, Valmaseda-Castellón E, Gay-Escoda C: Does com- (3-4):103-106, 1995.
puted tomography prevent inferior alveolar nerve injuries caused by Yilmaz Inal F, Yilmaz Camgoz Y, Daskaya H, et al: The effect of preop-
lower third molar removal? J Oral Maxillofac Surg 70(1):5-11, 2012. erative anxiety and pain sensitivity on preoperative hemodynamics,
Shoshani-Dror D, Shilo D, Ginini JG, et al: Controversy regarding the propofol consumption, and postoperative recovery and pain in endo-
need for prophylactic removal of impacted third molars: an overview, scopic ultrasonography, Pain Ther 10(2):1283-1293, 2021.
Quintessence Int 49(8):653-662, 2018. Zhu J, Zhang S, Yuan X, et al: Effect of platelet-rich fibrin on the con-
Sklavos A, Delpachitra S, Jaunay T, et al: Degree of compression of the trol of alveolar osteitis, pain, trismus, soft tissue healing, and swelling
inferior alveolar canal on cone-beam computed tomography and out- following mandibular third molar surgery: an updated systematic
comes of postoperative nerve injury in mandibular third molar sur- review and meta-analysis, Int J Oral Maxillofac Surg 50(3):398-406,
gery, J Oral Maxillofac Surg 79(5):974-980, 2021. 2021.

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28
Surgical Exposure of an Impacted
Maxillary Canine
B R U C E W. AN DE RS ON , S H A H R O K H C . B AG H ER I , J E NN IF E R M. D O L A N , a n d
E VAN M . BU SB Y

CC dentition, associated dentoalveolar structures, and location of

impacted teeth. Periapical “shift shots” can help determine
A 14-year-old male is referred to your office by his orthodontist whether the tooth is buccal/labial or palatal/lingual. (The SLOB
for exposure and bracketing of an impacted left maxillary canine rule [same lingual, opposite buccal] is frequently used to deter-
(the canines normally erupt between 11 and 12 years of age). The mine the position of the tooth on the subsequent x-ray film as the
maxillary canines are the second most commonly impacted teeth cone of the x-ray machine is moved anteriorly or posteriorly.)
(the most common are the third molars). Occlusal films, lateral cephalometric films, or computed tomogra-
phy (CT) scans can be used for precisely locating the position and
HPI orientation of impacted teeth.
In-office, small-field cone-beam computed tomography
The patient has a history of premature loss of the primary left (CBCT) provides the most convenient and valuable imaging
maxillary canine secondary to trauma. (Premature loss of teeth method; it demonstrates not only the canine position but also the
with subsequent arch length reduction is one of the many causes details of angulation, orientation, and relationship to adjacent
of impaction.) Orthodontic treatment has begun, and sufficient structures (see the figures in the section on CBCT in Chapter 1).
arch space has been accommodated for the guided eruption of the This information can be beneficial for the surgeon’s treatment
impacted canine. The patient has no history of any other im- plan and the choice of surgical approach in addition to aiding the
pacted or congenitally missing teeth and presents with an other- orthodontist in determining the path of eruption. CBCT may
wise full dentition. also detect root resorption of adjacent teeth that is not evident on
panoramic radiographs. Haney reported significant changes in
PMHX/PDHX/Medications/Allergies/SH/FH position diagnosis, root resorption detection, orthodontic vector
determination, and surgical access planning by a group of ortho-
Noncontributory.
dontists and oral surgeons who reviewed CBCT images compared
with review of traditional radiographs of the same patients.
Examination In the current patient, the panoramic radiograph shows a fully
General. The patient is a well-developed and well-nourished male formed impacted left maxillary cuspid with a mesioangular orien-
in no apparent distress. tation. Fig. 28.1 demonstrates the position of the impacted canine
Maxillofacial. He has a symmetrical facial appearance with no before the initiation of orthodontic therapy. The crown of the
obvious skeletal abnormalities. canine appears to have a pericoronal radiolucent lesion consistent
Intraoral. Orthodontic bands, brackets, and arch wires are in with a hyperplastic dental follicle (although a dentigerous cyst or
place. A well-healed edentulous space is present in the area of the other pathologic processes are also possible). No crestal bone loss
left maxillary cuspid with an adequate alveolar ridge. A small, is noted in the surrounding region. The full bony impacted third
painless, palpable bony buccal protuberance can be noted in the molars are also noted.
area of the left maxillary cuspid, consistent with the crown of the
impacted canine. (Clinical evaluation to determine palatal or buc- Labs
cal impaction is important and often sufficient to determine the
approach for access to the tooth.) The gingival and palatal tissues No laboratory studies are indicated for routine exposure and orth-
both appear healthy, with no notable periodontal defects. odontic bracket placement of impacted teeth unless dictated by
the medical history.
Imaging
Assessment
A panoramic radiograph is the initial screening study of choice for
evaluating impacted teeth. It provides an excellent overview of the Full bony mesioangular labially impacted left maxillary canine.

132
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 CHAPTER 28 Surgical Exposure of an Impacted Maxillary Canine 133

• Fig. 28.1 Panoramic radiograph demonstrating the horizontal impaction of the left maxillary canine
before orthodontic therapy. The full bony impacted third molars are also noted.

Treatment vestibular sulcus followed by bone removal, follicle removal, and

crown exposure and luxation as previously described. The distal
Current popular treatments of impacted canines can be divided aspect of the flap is positioned apically and sutured with chromic
into open and closed surgical techniques, differing slightly in re- gut at the level of the cervical margin, thus placing attached gin-
gard to palatal versus labial impactions. Autotransplantation and giva at the level of the cementoenamel junction. Again, the
extraction with implant replacement are less commonly used bracket with chain may be bonded at this time.
techniques and are described later with other historical tech- Closed Techniques. These surgical techniques are indicated
niques. Extraction of the primary canine may be considered if the when the crown is not near the alveolar process or is in a position
patient is between 10 and 13 years old and sufficient arch space that inhibits the apical repositioning of a flap (Figs. 28.2 and
has been created, allowing observation for normal eruption of the 28.3). In both palatal and labial impactions, a full-thickness mu-
permanent canine. Serial radiographs can be used to monitor coperiosteal flap is raised, allowing subsequent crown exposure,
eruption, and if no movement is observed over 12 months, alter- gentle luxation, and bonding of the orthodontic bracket with a
native techniques should be performed. chain. At this point, the chain may be brought through the distal
Open techniques. These surgical techniques are indicated aspect of the flap (or through a stab incision in the body of the
when the crown of the impacted canine is in an appropriate loca- flap), and the full flap is repositioned and sutured. In closed tech-
tion near the alveolar process, allowing exposure and access for niques, orthodontic forces may be applied after 1 week to allow
orthodontic bracket placement. For palatal impactions, the exci- for soft tissue healing.
sion of overlying soft tissue may be performed with a surgical
blade or electrocautery as a “window.” Care should be taken to Complications
preserve sufficient soft tissue between the “window” and the cervi-
cal margin of surrounding erupted teeth to avoid potential tissue The most prevalent complication associated with surgical expo-
necrosis and periodontal complications. Bone removal may be sure of impacted canines is failure of the orthodontic bracket
performed with a rotary instrument, rongeurs, or hand instru- bond or fracture of the chain. This is of greater consequence in
ments to expose the crown to the level of the cervical margin. closed techniques because it requires surgical reexposure of the
Complete exposure of the crown may not be feasible in cases in crown before replacement of the bracket. Moisture in the surgical
which the crown is in close proximity to incisor roots. Any dental field during bracket bonding may be the likely cause of this com-
follicle remnants should be excised at this time. Gentle luxation plication. Reexposure also is required with the occurrence of
of the tooth may be performed to rule out ankyloses, but luxation gingival overgrowth in open techniques.
of the tooth is controversial, with some studies suggesting this Periodontal defects may occur as a result of inappropriate flap
luxation may actually lead to ankylosis or root resorption. An design and/or bone loss adjacent to the surgical site. Damage to
orthodontic bracket with gold chain may be etched and bonded the erupting tooth and adjacent tooth roots, including root re-
to the crown with the chain attached passively to existing orth- sorption, may occur secondary to difficulty controlling the path
odontic arch wires. The wound may be left open or packed with of eruption. Devitalization of the pulp of the impacted tooth or
a periodontal dressing for a period of 4 to 5 days. It is generally neighboring incisors requires cessation of orthodontic movement
accepted that a period of 6 to 8 weeks is observed for both palatal and evaluation for possible endodontic treatment.
and labial impactions to allow for spontaneous eruption before Ankylosis of the impacted tooth should be considered if no
the application of orthodontic forces. The apically repositioned movement is observed after sufficient application of orthodontic
flap is the open technique of choice for labially impacted canines. forces and adequate time. Intrusion of the anchoring dentition
Electrocautery, or a “window” excision of overlying soft tissue, may be observed in this situation. Some suggest that the act of
should be avoided with labial impactions because it usually results gently luxating the tooth at the time of exposure may cause anky-
in a lack of attached gingiva after eruption, with a possible need losis as a result of subsequent bleeding and inflammation.
for a secondary graft procedure. A full-thickness mucoperiosteal Other complications include infection, flap necrosis secondary
flap with vertical releasing incisions is raised to the level of the to poor design or contact with acid etch, lack of keratinized tissue

t.me/Dr_Mouayyad_AlbtousH
134 S E C TI O N Dentoalveolar Surgery

A A

B B

C C
• Fig. 28.2 A labially impacted tooth #11 managed with a closed tunnel • Fig. 28.3 A palatally impacted tooth #6 exposed using a full-thickness
technique. (From Bagheri SC, Bell B, Khan HA: Current Therapy in Oral palatal flap. (From Bagheri SC, Bell B, Khan HA: Current Therapy in Oral
and Maxillofacial Surgery, St. Louis, 2012, Saunders.) and Maxillofacial Surgery, St. Louis, 2012, Saunders.)

secondary to poor flap design, and paresthesia of the palate (if the mandibular impactions have a 0.4% reported frequency. Most
nasopalatine nerve is injured) or of the lower lip, chin, mandibular impacted canines have an unknown cause; however, numerous
incisors, and gingiva in the case of impacted mandibular canines. causes have been suggested, including mechanical obstruction by
adjacent teeth, pathology, arch length discrepancy (more prevalent
Discussion in labial impactions), premature loss of deciduous teeth, associated
syndromes, questionable genetic predispositions, and endocrine
Excluding the third molars, the canines are the most commonly abnormalities, such as hypothyroidism and hypopituitarism.
treated impactions by oral and maxillofacial surgeons. The fre- Historical treatments of impacted canines include the place-
quency of impacted canines has been reported as 2% to 5%, with ment of crown forms or cervical wires. Adapted aluminum or
palatal impactions occurring more frequently than labial impac- plastic crown forms were commonly placed after exposure using a
tions. The male-to-female ratio is commonly reported as 1:2, and closed technique, with resulting erosion of overlying soft tissue

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 CHAPTER 28 Surgical Exposure of an Impacted Maxillary Canine 135

secondary to a foreign body reaction. When visible in the oral of the alveolus is complete. Despite these concerns, successful
cavity, the crown form was removed, and orthodontic brackets restoration using implants has been demonstrated in numerous
were placed. Wires secured around the cervical neck of the canine studies and warrants further investigation.
were also popularly used, but this was a more technically demand- The decision between an open or a closed technique is often left
ing procedure, sometimes requiring excessive manipulation of the up to the practitioner and may be one of personal choice. As men-
tooth, and erosion of the canine at the cervical neck has been re- tioned previously, certain physical location factors of the involved
ported with this technique. impacted tooth may dictate one technique over another. Some
Additional surgical options include autotransplantation, seg- studies have reported a twofold higher rate of complications for
mental osteotomy, and extraction with subsequent implant place- closed techniques compared with open techniques. The primary
ment. Autotransplantation may be indicated in circumstances of complication with closed techniques is bond or wire failure. Bond
deep impactions and involves the creation of a bony socket for the failure in open techniques is a minor complication, and some sug-
extracted and transplanted canine. Survival rates have been re- gest delaying bracket placement until after the observational pe-
ported at 70% and as high as 94% when the periodontal mem- riod, allowing greater control of moisture in the surgical field. The
brane is intact at the time of transplantation. This technique, primary complication with open techniques is soft tissue over-
however, is not commonly used because it is less predictable, and growth, which can be lessened with placement of a surgical pack.
several cases of external root resorption have been reported. Seg- More recent studies show no significant differences in surgical
mental osteotomy is seldom performed and carries the risks of a outcomes. No significant differences in subsequent periodontal
more technical procedure. The incidence of extraction and re- complications have been reported between the two groups. The
placement with osseointegrated implants has increased in recent consensus appears to be that both techniques are acceptable and
years, but the use of implants in growing children is still contro- provide predictable results for the treatment of impacted canines.
versial. Implants have been shown to migrate and may become
submerged as growth continues vertically. The latter complication ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
may be avoided by placement of the implant after vertical growth complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 135.e1

Bibliography Grisar K, Denoiseux B, Martin C, et al: Treatment for critically impacted

maxillary canines: clinical versus scientific evidence—a systematic re-
view, J Stomatol Oral Maxillofac Surg 123(3):e12-e19, 2022.
Alberto PL: Surgical exposure of impacted teeth, Oral Maxillofac Surg Grybienė V, Juozėnaitė D, Kubiliūtė K: Diagnostic methods and treat-
Clin North Am 32(4):561-570, 2020. ment strategies of impacted maxillary canines: a literature review,
Alberto PL: Management of the impacted canine and second molar, Oral Stomatologija 21(1):3-12, 2019.
Maxillofac Surg Clin North Am 19:59-68, 2007. Haney E, Gansky SA, Lee JS, et al: Comparative analysis of traditional
Bass T: Observation on the misplaced upper canine tooth, Dent Pract radiographs and cone beam computed-tomography volumetric im-
Dent Rec 18:25-33, 1967. ages in the diagnosis and treatment planning of maxillary impacted
Becker A, Chaushu S: Surgical treatment of impacted canines: what the canines, Am J Orthod Dentofacial Orthop 137:590-597, 2010.
orthodontist would like the surgeon to know, Oral Maxillofac Surg Jacobs SG: The impacted maxillary canine: further observations on aeti-
Clin North Am 27(3):449-458, 2015. ology, radiographic localization, prevention/interception of impac-
Caminiti MF, Sandor GK, Giambattistini C, et al: Outcomes of the tion, and when to suspect impaction, Aust Dent J 41(15):310-316,
surgical exposure, bonding and eruption of 82 impacted maxillary 1996.
canines, J Can Dent Assoc 64(8):572-579, 1998. Johnson W: Treatment of palatally impacted canine teeth, Am J Orthod
Celikoglu M, Kamak H, Oktay H, et al: Investigation of transmigrated 56(6):589-596, 1969.
and impacted maxillary and mandibular canine teeth in an orthodon- Koutzoglou SI, Kostaki A: Effect of surgical exposure technique, age, and
tic patient population, J Oral Maxillofac Surg 68:1001-1006, 2010. grade of impaction on ankylosis of an impacted canine, and the effect
Chaushu S, Becker A, Zeltser R, et al: Patient’s perception of recovery of rapid palatal expansion on eruption: a prospective clinical study,
after exposure of impacted teeth: a comparison of closed- versus open- Am J Orthod Dentofacial Orthop 143(3):342-352, 2013.
eruption techniques, J Oral Maxillofac Surg 63:323-329, 2005. Moss JP: Autogenous transplantation of maxillary canines, Br J Oral Surg
Felsenfeld AL, Aghaloo T: Surgical exposure of impacted teeth, Oral 26:775, 1968.
Maxillofac Surg Clin North Am 14:187-199, 2002. Parkin NA, Deery C, Smith AM, et al: No difference in surgical out-
Ferguson JW, Parvizi F: Eruption of palatal canines following surgical comes between open and closed exposures of palatally displaced
exposure: a review of outcomes in a series of consecutively treated maxillary canines, J Oral Maxillofac Surg 70:2026-2034, 2012.
cases, Br J Orthod 24(3):203-207, 1997. Pearson MH, Robinson SN, Reed R, et al: Management of palatally
Garcia A: Ankylosis of impacted canines: a retrospective post-surgical impacted canines: the findings of a collaborative study, Eur J Orthod
study, Int Orthod 11(4):422-431, 2013. 19(5):511-515, 1997.
Grisar K, Nys M, The V, et al: Long-term outcome of autogenously Pogrel MA: Evaluation of over 400 autogenous tooth transplants, J Oral
transplanted maxillary canines, Clin Exp Dent Res 5(1):67-75, 2019. Maxillofac Surg 45:205-211, 1987.
Grisar K, Chaabouni D, Romero LPG, et al: Autogenous transalveolar Tiwanna PS, Kushner GM: Management of impacted teeth in children,
transplantation of maxillary canines: a systematic review and meta- Oral Maxillofac Surg Clin North Am 17:365-373, 2005.
analysis, Eur J Orthod 40(6):608-616, 2018.

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29
Lingual Nerve Injury
SH A H R O K H C. B AG H ER I, RO G E R A . M EY E R , E VA N M. BUSBY, a n d JE NNIFE R M. D OL A N

CC aspects of the mandible reveals no abnormalities (texture, color,

and consistency of mucosa are within normal limits). Palpation
An 18-year-old female is referred to a microneurosurgeon for and percussion of the lingual surface of the posterior mandible
evaluation of numbness of her left tongue. adjacent to the third molar area produced a localized painful sen-
sation that radiated to the left tongue.
HPI Clinical neurosensory. This examination is performed at three
levels, A, B, and C (Box 29.1), because it is critical to determine
The patient had all four third molars surgically removed by an oral mechanoreceptive and nociceptive sensory deficits or alterations in
and maxillofacial surgeon 13 weeks before presentation. Upon fol- comparison with the patient’s intact side when working up LN in-
low-up at 7 days with the referring surgeon, the patient complained jury. Additionally, it can be useful to check for Tinel’s sign, though
of persistent loss of feeling in her left tongue and altered taste sensa- this may be a later presenting symptom (positive Tinel’s sign: a
tion. No neurosensory testing was done at that time. Six weeks after provocative test of regenerating nerve sprouts in which light percus-
surgery, the patient continued to report profound numbness of the sion over the nerve elicits a distal tingling sensation; it is often in-
left tongue and no improvement in taste perception. All surgical terpreted as a sign of small fiber recovery, but after LN injury with
wounds were healed. Neurosensory testing (NST) of the tongue complete severance, this response likely represents proximal stump
(pinprick and light touch) demonstrated total anesthesia (absence neuroma formation and phantom pain). Cranial nerves (CNs) II
of perception of any stimulation of the mucosa) of the anterior two- through XII were intact except for the left LN distribution, man-
thirds of the left tongue, floor of the mouth, and lingual gingiva. dibular division (V3 of the left trigeminal nerve [CN V]). The pa-
Photographic documentation of the affected area of the tongue was tient showed no response to any of the three levels of NST, which
obtained. An appointment was made for reevaluation of the patient supports a diagnosis of anesthesia.
in 4 weeks. At follow-up (10 weeks postsurgery), repeat NST re- In patients with abnormal pain sensations (allodynia, anesthe-
vealed no change (persistent total anesthesia) from the previous sia dolorosa, dysesthesia), a local anesthetic block of the involved
examination. The patient was subsequently referred to a microneu- nerve may be helpful in making treatment decisions. If the pain
rosurgeon for evaluation of left lingual nerve (LN) injury. is abolished during the duration of the local anesthetic block,
The patient also complained of pain radiating into her left there is a reasonable possibility of pain relief from microneurosur-
tongue when chewing food or brushing her left lower teeth gical repair of the injured nerve.
(allodynia) and frequent accidental biting of her tongue. (Allodynia
is defined as pain caused by a stimulus that does not normally pro- Imaging
duce pain. Dysesthesia is an unpleasant abnormal sensation, either
spontaneous or evoked, and anesthesia dolorosa is pain in an area or Panoramic radiograph (11 weeks postsurgery) reveals no evidence
a region that is anesthetic.) of retained root fragment or foreign bodies. The outline of the

PMHX/PDHX/Medications/Allergies/SH/FH • BOX 29.1 Performance Levels for Clinical

Noncontributory. Neurosensory
Level A (directional and two-point discrimination): Patient unable to feel the
Examination direction of the stimulus applied with a cotton swab and unable to feel a
single- vs two-point stimuli applied to the affected side. Control side within
General. The patient is a well-developed and well-nourished ado- normal limits (inability to discriminate two points farther than 6.5 mm apart
lescent female in no apparent distress. is considered abnormal).
Maxillofacial. There is no cervical lymphadenopathy. Maxi- Level B (contact detection): Patient does not experience pain upon repetitive
mum interincisal opening is 51 mm without mandibular devia- application of touch or pressure. Control side is within normal limits.
tion, and all extraction and surgical sites are healed. There are no Level C (pain sensitivity): Patient shows no response to pinprick, noxious
oral masses or ulcerations; no fasciculations, deviation, or atro- pressures, and heat on the left lingual nerve distribution. Control side is
phic changes of the tongue; and no evidence of recent tongue within normal limits.
trauma (scars or lacerations). Inspection of the lingual and buccal

136
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 29 Lingual Nerve Injury 137

socket of the right mandibular third molar is well demarcated and a standardized neurosensory examination. Patients with unaccept-
is appropriate for the stage of healing. Assessment of the LN is able partial or complete loss of sensation, with or without pain
possible with a magnetic resonance imaging study (preferably symptoms, are most likely to benefit from microsurgical repair of
magnetic resonance neurography), but this is not generally neces- nerve injuries.
sary in making treatment decisions. Surgical treatment of peripheral nerve injuries follows a stereo-
typical series of steps, performed in order. These include external
Labs decompression, internal neurolysis, preparation of nerve stumps
(including excision of scar tissue and neuromas), neurorrhaphy,
No routine or special laboratory tests are indicated for microneu- reconstruction of a nerve gap, and if the nerve is found not to be
rosurgical evaluation unless dictated by the medical history. repairable, other steps (Table 29.2). Specific intraoperative find-
ings dictate the surgical treatment modality.
Assessment In the current patient, under general anesthesia with a nasal
endotracheal tube, bupivacaine with epinephrine was injected
Left LN injury, exhibiting complete anesthesia to NST at 13 weeks after into the soft tissue off the operative field (in addition to an infe-
injury, is a neurotmesis, or Sunderland fifth-degree injury (i.e., nerve rior alveolar nerve block for vasoconstriction of the associated
injury with anatomic disruption of all axonal and sheath elements and/ proximal vessels). Using 3.53 loop magnification (or an operat-
or physiologic block of all impulse transmission, producing wallerian ing microscope can be used) and fiberoptic lighting, incisions
degeneration and probable neuroma formation) (Table 29.1). were made along the gingival margins of the premolar and molar
Surgical intervention is indicated for microrepair of the left teeth on both the buccal and lingual aspects of the left mandible
LN (i.e., excision of the proximal stump neuroma and, most and extended posterolaterally up the ascending ramus. The muco-
likely, neurorrhaphy [repair of a severed nerve by suturing the two periosteum was elevated from the region of the bicuspids and
nerve ends together]) or reconstruction of a nerve gap with a graft posteriorly. There was a defect in the lingual cortex of the left
to allow for a tension-free repair. mandible. The lingual periosteum was sharply incised with micro-
scissors, and the left LN was identified and dissected free to reveal
Treatment a total transection adjacent to the previously removed third molar
with a stump (or amputation) neuroma on the proximal segment.
The two most important factors in successful decision making The distal and proximal nerve stumps were freed of surrounding
regarding treatment of peripheral trigeminal nerve injuries are scar tissue, the proximal neuroma was excised, and the distal nerve
prompt evaluation of suspected nerve injuries and correct patient stump was freshened to visualize viable fascicles (Fig. 29.1A). The
selection (diagnosis). There is a time constraint on the interval
after injury in which a peripheral nerve can be repaired with rea-
sonable expectation of success, with most literature demonstrat- TABLE
ing worsening outcomes if repair is not performed within 6 29.2 Steps in Microsurgical Peripheral Nerve Repair
months of nerve injury. After injury, severed axons in the nerve
undergo wallerian degeneration over a period of 1 to 2 months. If Procedural Stepsa Description
the distal endoneurial sheaths of the necrotic axons are not recan- 1. External de- Removal of bone, scar tissue, and foreign mate-
nulated with new axonal sprouts from the proximal nerve stump compression rial (e.g., root canal filling material, missile
within a critical interval (probably 9–12 months after injury), the fragments, internal fixation wires, screws, or
endoneurial sheaths collapse and are replaced with scar tissue, plates); exposure of nerve
making reinnervation unlikely or impossible. The selection of 2. Internal neurol- Incision of epineurium, inspection of internal
patients who might benefit from surgical intervention is based on ysis nerve structure, removal of scar tissue, repair
of individual fascicles
3. Preparation of Excision of neuroma or scar tissue, exposure of
TABLE nerve stumps viable nerve tissue in nerve stumps, mobiliza-
29.1 Nerve Injury Classification
tion of proximal and distal nerve limbs to al-
Seddon Sunderland Histology Outcomes low approximation

Neurapraxia First degree No axonal dam- Rapid recovery 4. Neurorrhaphy Approximation and suturing of nerve stumps
age, no demy- (days to weeks) without tension
elination, and 5. Reconstruction Autogenous nerve graft; processed allogeneic
no neuroma of nerve gap nerve graft; alloplastic nerve guide
Axonotmesis Second, third, Some axonal Loss of sensation; 6. Nerve-sharing When proximal nerve is not available, anastomo-
and fourth damage, slow, incomplete procedure sis of proximal stump of nearby nerve (e.g.,
degree demyelination, recovery (weeks great auricular nerve) to viable distal stump of
possible to months); micro- injured nerve using a bridging autogenous
neuroma surgery may help nerve graft (e.g., sural nerve)
Neurotmesis Fifth degree Severe axonal Loss of sensation; 7. Irreparable Nerve capping; nerve redirection; neurectomy
damage, nerve spontaneous re- nerve injury (only for pain of terminal malignancy)
discontinuity, covery unlikely;
neuroma microsurgery a
All steps are performed in consecutive order as shown. The operation can be concluded at
formation may help any step at which the surgeon decides the procedure has been completed.

t.me/Dr_Mouayyad_AlbtousH
138 S E C TI O N Dentoalveolar Surgery

proximal and distal nerve limbs were mobilized by dissecting Postoperatively, the patient was closely monitored for adequate
them free of surrounding scar and connective tissue. This dissec- wound healing, and physical therapy was prescribed to restore
tion enabled the nerve endings to be brought together without normal mandibular opening and range of motion. Four months
tension and sutured (neurorrhaphy) using 8-0 ophthalmic nylon after the operation, the patient began to experience spontaneous
(Fig. 29.1B). (Tension across the suture line significantly compro- tingling sensations in her left tongue, and she could perceive the
mises regeneration.) The anastomosis was encircled with a resorb- hot or cold temperature of ingested liquids. One month later, the
able flexible collagen nerve cuff to prevent fibrous tissue ingrowth anterior two-thirds of the left tongue and lingual mandibular
(Fig. 29.1C). The mucosal incision was closed with chromic su- gingiva responded to painful stimuli (level C) and static light
tures, and the patient was extubated. touch (level B). At that time, daily sensory reeducation exercises
(SREs) were prescribed for the tongue and lingual gingiva, which
the patient performed three times daily. At 1-year follow-up, the
patient demonstrated both subjective and objective signs of left
LN sensory function. She continued the SREs for several more
months, after which two-point discrimination (level A) in the left
tongue was equal to that in the normal right tongue. Subjectively,
the left tongue seemed nearly normal to the patient, and she was
dismissed from care.

Complications
Like other surgical procedures, microneurosurgical intervention is
not without risks. Careful patient selection is of paramount impor-
tance. The indications for microneurosurgical intervention are not
always consistent in the literature. However, common indications
for surgical exploration and repair of the LN include the following:
• Spontaneous or stimulus-evoked hyperesthesia (a group of
painful responses to stimuli that includes allodynia, hyper-
A pathia [delayed onset of pain in response to repetitive stimuli,
such as tapping with a blunt object, with continuation of the
pain for seconds or minutes after withdrawal of the stimulus],
and hyperalgesia [an increased response to a stimulus that is
normally painful]) that is abolished temporarily by a local an-
esthetic block of the suspected nerve
• Constant, deep pain in an anesthetic (anesthesia dolorosa) or a
hypoesthetic area (e.g., the tongue) that is abolished by a local
anesthetic block of the suspected nerve
• Intolerable or unacceptable (to the patient) anesthesia or hypo-
esthesia, with or without pain, that shows no signs of recovery
(as determined by interval NST) and persists beyond 3 months
after injury
Patients with acceptable anesthesia or hypoesthesia or with
satisfactory neurosensory recovery without intolerable pain or
B dysfunction are generally not candidates for surgical nerve explo-
ration. It is possible for such patients to experience a worse
outcome, such as the development of anesthesia dolorosa in a
previously anesthetic but nonpainful region. Fortunately, this ap-
pears to be a rare event. Likewise, most patients with nerve injury
whose presurgical symptom is numbness rather than pain do not
develop painful sensations after microsurgical nerve repair. More
commonly, failure of peripheral trigeminal microneurosurgery is
related to inability to restore the preinjury sensory function. In
cases of total nerve severance (neurotmesis, or Sunderland fifth-
degree injury), the time lapse from injury to repair, proper surgi-
cal technique (e.g., tension-free closure), and the patient’s age and
health status are among the most important factors influencing
success. Best results are seen when repair is performed within 6
months of the date of injury. In cases of a witnessed nerve sever-
C ance, immediate primary nerve repair is indicated unless the sur-
gical site is contaminated (e.g., gunshot wound), the patient’s
• Fig. 29.1 A, Proximal and distal nerve stumps before reanastomosis. B, current medical status is compromised, or the surgeon does not
Neurorrhaphy with 8-0 nylon sutures. C, Repair protected by a resorbable have the training or instrumentation to complete the repair at
flexible collagen nerve cuff. that time. In such instances, either a delayed repair is done after

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 29 Lingual Nerve Injury 139

the injury site shows early signs of healing without infection, or most LN injuries, except in cases of substantial avulsive or ablative
the patient is referred to a surgeon with microsurgical training for loss of nerve tissue, can be repaired by neurorrhaphy, than requir-
completion of the nerve repair. This delay of a few days or weeks ing the additional surgery needed for reconstruction of a nerve
does not result in a statistically significant reduction in the success gap with a nerve graft.
rate of repair of peripheral nerve injuries. The reported incidence of temporary paresthesia of the LN
from third molar surgery is between 2% and 6%; fewer than
Discussion about 1% of these injuries result in a permanent deficit. Several
factors may be associated with an increased risk of LN injury,
The inferior alveolar nerve and the LN are the sensory nerves including lingual bone–splitting technique, aggressive curettage
most commonly injured during surgical treatment by oral and of the follicular sac or granulation tissue, excessive lingual bone
maxillofacial surgeons. Injury to these nerves is not always avoid- removal, lingual plate perforation by a drill or an instrument, and
able despite a good knowledge of the anatomy and meticulous deeply placed lingual sutures. Placement of a lingual retractor
surgical technique. The LN has a more variable and less predict- increases the incidence of temporary LN paresthesia but most
able course. Studies based on anatomic cadaveric dissections show likely decreases the incidence of permanent nerve injury.
that the LN is positioned above the lingual alveolar crest at the Upon injury to a nerve, the distal nerve segment undergoes
retromolar area in 14% of cases (see the section on third molar wallerian degeneration. The severed distal axons rapidly become
odontectomy earlier in this chapter). In other instances, the LN necrotic and are phagocytosed within 1 to 2 months, leaving the
travels through or inferior to the submandibular salivary gland endoneurial superstructure initially intact. New axonal sprouts
and courses anteriorly adjacent to the submandibular salivary extend from the proximal nerve stump and attempt to recannu-
duct. Removal of a mandibular third molar tooth is the surgical late the distal endoneurial tubules. If this does not occur within a
procedure most commonly associated with injuries to the LN and variable period of time (estimated in humans to be between 9 and
the inferior alveolar nerve (IAN), with those to the LN occurring 15 months), the endoneurial tubules progressively degenerate and
less frequently than those to the IAN. However, the LN, which is are replaced by scar tissue. When scar tissue has fully replaced the
located entirely within soft tissue, is less likely to spontaneously connective tissue framework, the regenerating proximal axons can
recover from injury compared with the inferior alveolar nerve. no longer recannulate the endoneurial tubules and reinnervate
This is hypothesized to be because of the position of the inferior their target tissue. Therefore, the best results for microneurosurgi-
alveolar nerve in the bony canal, which might serve as a conduit cal repair of nerve severance are achieved when surgery is per-
for nerve regeneration, although successful spontaneous regenera- formed as soon as the diagnosis is confirmed and the patient is
tion of the IAN does not occur predictably. willing to proceed with the procedure, given the risks and bene-
The total encasement of the LN within soft tissue offers one fits. Within 6 months of the injury, repair has a reasonable chance
important advantage in the surgical repair of this nerve. The LN of success (80%–90%) (defined as response to pressure and light
has a rather tortuous course, especially distally from the adjacent touch at normal thresholds, two-point discrimination at a thresh-
third molar area into the floor of the mouth. By identifying and old of ,15 mm, and no hyperesthesia), whereas beyond 12
carefully dissecting the distal limb of a severed LN, the surgeon months, the likelihood of success significantly decreases.
can straighten this tortuosity, thereby gaining up to 2 cm of
length. This additional length often allows the proximal and distal ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
nerve limbs to be brought together without tension. Therefore, complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 139.e1

Bibliography Meyer RA, Bagheri SC: Clinical evaluation of peripheral trigeminal nerve
injuries, Oral Maxillofac Surg Clin North Am 19(1):15, 2011.
Meyer RA, Bagheri SC: Etiology and prevention of nerve injuries. In
Al-Haj Husain A, Solomons M, Stadlinger B, et al: Visualization of the Miloro M, ed. Trigeminal Nerve Injuries, Heidelberg, 2013, Springer.
inferior alveolar nerve and lingual nerve using MRI in oral and maxil- Meyer RA, Bagheri SC: Nerve injuries from mandibular third molar re-
lofacial surgery: a systematic review, Diagnostics (Basel) 11(9):1657, moval, Oral Maxillofac Surg Clin North Am 19(1):63, 2011.
2021. Meyer RA, Rath EM: Sensory rehabilitation after trigeminal injury or
Bagheri SC, Meyer RA, Ali Khan H, et al: Microsurgical repair of the nerve repair, Oral Maxillofac Surg Clin North Am 13(2):365, 2001.
peripheral trigeminal nerve after mandibular sagittal split ramus oste- Meyer RA: Applications of microneurosurgery to the repair of trigeminal
otomy, J Oral Maxillofac Surg 68(11):2770, 2010. nerve injuries, Oral Maxillofac Surg Clin North Am 4(2):405, 1992.
Bagheri SC, Meyer RA, Ali Khan H, et al: Retrospective review of micro- Miloro M, Kolokythas A: Inferior alveolar and lingual nerve imaging,
surgical repair of 222 lingual nerve injuries, J Oral Maxillofac Surg Oral Maxillofac Surg Clin North Am 19(1):35, 2011.
68(4):715, 2010. Phillips C, Blakey G, Essick GK: Sensory retraining: a cognitive behav-
Bagheri SC, Meyer RA: Management of trigeminal nerve injuries. In ioral therapy for altered sensation, Oral Maxillofac Surg Clin North
Bagheri SC, Bell RB, Khan HA, eds: Current Therapy in Oral and Am 19(1):109, 2011.
Maxillofacial Surgery, St. Louis, 2011, Saunders, pp 224-237. Robert RC, Bacchetti P, Pogrel MA: Frequency of trigeminal nerve inju-
Donoff RB, Fagin AP: Lingual and inferior alveolar nerve injuries after ries following third molar removal, J Oral Maxillofac Surg 63(6):732-
third molar removal, Alpha Omegan 106(3-4):91-95, 2013. 735, 2005.
Ducic I, Yoon J: Reconstructive options for inferior alveolar and lingual Selvi F, Yıldırımyan N, Zuniga JR: Inferior alveolar and lingual nerve
nerve injuries after dental and oral surgery: an evidence-based review, injuries: a narrative review of diagnosis and management, Front Oral
Ann Plast Surg 82(6):653-660, 2019. Maxillofac Med 4:27, 2022.
Essick GK: Comprehensive clinical evaluation of perioral sensory func- Suhaym O, Miloro M: Does early repair of trigeminal nerve injuries in-
tion, Oral Maxillofac Surg Clin North Am 4(2):503, 1992. fluence neurosensory recovery? A systematic review and meta-analysis,
Gregg JM: Surgical management of lingual nerve injuries, Oral Maxillo- Int J Oral Maxillofac Surg 50(6):820-829, 2021.
fac Surg Clin North Am 4(2):417, 1992. Weyh A, Pucci R, Valentini V, et al: Injuries of the peripheral mandibular
Kogan M, Lee KC, Chuang SK, et al: Outcomes of direct lingual nerve nerve, evaluation of interventions and outcomes: a systematic review,
repair after an injury: a systematic review, J Oral Maxillofac Surg Craniomaxillofac Trauma Reconstr 14(4):337-348, 2021.
79(3):697-703, 2021. Wu W, Wu F, Liu D, et al: Visualization of the morphology and pathol-
Kushnerev E, Yates JM: Evidence-based outcomes following inferior al- ogy of the peripheral branches of the cranial nerves using three-di-
veolar and lingual nerve injury and repair: a systematic review, J Oral mensional high-resolution high-contrast magnetic resonance neurog-
Rehabil 42(10):786-802, 2015. raphy, Eur J Radiol 132:109137, 2020.
LaBanc JP: Classification of nerve injuries, Oral Maxillofac Surg Clin Ziccardi VB: Microsurgical techniques for repair of the inferior alveolar and
North Am 4(2):285, 1992. lingual nerves, Oral Maxillofac Surg Clin North Am 19(1):79, 2011.
Meyer RA, Bagheri SC: Clinical evaluation of nerve injuries. In Miloro Zuniga JR, Meyer RA, Gregg JM, et al: The accuracy of clinical neurosensory
M, ed. Trigeminal Nerve Injuries, Heidelberg, 2013, Springer. testing for nerve injury diagnosis, J Oral Maxillofac Surg 56:2-8, 1998.

t.me/Dr_Mouayyad_AlbtousH
30
Endodontic-Related Inferior Alveolar
Nerve Injuries
K EI T H A . S O NNE V E L D a n d S H A H R O K H C . B AG H ER I

CC Vital signs. Temperature is 98.9°F, blood pressure is 116/72 mm

Hg, pulse rate is 85 bpm, and respiratory rate is 12 breaths per minute.
A 59-year-old female presents to your office for evaluation of Maxillofacial. No significant extraoral edema or erythema
numbness of her lower lip with pain that she reports as “consistent noted. Her neck shows full range of motion. There is no remark-
with episodes of very severe pain.” able lymphadenopathy on palpation. The inferior border and angle
of the mandible are easily palpable and nontender. No abnormali-
HPI ties in facial animation and no gross asymmetries are noted.
Cranial Nerves
The patient had root canal therapy (RCT) on tooth #29 com- • Level A: Right side brush stroke: 0 of 4. Left side brush stroke:
pleted about 4 months earlier. She said that the dentist performed 4 of 4. Two-point discrimination: Right: Unable to feel. Two-
it in two visits, and after the first visit, she developed a painful point discrimination: 3 mm
sensation, which worsened over the first several days. The dentist • Level B: Right: 4.56. Left: 1.65
prescribed her antibiotics and a steroid course and completed the • Level C: Right: no response; left: normal response
root canal treatment several weeks later. The painful sensation was For a surgeon evaluating the status of a nerve, a set of standard-
never relieved, but instead the patient developed numbness in her ized tests can be used to quantify level of nerve dysfunction, and they
lower teeth, lower lip, and chin area on the right side. She de- should be done comparing the affected nerve with an unaffected
scribes the painful sensation as always present at some basal level, nerve as similar as possible (e.g., testing the affected right inferior
which changes daily but also has episodes of very severe pain she alveolar nerve [IAN] should be compared with the unaffected left
describes as “stabbing” and “electrical.” The frequency of these IAN). These tests differentiate between injuries affecting different
severe pain episodes varies on a day-to-day basis and she has not nerve fibers because the different fibers transmit various stimuli.
been able to figure out any particular factors that may exacerbate Painful sensation is difficult to quantify because interpretation of
it. She is very worried about what may happen without any treat- painful sensation is very subjective: what stimulus evokes a response
ment because she has had no improvement. Her primary care in one person may not evoke the same response in another person.
physician prescribed her gabapentin and tapered her up to a dos- This is contrasted with diminished normal sensation in that the
age of 300 mg three times daily, but she could not tolerate the side standardized set of tests can quantify the level of sensation present.
effects for only modest improvement in her discomfort.
Imaging
PMHX/PDHX/Medications/Allergies/SH/FH
The patient’s panoramic radiograph shows a speckled radiopacity sur-
The patient reports only hypothyroidism, which is being con- rounding the mandibular canal and apex of tooth #29 (Fig. 30.2).
trolled using levothyroxine, and osteoporosis, for which she is Panoramic radiograph is a good initial screening for IAN injuries, but
only taking vitamin D and calcium supplementation. Her surgical further characterization may be obtained using cone-beam computed
history is only significant for breast augmentation and hysterec- tomography. The role for magnetic resonance neurography shows
tomy. She has no drug allergies. She is a nonsmoker and only promise in evaluating injuries to the peripheral trigeminal nerve,
drinks alcohol socially. however the widespread use is limited by the abilities for this imaging
protocol to be performed at local facilities.
Examination
Labs
General. The patient is a well-developed, well-nourished adult
female with a nontoxic appearance. She has normal mentation Evaluation of a patient with an injury to the peripheral trigeminal
and shows moderate signs of distress because today is a “bad nerve has no requirement for lab work. If surgical intervention is
day.” indicated, preoperative labs may be necessary.

140
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 CHAPTER 30 Endodontic-Related Inferior Alveolar Nerve Injuries 141

1 Injection injury (needle trauma and/or neurotoxicity)

2 Mechanical injury during extraction

- Stretch (neuropraxia) or partial transection (axonotmesis)
V3
- Complete transection injury (neurotmesis) from drill or
1 instrumentation
LN
3 Injury from flap design or unusual position of LN on or close
to retormolar pad
Tongue
4 Thermal or burn injury (e.g., use of electrocautery) (uncommon)
2
3rd molar

Direct needle
injury and/or
presure injury
from intraneural
injection

• Fig. 30.1 Positive mechanisms of lingual nerve (LN) injury.

• Fig. 30.2 Panoramic radiograph on consultation showing a speckled

appearance of radiopaque material surrounding the apex of tooth #29 and
the mental foramen.

Assessment
Anesthesia dolorosa secondary to endodontic IAN injury.

Treatment
This patient was treated with exploration of the right IAN, with the
surgeon finding revealing a neuroma-in-continuity (Fig. 30.3). The
neuroma was resected, direct neurorrhaphy was performed, and
the repair was entubulated (Fig. 30.4) with an amnion-chorion
membrane (Axoguard, Axogen Inc.). Surgical access was achieved
through a buccal vestibular incision followed by a buccal corticot-
omy to access the proximal IAN, and the mental foramen was re- • Fig. 30.3 Surgical exploration of this nerve showing a large granuloma-
moved to allow for full access to this injury. Often if the injury is tous neuroma-in-continuity of the inferior alveolar nerve.
more proximal along the nerve, then the mental foramen will not
need to be accessed (Fig. 30.5). By releasing the nerve from the
foramen, it may allow for direct coaptation and neurorrhaphy with- cannot make the patient any more anesthetic, so the benefits of
out an interposition nerve allograft. repair certainly outweigh the risks of more complete sensation
The decision on whether or not to explore a suspected nerve loss. Conversely, severe neuropathic pain without any type of
injury should be patient-centered. The issue of value depends on sensory deficit results in patients who generally prefer to take the
the clinical presentation. With every procedure, there are risks chance at pain improvement knowing the risk that they may lose
associated and the potential to have worsening of the condition. sensation. It is when the level of neuropathic pain or sensory func-
For a patient with a nerve injury with anesthesia and no neuro- tion is not at an extreme when the decision is not as clear, and it
pathic pain component, exploration and an attempt at repair should be a decision made between the surgeon and the patient.

t.me/Dr_Mouayyad_AlbtousH
142 S E C TI O N Dentoalveolar Surgery

nerve, so a more aggressive treatment (continuity resection) may

be rendered because the only likely change is improvement rather
than a worsening of her condition. For many patients with nerve
injuries, the return of sensation is a major consideration when
deliberating about potential nerve exploration (e.g., what are the
chances it gets back to normal?). This return to FSR has several
factors, namely time elapsed since injury, experience of the sur-
geon, and age of the patient. The best likelihood of recovery is
from as early as a condition that would indicate a repair is diag-
nosed, for example, a visualized transection of a nerve being
treated immediately.
For nonwitnessed injuries, most often a 3-month period of
evaluation for improvement in clinical condition is recommended.
If at 3 months the clinical NST shows no or minimal improve-
ment, exploration and repair may be indicated. The more time
that has elapsed since the initial injury results in a lower likeli-
hood of achieving FSR, which shows a drop around 9 months and
reduces precipitously at 12 months.

Discussion
Endodontic therapy has for many years been a mainstay of the
dental treatment armamentarium for abatement of infectious
disease and restoration of tooth form and function. As with any
treatment, complications exist and RCT is no different. Several
mechanisms exist as far as how RCT can affect the IAN: filing
past the apex causing direct trauma to the IAN, overextension of
• Fig. 30.4 After resection of the neuroma, the distal end was released gutta percha into the mandibular canal, or expression of various
from the mental foramen, and a direct neurorrhaphy and entubulation was medicaments into the mandibular canal.
performed. Endodontic-related IAN injuries are a rare entity but do have
severe consequences. There is a paucity of research on the topic;
this research generally exists in mostly case reports and small case
series, with the exception of a single retrospective cohort study of
more than 20 cases. In this study, almost 74% of patients pre-
sented with neuropathic pain as the chief complaint about their
condition. After nerve exploration and indicated repair, the suc-
cess rate in achieving FSR was less than 50%, but it did lower the
perceived pain on a visual analog scale by approximately 2 points.
One major factor potentially affecting this less-than-ideal out-
come is that the average time from injury until presentation for
consultation was 7.9 months. Because time is a major factor in
achieving a good result from microneurosurgery, this extending
period of time likely plays a major role in the number of patients
achieving FSR because following consultation, there is then the
process of obtaining insurance authorization, medical optimiza-
• Fig. 30.5 Postoperative radiograph showing the radiolucency created by tion, and getting operating room time, which further extends the
the corticotomy with an absence of remaining radiopaque material and no time to exploration and repair.
remaining mental foramen. The discussion of these types of injuries must also consider the
mechanisms. Overfiling and overextension of gutta percha is trau-
matic to the IAN, but the medicaments that can be expressed into
In this particular case, the patient had complete anesthesia and the mandibular canal are likely a chemical injury. These medica-
severe neuropathic pain, so the proposal to explore and repair was ments can be sodium hypochlorite, calcium hydroxide, and euge-
readily accepted by the patient. After the repair, she had complete nol. All of these components are considered neurotoxic, and when
resolution of her neuropathic pain and returned to functional sen- expressed into the mandibular canal, it can create a persistent
sory recovery (FSR) with a Medical Research Council Scale score of neurotoxicity that can result in extreme states of neuropathic
S3 as evaluated at a follow-up 3 months after the procedure. pain. It is important to consider this difference because the high
majority of research on peripheral trigeminal nerve injuries is re-
Complications lated to traumatic injuries (third molar extraction, dental implant
placement, osteotomies, pathology), so it may be that because the
For nerve injuries, the surgical repair rendered is dictated by the mechanism is different, the treatment recommendations are dif-
patient’s condition as well as the surgical findings. This particular ferent. It is with this that many surgeons with a practice involving
patient had neuropathic pain with complete anesthesia of the microneurosurgery consider medication expression into the canal

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 30 Endodontic-Related Inferior Alveolar Nerve Injuries 143

to be a surgical urgency: exploration to debride the canal of all been borne out through literature, but conventional wisdom
remaining foreign material should be done as soon as possible. suggests that earlier debridement would result in better out-
The decision to explore a nerve after an endodontic IAN comes. The rare nature of this complication makes it somewhat
injury can be made rather quickly after it is diagnosed, but the difficult to disseminate this through to the general dental
limiting factor in the timeline is the presentation to an office world, but it is incumbent upon the oral and maxillofacial sur-
capable of making this decision. By this it means that the den- gical community to educate dentists on options that exist to
tist or endodontist who performs the root canal should not just manage situations.
wait and hope it goes away because the persistent chemical
challenge may be continually damaging the nerve, and the best ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
results would come with immediate debridement. This has not complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 143.e1

Bibliography Pogrel MA: Damage to the inferior alveolar nerve as the result of root
canal therapy, J Am Dent Assoc 138(1):65-69, 2007. doi:10.14219/
jada.archive.2007.0022.
Bagheri SC, Meyer RA: When to refer a patient with a nerve injury to a Pogrel MA, Jergensen R, Burgon E, et al: Long-term outcome of tri-
specialist, J Am Dent Assoc 145(8):859-861, 2014. doi:10.14219/ geminal nerve injuries related to dental treatment, J Oral Maxillofac
jada.2014.45. Surg 69(9):2284-2288, 2011. doi:10.1016/j.joms.2011.02.023.
Bagheri SC, Meyer RA, Steed MB, et al: Microsurgical repair of the in- Scolozzi P, Lombardi T, Jaques B: Successful inferior alveolar nerve de-
ferior alveolar nerve: success rate and factors, J Oral Maxillofac Surg compression for dysesthesia following endodontic treatment: report
70(8):1978-1990, 2012. doi:10.1016/j.joms.2011.08.030. of 4 cases treated by mandibular sagittal osteotomy, Oral Surg Oral
Bianchi B, Ferri A, Varazzani A, et al: Microsurgical decompression of infe- Med Oral Pathol Oral Radiol Endod 97(5):625-631, 2004.
rior alveolar nerve after endodontic treatment complications, J Craniofac doi:10.1016/j.tripleo.2004.01.002.
Surg 28(5):1365-1368, 2017. doi:10.1097/SCS.0000000000003672. Serrada I, Hordacre B, Hillier SL: Does sensory retraining improve sensa-
Biglioli F, Kutanovaite O, Autelitano L, et al: Surgical treatment of pain- tion and sensorimotor function following stroke? A systematic review
ful inferior alveolar nerve injuries following endodontic treatment: a and meta-analysis, Front Neurosci 13:402, 2019. doi:10.3389/fnins.
consecutive case series of seven patients, Oral Maxillofac Surg 2019.00402.
21(4):461-466, 2017. doi:10.1007/s10006-017-0656-8. Sonneveld KA, Hasstedt KL, Meyer RA, et al: Microsurgical repair of
Cox B, Zuniga JR, Panchal N, et al: Magnetic resonance neurography in inferior alveolar nerve injuries associated with endodontic treatment:
the management of peripheral trigeminal neuropathy: experience in a results on sensory function and relief of pain, J Oral Maxillofac Surg
tertiary care centre, Eur Radiol 26(10):3392-3400, 2016. doi:10.1007/ 79(7):1434-1446, 2021. doi:10.1016/j.joms.2021.01.037.
s00330-015-4182-5. Susarla SM, Kaban LB, Donoff RB, et al: Functional sensory recovery
González-Martín M, Torres-Lagares D, Gutiérrez-Pérez JL, et al: Inferior after trigeminal nerve repair, J Oral Maxillofac Surg 65(1):60-65,
alveolar nerve paresthesia after overfilling of endodontic sealer into 2007. doi:10.1016/j.joms.2005.11.115.
the mandibular canal, J Endod 36(8):1419-1421, 2010. doi:10.1016/j. Tuğ Kılkış B, Er K, Taşdemir T, et al: Neurotoxicity of various root canal
joen.2010.03.008. sealers on rat sciatic nerve: an electrophysiologic and histopathologic
Hillerup S: Iatrogenic injury to the inferior alveolar nerve: etiology, signs study, Clin Oral Investig 19(8):2091-2100, 2015. doi:10.1007/
and symptoms, and observations on recovery, Int J Oral Maxillofac s00784-015-1447-y.
Surg 37(8):704-709, 2008. doi:10.1016/j.ijom.2008.04.002. Ziccardi VB, Steinberg MJ: Timing of trigeminal nerve microsurgery: a
Meyer RA, Bagheri SC: Microsurgical reconstruction of the trigeminal review of the literature, J Oral Maxillofac Surg 65(7):1341-1345,
nerve, Oral Maxillofac Surg Clin North Am 25(2):287-302, 2013. 2007. doi:10.1016/j.joms.2005.11.090.
doi:10.1016/j.coms.2013.01.002. Zilliox LA: Neuropathic pain, Continuum (N Y) 23(2):512-532, 2017.
Meyer RA, Bagheri SC: Etiology and prevention of nerve injuries. In doi:10.1254/fpj.143.215.
Miloro M, ed. Trigeminal Nerve Injuries, New York, 2013, Springer, Zuniga JR, Mistry C, Tikhonov I, et al: Magnetic resonance neurography
pp 27-61. of traumatic and nontraumatic peripheral trigeminal neuropathies,
Meyer RA, Bagheri SC: Clinical evaluation of peripheral trigeminal nerve J Oral Maxillofac Surg 76(4):725-736, 2018. doi:10.1016/j.joms.2017.
injuries, Atlas Oral Maxillofac Surg Clin North Am 19(1):15-33, 2011. 11.007.
doi:10.1016/j.cxom.2010.11.002. Zuniga JR, Yates DM: Factors determining outcome after trigeminal
Olsen JJ, Thorn JJ, Korsgaard N, et al: Nerve lesions following apical nerve surgery for neuropathic pain, J Oral Maxillofac Surg 74(7):1323-
extrusion of non-setting calcium hydroxide: a systematic case review 1329, 2016. doi:10.1016/j.joms.2016.02.005.
and report of two cases, J Craniomaxillofac Surg 42(6):757-762, 2014. Zuniga JR, Meyer RA, Davis LF: The accuracy of clinical neurosensory test-
doi:10.1016/j.jcms.2013.11.007. ing for nerve injury diagnosis, J Oral Maxillofac Surg 56(1):2-8, 1998.
Phillips C, Blakey G, Essick GK: Sensory retraining: a cognitive behav- Zuniga JR, Yates DM, Phillips CL: The presence of neuropathic pain
ioral therapy for altered sensation, Atlas Oral Maxillofac Surg Clin predicts postoperative neuropathic pain following trigeminal nerve
North Am 19(1):109-118, 2011. doi:10.1016/j.cxom.2010.11.006. repair, J Oral Maxillofac Surg 72(12):2422-2427, 2014. doi:10.1016/j.
Phillips C, Kim SH, Essick G, et al: Sensory retraining after orthognathic joms.2014.08.003.
surgery: effect on patient report of altered sensations, Am J Orthod Den-
tofac Orthop 136(6):788-794, 2009. doi:10.1016/j.ajodo.2008.07.015.

t.me/Dr_Mouayyad_AlbtousH
30
Endodontic-Related Inferior Alveolar
Nerve Injuries
K EI T H A . S O NNE V E L D a n d S H A H R O K H C . B AG H ER I

CC Vital signs. Temperature is 98.9°F, blood pressure is 116/72 mm

Hg, pulse rate is 85 bpm, and respiratory rate is 12 breaths per minute.
A 59-year-old female presents to your office for evaluation of Maxillofacial. No significant extraoral edema or erythema
numbness of her lower lip with pain that she reports as “consistent noted. Her neck shows full range of motion. There is no remark-
with episodes of very severe pain.” able lymphadenopathy on palpation. The inferior border and angle
of the mandible are easily palpable and nontender. No abnormali-
HPI ties in facial animation and no gross asymmetries are noted.
Cranial Nerves
The patient had root canal therapy (RCT) on tooth #29 com- • Level A: Right side brush stroke: 0 of 4. Left side brush stroke:
pleted about 4 months earlier. She said that the dentist performed 4 of 4. Two-point discrimination: Right: Unable to feel. Two-
it in two visits, and after the first visit, she developed a painful point discrimination: 3 mm
sensation, which worsened over the first several days. The dentist • Level B: Right: 4.56. Left: 1.65
prescribed her antibiotics and a steroid course and completed the • Level C: Right: no response; left: normal response
root canal treatment several weeks later. The painful sensation was For a surgeon evaluating the status of a nerve, a set of standard-
never relieved, but instead the patient developed numbness in her ized tests can be used to quantify level of nerve dysfunction, and they
lower teeth, lower lip, and chin area on the right side. She de- should be done comparing the affected nerve with an unaffected
scribes the painful sensation as always present at some basal level, nerve as similar as possible (e.g., testing the affected right inferior
which changes daily but also has episodes of very severe pain she alveolar nerve [IAN] should be compared with the unaffected left
describes as “stabbing” and “electrical.” The frequency of these IAN). These tests differentiate between injuries affecting different
severe pain episodes varies on a day-to-day basis and she has not nerve fibers because the different fibers transmit various stimuli.
been able to figure out any particular factors that may exacerbate Painful sensation is difficult to quantify because interpretation of
it. She is very worried about what may happen without any treat- painful sensation is very subjective: what stimulus evokes a response
ment because she has had no improvement. Her primary care in one person may not evoke the same response in another person.
physician prescribed her gabapentin and tapered her up to a dos- This is contrasted with diminished normal sensation in that the
age of 300 mg three times daily, but she could not tolerate the side standardized set of tests can quantify the level of sensation present.
effects for only modest improvement in her discomfort.
Imaging
PMHX/PDHX/Medications/Allergies/SH/FH
The patient’s panoramic radiograph shows a speckled radiopacity sur-
The patient reports only hypothyroidism, which is being con- rounding the mandibular canal and apex of tooth #29 (Fig. 30.2).
trolled using levothyroxine, and osteoporosis, for which she is Panoramic radiograph is a good initial screening for IAN injuries, but
only taking vitamin D and calcium supplementation. Her surgical further characterization may be obtained using cone-beam computed
history is only significant for breast augmentation and hysterec- tomography. The role for magnetic resonance neurography shows
tomy. She has no drug allergies. She is a nonsmoker and only promise in evaluating injuries to the peripheral trigeminal nerve,
drinks alcohol socially. however the widespread use is limited by the abilities for this imaging
protocol to be performed at local facilities.
Examination
Labs
General. The patient is a well-developed, well-nourished adult
female with a nontoxic appearance. She has normal mentation Evaluation of a patient with an injury to the peripheral trigeminal
and shows moderate signs of distress because today is a “bad nerve has no requirement for lab work. If surgical intervention is
day.” indicated, preoperative labs may be necessary.

140
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 30 Endodontic-Related Inferior Alveolar Nerve Injuries 141

1 Injection injury (needle trauma and/or neurotoxicity)

2 Mechanical injury during extraction

- Stretch (neuropraxia) or partial transection (axonotmesis)
V3
- Complete transection injury (neurotmesis) from drill or
1 instrumentation
LN
3 Injury from flap design or unusual position of LN on or close
to retormolar pad
Tongue
4 Thermal or burn injury (e.g., use of electrocautery) (uncommon)
2
3rd molar

Direct needle
injury and/or
presure injury
from intraneural
injection

• Fig. 30.1 Positive mechanisms of lingual nerve (LN) injury.

• Fig. 30.2 Panoramic radiograph on consultation showing a speckled

appearance of radiopaque material surrounding the apex of tooth #29 and
the mental foramen.

Assessment
Anesthesia dolorosa secondary to endodontic IAN injury.

Treatment
This patient was treated with exploration of the right IAN, with the
surgeon finding revealing a neuroma-in-continuity (Fig. 30.3). The
neuroma was resected, direct neurorrhaphy was performed, and
the repair was entubulated (Fig. 30.4) with an amnion-chorion
membrane (Axoguard, Axogen Inc.). Surgical access was achieved
through a buccal vestibular incision followed by a buccal corticot-
omy to access the proximal IAN, and the mental foramen was re- • Fig. 30.3 Surgical exploration of this nerve showing a large granuloma-
moved to allow for full access to this injury. Often if the injury is tous neuroma-in-continuity of the inferior alveolar nerve.
more proximal along the nerve, then the mental foramen will not
need to be accessed (Fig. 30.5). By releasing the nerve from the
foramen, it may allow for direct coaptation and neurorrhaphy with- cannot make the patient any more anesthetic, so the benefits of
out an interposition nerve allograft. repair certainly outweigh the risks of more complete sensation
The decision on whether or not to explore a suspected nerve loss. Conversely, severe neuropathic pain without any type of
injury should be patient-centered. The issue of value depends on sensory deficit results in patients who generally prefer to take the
the clinical presentation. With every procedure, there are risks chance at pain improvement knowing the risk that they may lose
associated and the potential to have worsening of the condition. sensation. It is when the level of neuropathic pain or sensory func-
For a patient with a nerve injury with anesthesia and no neuro- tion is not at an extreme when the decision is not as clear, and it
pathic pain component, exploration and an attempt at repair should be a decision made between the surgeon and the patient.

t.me/Dr_Mouayyad_AlbtousH
142 S E C TI O N Dentoalveolar Surgery

nerve, so a more aggressive treatment (continuity resection) may

be rendered because the only likely change is improvement rather
than a worsening of her condition. For many patients with nerve
injuries, the return of sensation is a major consideration when
deliberating about potential nerve exploration (e.g., what are the
chances it gets back to normal?). This return to FSR has several
factors, namely time elapsed since injury, experience of the sur-
geon, and age of the patient. The best likelihood of recovery is
from as early as a condition that would indicate a repair is diag-
nosed, for example, a visualized transection of a nerve being
treated immediately.
For nonwitnessed injuries, most often a 3-month period of
evaluation for improvement in clinical condition is recommended.
If at 3 months the clinical NST shows no or minimal improve-
ment, exploration and repair may be indicated. The more time
that has elapsed since the initial injury results in a lower likeli-
hood of achieving FSR, which shows a drop around 9 months and
reduces precipitously at 12 months.

Discussion
Endodontic therapy has for many years been a mainstay of the
dental treatment armamentarium for abatement of infectious
disease and restoration of tooth form and function. As with any
treatment, complications exist and RCT is no different. Several
mechanisms exist as far as how RCT can affect the IAN: filing
past the apex causing direct trauma to the IAN, overextension of
• Fig. 30.4 After resection of the neuroma, the distal end was released gutta percha into the mandibular canal, or expression of various
from the mental foramen, and a direct neurorrhaphy and entubulation was medicaments into the mandibular canal.
performed. Endodontic-related IAN injuries are a rare entity but do have
severe consequences. There is a paucity of research on the topic;
this research generally exists in mostly case reports and small case
series, with the exception of a single retrospective cohort study of
more than 20 cases. In this study, almost 74% of patients pre-
sented with neuropathic pain as the chief complaint about their
condition. After nerve exploration and indicated repair, the suc-
cess rate in achieving FSR was less than 50%, but it did lower the
perceived pain on a visual analog scale by approximately 2 points.
One major factor potentially affecting this less-than-ideal out-
come is that the average time from injury until presentation for
consultation was 7.9 months. Because time is a major factor in
achieving a good result from microneurosurgery, this extending
period of time likely plays a major role in the number of patients
achieving FSR because following consultation, there is then the
process of obtaining insurance authorization, medical optimiza-
• Fig. 30.5 Postoperative radiograph showing the radiolucency created by tion, and getting operating room time, which further extends the
the corticotomy with an absence of remaining radiopaque material and no time to exploration and repair.
remaining mental foramen. The discussion of these types of injuries must also consider the
mechanisms. Overfiling and overextension of gutta percha is trau-
matic to the IAN, but the medicaments that can be expressed into
In this particular case, the patient had complete anesthesia and the mandibular canal are likely a chemical injury. These medica-
severe neuropathic pain, so the proposal to explore and repair was ments can be sodium hypochlorite, calcium hydroxide, and euge-
readily accepted by the patient. After the repair, she had complete nol. All of these components are considered neurotoxic, and when
resolution of her neuropathic pain and returned to functional sen- expressed into the mandibular canal, it can create a persistent
sory recovery (FSR) with a Medical Research Council Scale score of neurotoxicity that can result in extreme states of neuropathic
S3 as evaluated at a follow-up 3 months after the procedure. pain. It is important to consider this difference because the high
majority of research on peripheral trigeminal nerve injuries is re-
Complications lated to traumatic injuries (third molar extraction, dental implant
placement, osteotomies, pathology), so it may be that because the
For nerve injuries, the surgical repair rendered is dictated by the mechanism is different, the treatment recommendations are dif-
patient’s condition as well as the surgical findings. This particular ferent. It is with this that many surgeons with a practice involving
patient had neuropathic pain with complete anesthesia of the microneurosurgery consider medication expression into the canal

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 30 Endodontic-Related Inferior Alveolar Nerve Injuries 143

to be a surgical urgency: exploration to debride the canal of all been borne out through literature, but conventional wisdom
remaining foreign material should be done as soon as possible. suggests that earlier debridement would result in better out-
The decision to explore a nerve after an endodontic IAN comes. The rare nature of this complication makes it somewhat
injury can be made rather quickly after it is diagnosed, but the difficult to disseminate this through to the general dental
limiting factor in the timeline is the presentation to an office world, but it is incumbent upon the oral and maxillofacial sur-
capable of making this decision. By this it means that the den- gical community to educate dentists on options that exist to
tist or endodontist who performs the root canal should not just manage situations.
wait and hope it goes away because the persistent chemical
challenge may be continually damaging the nerve, and the best ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
results would come with immediate debridement. This has not complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 143.e1

Bibliography Pogrel MA: Damage to the inferior alveolar nerve as the result of root
canal therapy, J Am Dent Assoc 138(1):65-69, 2007. doi:10.14219/
jada.archive.2007.0022.
Bagheri SC, Meyer RA: When to refer a patient with a nerve injury to a Pogrel MA, Jergensen R, Burgon E, et al: Long-term outcome of tri-
specialist, J Am Dent Assoc 145(8):859-861, 2014. doi:10.14219/ geminal nerve injuries related to dental treatment, J Oral Maxillofac
jada.2014.45. Surg 69(9):2284-2288, 2011. doi:10.1016/j.joms.2011.02.023.
Bagheri SC, Meyer RA, Steed MB, et al: Microsurgical repair of the in- Scolozzi P, Lombardi T, Jaques B: Successful inferior alveolar nerve de-
ferior alveolar nerve: success rate and factors, J Oral Maxillofac Surg compression for dysesthesia following endodontic treatment: report
70(8):1978-1990, 2012. doi:10.1016/j.joms.2011.08.030. of 4 cases treated by mandibular sagittal osteotomy, Oral Surg Oral
Bianchi B, Ferri A, Varazzani A, et al: Microsurgical decompression of infe- Med Oral Pathol Oral Radiol Endod 97(5):625-631, 2004.
rior alveolar nerve after endodontic treatment complications, J Craniofac doi:10.1016/j.tripleo.2004.01.002.
Surg 28(5):1365-1368, 2017. doi:10.1097/SCS.0000000000003672. Serrada I, Hordacre B, Hillier SL: Does sensory retraining improve sensa-
Biglioli F, Kutanovaite O, Autelitano L, et al: Surgical treatment of pain- tion and sensorimotor function following stroke? A systematic review
ful inferior alveolar nerve injuries following endodontic treatment: a and meta-analysis, Front Neurosci 13:402, 2019. doi:10.3389/fnins.
consecutive case series of seven patients, Oral Maxillofac Surg 2019.00402.
21(4):461-466, 2017. doi:10.1007/s10006-017-0656-8. Sonneveld KA, Hasstedt KL, Meyer RA, et al: Microsurgical repair of
Cox B, Zuniga JR, Panchal N, et al: Magnetic resonance neurography in inferior alveolar nerve injuries associated with endodontic treatment:
the management of peripheral trigeminal neuropathy: experience in a results on sensory function and relief of pain, J Oral Maxillofac Surg
tertiary care centre, Eur Radiol 26(10):3392-3400, 2016. doi:10.1007/ 79(7):1434-1446, 2021. doi:10.1016/j.joms.2021.01.037.
s00330-015-4182-5. Susarla SM, Kaban LB, Donoff RB, et al: Functional sensory recovery
González-Martín M, Torres-Lagares D, Gutiérrez-Pérez JL, et al: Inferior after trigeminal nerve repair, J Oral Maxillofac Surg 65(1):60-65,
alveolar nerve paresthesia after overfilling of endodontic sealer into 2007. doi:10.1016/j.joms.2005.11.115.
the mandibular canal, J Endod 36(8):1419-1421, 2010. doi:10.1016/j. Tuğ Kılkış B, Er K, Taşdemir T, et al: Neurotoxicity of various root canal
joen.2010.03.008. sealers on rat sciatic nerve: an electrophysiologic and histopathologic
Hillerup S: Iatrogenic injury to the inferior alveolar nerve: etiology, signs study, Clin Oral Investig 19(8):2091-2100, 2015. doi:10.1007/
and symptoms, and observations on recovery, Int J Oral Maxillofac s00784-015-1447-y.
Surg 37(8):704-709, 2008. doi:10.1016/j.ijom.2008.04.002. Ziccardi VB, Steinberg MJ: Timing of trigeminal nerve microsurgery: a
Meyer RA, Bagheri SC: Microsurgical reconstruction of the trigeminal review of the literature, J Oral Maxillofac Surg 65(7):1341-1345,
nerve, Oral Maxillofac Surg Clin North Am 25(2):287-302, 2013. 2007. doi:10.1016/j.joms.2005.11.090.
doi:10.1016/j.coms.2013.01.002. Zilliox LA: Neuropathic pain, Continuum (N Y) 23(2):512-532, 2017.
Meyer RA, Bagheri SC: Etiology and prevention of nerve injuries. In doi:10.1254/fpj.143.215.
Miloro M, ed. Trigeminal Nerve Injuries, New York, 2013, Springer, Zuniga JR, Mistry C, Tikhonov I, et al: Magnetic resonance neurography
pp 27-61. of traumatic and nontraumatic peripheral trigeminal neuropathies,
Meyer RA, Bagheri SC: Clinical evaluation of peripheral trigeminal nerve J Oral Maxillofac Surg 76(4):725-736, 2018. doi:10.1016/j.joms.2017.
injuries, Atlas Oral Maxillofac Surg Clin North Am 19(1):15-33, 2011. 11.007.
doi:10.1016/j.cxom.2010.11.002. Zuniga JR, Yates DM: Factors determining outcome after trigeminal
Olsen JJ, Thorn JJ, Korsgaard N, et al: Nerve lesions following apical nerve surgery for neuropathic pain, J Oral Maxillofac Surg 74(7):1323-
extrusion of non-setting calcium hydroxide: a systematic case review 1329, 2016. doi:10.1016/j.joms.2016.02.005.
and report of two cases, J Craniomaxillofac Surg 42(6):757-762, 2014. Zuniga JR, Meyer RA, Davis LF: The accuracy of clinical neurosensory test-
doi:10.1016/j.jcms.2013.11.007. ing for nerve injury diagnosis, J Oral Maxillofac Surg 56(1):2-8, 1998.
Phillips C, Blakey G, Essick GK: Sensory retraining: a cognitive behav- Zuniga JR, Yates DM, Phillips CL: The presence of neuropathic pain
ioral therapy for altered sensation, Atlas Oral Maxillofac Surg Clin predicts postoperative neuropathic pain following trigeminal nerve
North Am 19(1):109-118, 2011. doi:10.1016/j.cxom.2010.11.006. repair, J Oral Maxillofac Surg 72(12):2422-2427, 2014. doi:10.1016/j.
Phillips C, Kim SH, Essick G, et al: Sensory retraining after orthognathic joms.2014.08.003.
surgery: effect on patient report of altered sensations, Am J Orthod Den-
tofac Orthop 136(6):788-794, 2009. doi:10.1016/j.ajodo.2008.07.015.

t.me/Dr_Mouayyad_AlbtousH
31
Displaced Root Fragments During
Dentoalveolar Surgery
DAN IE L L E M. C U N N I N G H A M a n d S H A H R O K H C . B AG H ER I

CC structures (e.g., the maxillary sinus). Evaluation of the size and

shape of the tooth, degree of sinus pneumatization, and amount
A 41-year-old male is referred to your office for extraction of a of bone is important for assessment of possible risks for oral antral
nonrestorable left maxillary first molar. exposure or root fracture.
For the current patient, the panoramic radiograph reveals a
HPI long palatal root of the left maxillary first molar that appears to
partially project into the sinus. There is a loss of continuity of the
Four years earlier, the patient had undergone a root canal proce- maxillary sinus in the area of the palatal root (suggestive of a peri-
dure because of extensive caries on the left maxillary first molar, apical scar secondary to the previous root canal or a pathologic
without any complications. (Extractions of endodontically treated process involving the maxillary sinus).
teeth have a greater probability of root fracture and displace-
ment.) He did not pursue restoration of the tooth because of fi- Labs
nancial reasons and has now been referred for extraction of the
failed root canal. He presented to his general dentist with a com- No laboratory testing is indicated before routine dentoalveolar
plaint of pain and mild gingival swelling adjacent to the left surgery unless dictated by the medical history.
maxillary first molar.
Assessment
PMHX/PDHX/Medications/Allergies/SH/FH
Nonrestorable carious left maxillary first molar requiring extraction.
Noncontributory. The patient does not use tobacco. Preoperative assessment of this patient should alert the surgeon
Medical comorbidities that compromise wound healing (e.g., to the increased likelihood of root fracture or oral antral commu-
chronic steroid therapy, smoking cigarettes, diabetes, radiation nication upon surgical removal of the left maxillary first molar.
therapy, and malnutrition) may increase the likelihood of persis- Well-informed patients are more accepting of necessary secondary
tent oral antral communications, requiring repeat surgical closure. procedures (e.g., oral antral closure, root retrieval from the sinus,
However, the regional anatomy of the area, such as the length of or nerve repair).
the roots, extent of sinus pneumatization, and amount and qual-
ity of surrounding bone, is also important. Treatment
Examination After injection of a local anesthetic with epinephrine, extraction
of the left maxillary first molar was attempted using an elevator
Intraoral. The patient has localized gingival edema and erythema and forceps. Removal of the tooth revealed fracture of the palatal
of the left maxillary first molar, with no vestibular fluctuance. root with the root fragment retained within the palatal socket. A
There is a 2-mm draining fistula on the buccal gingiva. A large root tip pick was used to retrieve the fragment. During elevation,
carious lesion is present on the mesial–occlusal surface of the the root tip suddenly disappeared from the surgical field. Evalua-
tooth. The left maxillary second and third molars (teeth #15 and tion of the socket revealed a dark hole, suggesting that the frag-
#16) are missing, with significant resorption of the posterior max- ment has dislodged into the maxillary sinus.
illary ridge. Upon diagnosis of a displaced root into the maxillary sinus,
several maneuvers may be attempted to retrieve the fragment. It is
Imaging possible for a fragment to be displaced below the Schneiderian
membrane without actual dislodgment into the maxillary an-
The periapical or panoramic radiograph is the minimal imaging trum. If the membrane appears intact, this diagnosis should be
modality necessary before the extraction of a tooth. The pan- considered. In cases of dislodgment into the sinus, a perforation
oramic radiograph allows better evaluation of the surrounding into the antrum may be visible. Asking the patient to exhale while

144
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 CHAPTER 31 Displaced Root Fragments During Dentoalveolar Surgery 145

pinching the nose may demonstrate air or bubbles exiting the • BOX 31.1 Complications of Dentoalveolar
socket, confirming the diagnosis of sinus perforation. Immedi- Surgery
ately on diagnosis, a small suction tip can be placed at the apex of
the extraction socket in an attempt to remove the fragment. The Intraoperative Complications
procedure can be repeated with the patient placed in an upright • Root fracture (increased incidence with age and root canal therapy)
position. If this maneuver fails, the maxillary sinus can be irri- • Injury to adjacent structures (lingual nerve, inferior alveolar nerve, mental
gated with normal saline followed by suctioning to allow root nerve, greater palatine artery and vein, and adjacent teeth and restora-
retrieval. If the root fragment cannot be visualized, the procedure tions)
should be aborted. The following two treatment approaches • Maxillary tuberosity fracture (seen with maxillary second and third molar
extractions, with an increasing incidence with age)
should be considered: • Oral antral communication
• Closure of the sinus communication, leaving the root frag- • Displacement of the tooth fragments (or entire tooth) outside of the tooth
ment in place. The patient is subsequently monitored with socket. Root fragments can be displaced into the maxillary sinus, inferior
panoramic radiographs to document the position of the root. alveolar canal, infratemporal fossa (uncommon complication of maxillary
In patients who are asymptomatic, with small fragments that third molar extractions), sublingual space (perforation of the lingual cortex
are fixed in the antrum, it is possible to simply observe the root above the mylohyoid attachment), or submandibular space (perforation be-
with serial radiographs. low the mylohyoid attachment)
• Closure of the sinus perforation followed by immediate or • Hemorrhage (bleeding in an otherwise noncoagulopathic patient is almost
delayed removal of the root fragment via a Caldwell-Luc, always easily controlled with local measures)
• Temporomandibular joint pain (secondary to acute temporomandibular joint
transalveolar, or endoscopic sinus surgery. The root tip may
muscle spasm, especially with preexisting internal derangement)
change position secondary to the movement of ciliary cells of • Mandibular fracture (an uncommon but known complication of mandibular
the epithelial cells of the maxillary mucosa, patient’s head posi- third molar extractions)
tion, and negative pressure caused by inhaling and the size of • Failure to achieve adequate local anesthesia
the ostium; therefore, updated imaging is imperative, prefera-
ble three-dimensional (computed tomography [CT] or cone- Postoperative Complications
beam computed tomography [CBCT]). • Alveolar osteitis (dry socket)
• These treatment options are addressed in more detail in the • Wound infection
Discussion section. • Periodontal complications (loss of gingival attachment levels or develop-
ment of periodontal pockets)
• Poor wound healing, causing delayed recovery
Complications • Alveolar bone abnormalities or irregularities (may require repeat minor al-
veoplasty)
Displacement of a tooth or root fragment into the maxillary sinus • Osteoradionecrosis
in a known complication of maxillary dentoalveolar surgery. Al- • Bisphosphonate-induced osteonecrosis of the jaws
though several preoperative findings (described earlier) can iden-
tify patients at risk, this complication can occur in any patient.
Other possible complications of dentoalveolar surgery are listed in
Box 31.1. There have also been a few case reports of serious complications,
Pain and swelling are inevitable consequences of all surgical including cavernous sinus thrombosis, meningitis, and subdural
interventions. However, measures to minimize pain and swelling empyema in addition to pneumonias secondary to inhalation of
(preoperative steroids, short operative time, and careful surgical the root tip that has migrated to the ostium and been dislodged
technique) may increase the patient’s comfort and satisfaction. during a sneeze or cough. Although these complications are ex-
ceedingly rare, it does steer treatment options toward removal of
Discussion the foreign object.
A standard procedure used to retrieve foreign bodies from the
The palatal root of the maxillary first molar is the most likely root maxillary sinus is the Caldwell-Luc procedure. A vestibular inci-
to be pushed into the maxillary sinus, secondary to its divergence sion is used to access the canine fossa. A perforation is made in the
and increased chance of fracture during extraction. There is some anterior maxillary wall, allowing visualization of the sinus. This can
controversy regarding the optimal management of root fragments be enlarged to gain access to the sinus as needed. Careful attention
displaced into the maxillary sinus. Many surgeons advocate re- to the infraorbital nerve prevents postoperative hypoesthesia.
moval of all root fragments from the sinus regardless of any pre- Access to the maxillary sinus can also be gained via a transal-
existing sinus or periapical pathology. It is hypothesized that a veolar approach by extending the opening of the extraction
root tip may act as a foreign body in the sinus, leading to polyps socket. Removal of buccal bone beyond the apex of the socket
or sinusitis. No randomized trials have evaluated this issue, and allows exposure of the antral mucosa. If the membrane has not
most authors argue that the decision needs to be made on a case- been violated, this tissue plane may be explored; otherwise, an
by-case basis. It is recommended that if the root tip is small opening can be made through the membrane to allow sinus explo-
(,3 mm) and the sinus and the tooth demonstrate no preexisting ration. The opening is closed primarily using a buccal flap. This
pathology, only minimal attempts should be made to retrieve the technique provides superior exposure to the antral floor (exposing
root. Fragments may fibrose into the sinus membrane, without the most likely position of the dislodged tooth). However, if the
any long-term sequelae. Case reports of retrieved maxillary im- patient is interested in replacing the edentulous area with an im-
plants that had migrated or perforated the sinus mucosa have plant, this approach would compromise the alveolar ridge bone,
demonstrated no inflammatory changes in the mucosa (both which is important for implant restorations.
clinically and radiographically). However, other case reports have Prevention of root displacement is the best treatment. If a root tip
found that migration of a cover screw has caused acute sinusitis. is fractured and the clinician suspects the possibility of displacement

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146 S E C TI O N Dentoalveolar Surgery

into the sinus, blind attempts at elevation of the fragment should be object larger than 20 mm and by the inability to remove such an
avoided. The use of adequate lighting (headlight) and full exposure of object through the narrow and complicated pathway. An endo-
the area usually allow successful retrieval of the root from the socket. scope can be used in combination with a Caldwell-Luc access to
A variety of methods, including the use of endodontic files to remove minimize the amount of surgical trauma. It is possible to retrieve
root tips, have been described. the implant via the initial osteotomy site; however, this could
It is generally recommended that exposure of the sinus via the compromise future implant placement.
oral cavity warrants antibiotic therapy and “sinus precautions” Although commonly discussed but rarely reported, displace-
regardless of the decision to retain or retrieve a tooth fragment. ment of the maxillary third molar into the infratemporal fossa is
The sinus flora includes the bacteria Haemophilus influenzae, a potential complication. A number of case reports have discussed
Streptococcus pneumoniae, and Moraxella catarrhalis. Nasal decon- various treatment techniques. The infratemporal fossa is the space
gestants, such as oxymetazoline (Afrin) or pseudoephedrine, are inferior and medial to the zygomatic arch, with possible superior
used to improve sinus drainage. Topical application of oxymetazo- extension superficial or deep to the temporalis muscle. A CBCT
line (an a-agonist) causes arteriolar vasoconstriction, resulting in scan can demonstrate the position of the tooth (it also shows
nasal mucosal shrinkage, which allows for improved drainage. whether the tooth was displaced into the maxillary antrum or the
Oxymetazoline should not be used for longer than 3 to 5 days infratemporal fossa); however, magnetic resonance imaging or
secondary to the development of rhinitis medicamentosa, causing contrast-enhanced CT can better determine the location of the
rebound nasal congestion. Decongestants containing pseudo- tooth in relation to the muscular (and soft tissue) anatomy. Upon
ephedrine (a sympathomimetic, a-adrenergic agonist) cause vaso- displacement of the tooth, the surgical incision can be enlarged to
constriction by selectively acting on the peripheral areceptors, attempt extraction of the tooth via the displacement tract. If the
without the central nervous system side effects. These medications tooth can be palpated, a spinal needle can also be used to push the
are frequently available in combination with an antihistamine or tooth inferiorly toward the oral cavity for retrieval. If this is not
antitussive agents. successful, the patient can be placed on antibiotics, and retrieval
In addition to root tip displacement into the maxillary sinus, can be attempted in the operating room using endotracheal intu-
case reports have found displacement of implants, either during bation. If possible, delaying the procedure for 6 weeks allows
placement or at a later time (Fig. 31.1). The same techniques have fibrosis and encapsulation of the tooth, which minimizes move-
been reported for retrieval as those used for root tips; however, ment during removal. Other techniques include a coronal
waiting is not recommended. Generally either immediate or early approach (including a Gilles approach) and intraoral access by
retrieval is warranted because the implant can act as a nidus of removal of the coronoid process. Intraoperative navigation guided
infection. There is a limitation on the size of the objects that can by CT can be used via an intraoral or a small temporal incision or
be removed using an endoscopic technique. A transnasal ap- a combination of the two. This approach is technique sensitive
proach is limited both by the endoscope’s inability to pick up an and may be more costly.

• Fig. 31.1 Cone-beam computed tomography scan demonstrating a displaced implant into the upper
aspect of the left maxillary sinus.

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 CHAPTER 31 Displaced Root Fragments During Dentoalveolar Surgery 147

Extraction of mandibular molars can be complicated by dis- of the immediate region. Care should be taken not to injure the
placement of root tips through a perforated lingual cortex into the lingual nerve. In the event of failure to identify the tooth, the
submandibular or sublingual space (depending on the attachment procedure should be aborted and the patient placed on antibiotics.
of the mylohyoid muscle). The lingual plate at the area of the A waiting period of 4 to 6 weeks has been recommended to allow
mandibular third molars can be very thin and, in some instances, the development of fibrosis around the tooth to facilitate removal.
fenestrated. Upon identification of a tooth fragment that is likely A CT scan may be obtained to visualize the exact position of the
to be dislodged from the socket, placement of a finger along the tooth, allowing careful preoperative planning. For small root frag-
medial aspect of the lingual cortex can frequently prevent this ments (,5 mm) that are not associated with any pathology, the
complication. surgeon may elect to observe the tooth and remove the fragment
If a tooth becomes dislodged into the submandibular or sublin- only if it becomes symptomatic.
gual space, attempts at removal should be made through the ex-
traction socket or the perforation. If this maneuver is unsuccessful, ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
a lingual mucoperiosteal flap can be elevated to allow exploration complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 147.e1

Bibliography Karumaran CS, Ramachandran AK, Venkatesan R: Chronic sinusitis of

odontogenic origin due to an undiagnosed displaced root fragment in
the maxillary sinus and the role of cone beam computed tomography
Barclay JK: Root in the maxillary sinus, Oral Surg Oral Med Oral Pathol in successful management, Indian J Dent Res 29:847-851, 2018.
64:162-164, 1987. Lee FM: Management of the displaced root in the maxillary sinus, Int J
Beech AN, Farrier JN: The importance of prompt referral when tooth Oral Maxillofac Surg 7:374-379, 1978.
roots are displaced into the maxillary antrum, Dent Update 43:760- Nakamura N, Mitsuyasu T, Ohishi M: Endoscopic removal of a dental
765, 2016. implant displaced into the maxillary sinus: technical note, Int J Oral
Bodner L, Zion B, Puterman M: Removal of a maxillary third molar from Maxillofac Surg 33:195-197, 2004.
the infratemporal fossa. a case report, J Med Cases 3(2):97-99, 2012. Peterson LJ, Ellis E, Hupp JR, et al: Contemporary Oral and Maxillofacial
Campbell A, Costello B: Retrieval of a displaced third molar using navigation Surgery, St. Louis, 1993, Mosby, pp 279-280.
and active image guidance, J Oral Maxillofac Surg 68:480-485, 2010. Seigneur M, Cloitre A, Malard O, et al: Teeth roots displacement in the
Chrcanovic B, Custódio A: Surgical removal of dental implants into the maxillary sinus: characteristics and management, J Oral Med Oral
maxillary sinus: a case report, Serbian Dent J 56:139-144, 2009. Surg 26:34, 2020.
Colbert S, Cameron M, Williams J: Septic thrombosis of the cavernous Selvi F, Cakarer S, Keskin C, et al: Delayed removal of a maxillary molar
sinus and dental infection, Br J Oral Maxillofac Surg 49:e25-e26, accidentally displaced into the infratemporal fossa, J Craniofac Surg
2011. 22(4):1391-1393, 2011.
Friedlich J, Rittenberg BN: Endoscopically assisted Caldwell-Luc proce- Sims AP: A dental root in the ostium of the maxillary antrum, Br J Oral
dure for removal of a foreign body from the maxillary sinus, J Can Maxillofac Surg 23:67-73, 1985.
Dent Assoc 71:2000-2001, 2005. Speilman AI, Laufer D: Use of a Hedstrom file for removal of fractured
Gulbrandsen SR, Jackson IT, Turlington EG: Recovery of a maxillary root tips, J Am Dent Assoc 111(6):970, 1985.
molar from the infratemporal space via a hemicoronal approach, J Tocaciu S, Sillifant P: Spontaneous clearance of a dislodged root in the
Oral Maxillofac Surg 45(3):279-282, 1987. maxillary antrum, Oral Surg 11:224-247, 2018.
Iida S, Tanaka N, Kogo M, et al: Migration of dental implant into the Ueda M, Kaneda T: Maxillary sinusitis caused by a dental implant: report
maxillary sinus: a case report, Int J Oral Maxillofac Surg 29(5):358- of two cases, J Oral Maxillofac Surg 50:285-287, 1992.
359, 2000. Woolley EJ, Patel M: Subdural empyema resulting from displacement of
Jose A, Nagori SA, Bhutia O, et al: Odontogenic infection and pachy- a root into the maxillary antrum, Br Dent J 182:430-432, 1997.
meningitis of the cavernous sinus, Br J Oral Maxillofac Surg 52:
e27-e29, 2014.

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32
Posterior Mandibular Implants
S A N I L B . N I G A LY E, DA N IE L P. C A R U S O, FAR AN GI S FARS IO, V L A D I M I R F R I A S , a n d
M I C H A E L R. M A R K I E W IC Z

CC Planning should allow for buccal bone thickness of least 2 mm

and lingual bone thickness of 1 mm (implant diameter 1 3 mm).
The patient states, “I need to have two teeth on the lower right Greater buccal bone is desirable because of greater resorption pat-
evaluated for possible removal and implants.” terns on the buccal aspect. To maintain a margin of safety, the
apical extent of the implant should be planned no closer than
HPI 2 mm from the inferior alveolar nerve (IAN). No other soft tissue
or bony abnormalities are noted, and the patient opens 45 mm.
The patient is a 66-year-old female with stable moderate peri- (Restricted mouth opening can pose a problem for implant place-
odontitis. Previously treated with periodontal therapy, she is now ment.) Diagnostic casts or stereolithographic models can aid in
managed by her general dentist and home care. Despite this man- determining arch relationship, occlusal discrepancies, occlusal
agement, her disease has progressed on the teeth on the lower plane curves, tooth position, and adequacy of vertical and hori-
right (teeth #29 and #30) and have become mobile. Her general zontal space for prosthetic components.
dentist has deemed the prognosis for these teeth to be hopeless
and has recommended removal with replacement with two dental Imaging
implant–supported prostheses.
The preoperative planning radiography shows that the proposed
PMHX/PDHX/Medications/Allergies/SH/FH implant sites as 8.5 mm wide in the buccolingual dimension
(Fig. 32.1) with the apex of the implant placement approximately
The patient has a noncontributory medical history, including an 7 mm above the inferior alveolar neurovascular bundle and the
unremarkable heart murmur, osteoarthritis, osteoporosis, and osteo- center of the implant in line with functional cusp of the opposing
penia. She denies the administration of a bisphosphonate or receptor
activator of nuclear factor- B ligand (RANKL) inhibitors. There is
no history of smoking or bruxism or parafunctional habits. The only
medications that she takes are supplements (calcium, vitamin D3,
and collagen peptides). She is allergic to latex and codeine. 16.41 mm

Examination 1 1 8.48 mm

Clinical examination revealed no associated temporomandibular

joint dysfunction. Intraoral examination of the posterior mandi-
ble grossly demonstrates good ridge form buccolingually, which is
rounded and wide (6–8 mm). However, a composite hard and
soft tissue defect was appreciated consistent with vertical bone
loss, which was later noted on imaging. A periodontal evaluation
showed probing depths measured at 1 to 2 mm with moderate
dental mobility (class I/II) of both teeth, and a class 2 furcation
defect was clinically appreciated on tooth #30. Dental tissue loss
was noted as toothbrush abrasion and attributed to aggressive
hygiene techniques and root surface exposure. A sound opposing
dentition and a level occlusal plane were noted. The anteroposte-
rior (AP) ridge space is adequate for placement of two implants to
replace the lower right second bicuspid and first molar. This is
determined by consideration of the following biologic parameters
for dental implant placement. The distance from an implant to an • Fig. 32.1 Preoperative cone-beam computed tomography scan (coronal
adjacent natural tooth and between adjacent implants at the cut) showing an alveolar width of 8.5 mm in the buccolingual dimension
coronal–crestal aspect should be 2 mm and 3 mm, respectively. at the proposed implant site.

149
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150 S E C TI O N Dental Implant Surgery

• Fig. 32.4 Preoperative cone-beam computed tomography scan (axial

cut) showing an anteroposterior distance of 19.82 mm and thus allowing
for appropriate placement of two 5-mm-diameter implants.

implants when all other parameters are accounted for (Fig. 32.4).
The bone quality is type II (Box 32.1).
These data can be used for surgical guide fabrication or for
• Fig. 32.2 Preoperative cone-beam computed tomography scan (coronal intraoperative measurements if a free-handed approach is used. A
cut) showing a distance of 7 mm between the apex of the proposed surgical guide can be generated from the data contained in the
implant and the inferior alveolar canal cortex. The proposed implant is also cone-beam computed tomography (CBCT) if the surgeon thinks
aligned with the functional cusp of the opposing tooth. it is necessary, and instrumentation keyed to this guide can be
applied for precision placement; otherwise, a surgical guide is
prepared on the study models. Panoramic two-dimensional (2D)
tooth (Fig. 32.2). The distal implant (site #30) is planned slightly radiography and bone mapping can be used in situations in which
mesial to maintain a distance from the vertical defect on tooth the tip of the implant is estimated to be greater than 1 mm from
#31. There is 3.44 mm of interimplant distance planned the IAN canal provided that the canal is radiographically identifi-
(Fig. 32.3). The AP space availability measures at 19.82 mm, able, patient positioning is correct, and the magnification rate is
which allows comfortable placement of two 5-mm diameter known and accounted for.

Labs
No laboratory testing is indicated for implant placement unless
dictated by the medical history or anesthesia concerns.

Assessment
A 66-year-old female with osteopenia and osteoarthritis presents
with moderate periodontal disease with severe abrasion lesions
necessitating removal of the lower right second bicuspid and first

• BOX 32.1 Bone Classification Based on

Radiographic and Clinical Parameters
Type I: Entire jaw composed of homogenous compact bone; has the tactile
sense of drilling into oak or maplewood
Type II: A thick layer of compact bone surrounding a core of dense trabecular
bone; has the tactile sense of drilling into white pine or spruce
Type III: A thin layer of cortical bone surrounding a core of dense trabecular
bone of favorable strength; has the tactile sense of drilling into balsa wood
• Fig. 32.3 Preoperative cone-beam computed tomography scan (sagittal
Type IV: A thin layer of cortical bone surrounding a core of low-density trabecular
cut) showing appropriate placement of both implants in the mesiodistal
bone; has the tactile sense of drilling into Styrofoam
dimension with maintenance of the appropriate interimplant distance and
accounting for the vertical bony defect mesial to tooth #31.

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 CHAPTER 32 Posterior Mandibular Implants 151

molar. Treatment options discussed include no replacement versus occur independent of the site of placement include fibrous inte-
fixed partial denture versus dental implant therapy with osseous gration, buccal cortex dehiscence, and damage to adjacent teeth
grafting for ridge regeneration. and implants. Aspiration or swallowing of implant components is
also a procedural concern; the use of floss ligatures and oral pack-
Treatment ings can help to minimize this risk.
The posterior mandible poses unique challenges for implant
The patient elected to undergo extraction of the two teeth with placement based on its anatomy, proximity to vital structures, and
site regeneration with corticocancellous allograft. Guided bone relatively difficult access. Understanding the anatomy and accounting
regeneration was accomplished with amnion–chorion membrane for all dimensions during placement are crucial for obtaining excel-
and a collagen plug. This was allowed to heal for a period of lent outcomes.
14 weeks at which time the patient returned for a repeat com- The foremost limiting factor for placement of implants in the
puted tomography scan and implant placement. Local anesthesia posterior mandible is the available height of bone above the in-
was delivered, and a bite block was used to maintain adequate ferior alveolar canal (IAC). Impingement of the IAN can lead to
opening and provide support for the temporomandibular joint hypoesthesia or anesthesia. It is generally agreed that 2 mm or
(TMJ) and masticatory muscles. A crestal full-thickness muco- more should remain between the implant and cortical border of
periosteal incision was made from the mesial of tooth #31 to the the canal. If a patient experiences neurosensory changes imme-
distal of tooth #28 and then in the intrasulcular space buccally to diately within the postoperative period (after local anesthesia
the interdental papilla between the canine and first bicuspid. A has subsided), the implant should be backed out as soon as pos-
full-thickness flap was reflected sufficient to visualize the bony sible or removed and replaced with a smaller implant. In ques-
ridge and appreciate the buccal and lingual cortices. A vacuum- tionable cases, CBCT can be used to assess the distance between
formed template of an anatomic wax-up was used to ensure that the implant and IAC to determine the need for intervention.
the spacing of the implants would correspond to the clinical Panoramic radiography is not sensitive enough to rule out spac-
crowns. Spacing and paralleling of the implants was accomplished ing issues because of distortion and superimposition of nearby
using a paralleling guide pin system, which allowed for control of structures.
spacing in addition to paralleling. The osteotomies were per- The inferior alveolar artery also resides within the IAC and is
formed using manufacturer specific protocols under irrigation typically positioned superior to the namesake nerve. Damage to
with normal saline. Type 2 (D2) bone was encountered in the the artery alone may lead to a hematoma within an enclosed space
posterior mandible. Tissue-level implants were used to position and subsequent damage to the IAN. It is important to remember
the abutment implant interface away from the bone margin to that damage to the IAC and its contents can be caused by the
minimize future crestal bone loss. Closure screws were placed on osteotomy drill or by the implant itself if submerged too apically.
the implants, and the tissue was closed around the neck of the Implant guides and drill stops are useful tools for controlling the
implant using 3-0 chromic gut suture. Postoperative radiography depth of the osteotomy. If there is an insufficient height of bone
with a periapical radiograph was taken to verify spacing and posi- to support an implant, ridge augmentation or nerve repositioning
tioning of the implant. The patient was sent home with instruc- could be considered, although these procedures also carry a risk of
tions to use over-the-counter pain medication for postoperative neurosensory changes. Providers must also be cognizant of the
pain management and amoxicillin 875 mg twice a day for 7 days path of the lingual nerve and ensure minimal or careful elevation
as a prophylactic measure. The patient returned to the office in of the lingual tissue in the posterior mandible.
3 months for uncovering of the implants, and verification of Another anatomic feature of the posterior mandible compli-
osseointegration was accomplished with a torque challenge to cating implant placement is the presence of a lingual undercut.
50 Ncm of torque. A periapical radiograph was taken at this time This lingual concavity varies in severity but is present in most of
to identify any osseous abnormalities or marginal bone loss that the general population, with the highest frequency occurring in
may have occurred. the second molar region. Also, the edentulous posterior mandible
tends to resorb in a buccal-to-lingual fashion. Both anatomic
Surgical Complications constraints require that the apex of the osteotomy be angulated
buccally. Failure to consider these factors may lead to perforation
The success of an endosseous dental implant is dictated by several of the lingual cortex with the potential for subsequent hemor-
factors, including its stability, functionality, and esthetics. In the rhage, salivary gland injury, and infection. An extruded implant
era of three-dimensional (3D) imaging, virtual surgical planning, can also act as a source of constant tissue irritation. Shorter ta-
and guided implant surgery, the success rate for implant place- pered implants can be helpful in avoiding perforations while also
ment is high. Despite these advances, complications can still oc- ensuring that the implant is not excessively angulated, thus com-
cur, and it is important to be aware of the pitfalls and know how plicating restoration and function.
to manage them.
Early implant failure is often associated with a lack of primary Discussion
stability, which may occur either at the time of surgery because of
poor placement (e.g., insufficient bone stock) or over the ensuing A number of factors need to be considered before placement and
postoperative days because of early loading protocols, surgical restoration of a mandibular implant. A problem-focused exami-
trauma (e.g., overheating of the osteotomy site), or infection. nation, highlighted in this chapter, focuses on the area of interest.
Most infections can be managed conservatively with antibiotics, However, an examination of the entire oral cavity should be per-
debridement, or incision and drainage. Implant removal should formed to identify patterns for failure or the presence and extent
be reserved as a last resort. of disease processes. A comprehensive clinical examination in-
Late implant failure is most frequently a result of occlusal cludes the clinician considering TMJ function, evidence of para-
overburden and peri-implantitis. Other complications that may functional behavior, periodontal status, and occlusion.

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152 S E C TI O N Dental Implant Surgery

Both the quality and quantity of bone must be considered for restores the alveolar contours, and prosthetically guided surgery
successful implant placement. Historically, implant surgery has can aid in placing the screw channels in the central fossa of the
been planned using 2D panoramic radiography with a surgical mandibular teeth, eliminating the loss of cuspal anatomy.
planning template coupled with bone-mapping techniques. A far Another complicating factor is the positioning of the IAN and
simpler and more accurate methodology involves CBCT. The the emergence of the mental nerve, which may cause an implant
advent of cone-beam technology affords the clinician accurate 3D to be placed in a suboptimal position to avoid this structure.
data with minimal distortion and is currently the imaging of These situations are compensated for by overcontouring the
choice for implant planning and placement. Surgical planning crown to maintain contacts; however, excessive cantilevers are to
software may be used to simulate implant and restoration position be avoided to maintain healthy peri-implant tissues and prevent
to verify adequate bone volume restorative requirements in the material fractures or screw loosening. Placing the implant too
preoperative workup. deep or shallow compared with the alveolar margin to avoid the
Beginning with the end in mind will help to identify potential IAN can pose restorative challenges as well. Implants that are
pitfalls before they occur. Hence, prosthetically driven surgery placed too apically can be restored with an elongated abutment
should be in the forefront of the clinician’s mind when beginning to compensate for this; however this comes at the risk of a pos-
any implant treatment plan. Surgical guide options are operator sible misfit at the implant-abutment interface and bone loss.
dependent. A vacuum-formed template created over an anatomic Implants placed too coronally likewise risk excessive loss of mar-
wax-up was used in this case. This can be accomplished with di- ginal bone because of the contact of the soft tissue with the
agnostic models and a wax-up of the proposed locations of the roughened surface of the implant.
teeth. A vacuum-formed template can be created over this and Materials commonly used for posterior fixed reconstruction
then used intraoperatively to position the implants relative to the are ceramo-metal or zirconia-based alternatives. Both materials
proposed locations of the crowns. Although a surgical guide is not exhibit the strength and esthetics to adequately restore posterior
essential, it does help to idealize the placement of the implant single or multiple teeth cases and allow for a well-fitting screw
with respect to the digitally planned position of the crown. retained restoration to manufacturer supplied abutments. An
Similarly, a static printed surgical guide with or without metal alternative is a customizable abutment with a machined implant
guide sleeves, dynamic navigation, and robotic-assisted surgery contact and customizable coronal portion that can be used for
may also be used. screw-retained or cementable crowns.
Marginal bone loss on implants is a common phenomenon. To Host factors such as smoking are known to increase the risk of
minimize bone loss on adjacent structures, a minimal distance failure of dental implants. Smoking provides an anaerobic envi-
from implant to adjacent structure should be maintained. A ronment that facilitates the growth of periodontal pathogens and
minimum distance of 3.0 mm from implant to implant and contributes to attachment loss. Consequently, smokers have a
2.0 mm from implant to natural adjacent tooth at the ridge crest greater than twofold increase in marginal bone loss, postoperative
are recommended for optimal hard and soft tissue preservation. infections, and implant failure compared with nonsmokers.
Interarch space requirements (osseous ridge to opposing Immune cell function plays a vital role in integration and
occlusal surface) should be considered as well with the optimal maintenance of implanted medical devices. Vitamin D is a potent
vertical restorative space being 9 to 10 mm in the posterior re- immunomodulator. Vitamin D supplementation in patients who
gions. Restorative space should consider soft tissue thickness, as are known to be vitamin D deficient can reduce the risk of failure
well as abutment height and prosthetic crown space requirements. because low vitamin D levels have been correlated with early im-
Factors such as dental attrition, which can result in loss of vertical plant failure. This patient with a history of osteopenia and osteo-
dimension of occlusion, and supereruption of the opposing tooth porosis is currently supplementing her vitamin D with oral daily
should be considered in the examination because they may en- intake, a favorable step towards successful implant treatment.
croach on vertical restorative space and result in restorative com- There are no standardized protocols for prescribing antibiotics
plications. If interarch restorative space is limited, restorative in the pre- or postoperative period for dental implant surgery.
challenges may be mitigated by selecting a bone-level restorative Antibiotic resistance and other complications related to disrup-
platform instead of a tissue-level restorative platform to increase tion of gut flora must be considered when determining the dura-
the amount of space available for the abutment–crown complex. tion and type of antibiotic to be used. Based on recent data, there
The severity of periodontal disease influences implant survival. have been shown to be improved clinical outcomes, specifically
Chronic stable periodontitis is not a contraindication to dental lower implant failure rates, when patients are administered a sin-
implant therapy; however, a maintenance program for the patient gle preoperative dose of antibiotics. Although penicillin and
must be considered to maintain disease control especially if dis- penicillin derivatives are the most administered antibiotics for
ease persists in areas adjacent to the implant sites. dental implant surgery, the data are inconclusive about which
Implant reconstruction in the posterior mandible is often antibiotic provides the most benefit.
complicated by the angulation of the body of the mandible or
loss of alveolar housing, which can cause an excessive lingual or ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
buccal angulation of the implant. Socket grafting of the site complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 152.e1

Bibliography implant placement in posterior mandible, Implant Dent 23(6):648-

652, 2014. doi:10.1097/ID.0000000000000160.
Lin MH, Mau LP, Cochran DL, et al: Risk assessment of inferior alveolar
Afshari Z, Yaghini J, Naseri R: Levels of smoking and peri-implant nerve injury for immediate implant placement in the posterior man-
marginal bone loss: a systematic review and meta-analysis, J Evid- dible: a virtual implant placement study, J Dent 42(3):263-270, 2014.
Based Dent Pract 22(3):101721, 2022. doi:10.1016/j. doi:10.1016/j.jdent.2013.12.014.
jebdp.2022.101721 Paz A, Stanley M, Mangano FG, et al: Vitamin D deficiency and early
Andre A, Ogle OE: Vertical and horizontal augmentation of deficient implant failure: outcomes from a pre-surgical supplementation pro-
maxilla and mandible for implant placement, Dent Clin North Am gram on vitamin D levels and antioxidant scores, Oral Health Prev
65(1):103-123, 2021. doi:10.1016/j.cden.2020.09.009. Dent 19(1):495-502, 2021. doi:10.3290/j.ohpd.b2082063.
Barewal RM, Stanford C, Weesner TC: A randomized controlled clinical Resnik RR (ed): Misch’s Contemporary Implant Dentistry, 4th ed, Elsevier;
trial comparing the effects of three loading protocols on dental im- 2020.
plant stability, Int J Oral Maxillofac Implants 27(4):945-956, 2012. Rios HF, Borgnakke WS, Benavides E: The use of cone-beam computed
Kim AS, Abdelhay N, Levin L, et al: Antibiotic prophylaxis for implant tomography in management of patients requiring dental implants: an
placement: a systematic review of effects on reduction of implant American Academy of Periodontology best evidence review, J Peri-
failure, Br Dent J 228(12):943-951, 2020. doi:10.1038/s41415-020- odontol 88(10):946-959, 2017. doi:10.1902/jop.2017.160548.
1649-9. Seong WJ, Korioth TW, Hodges JS: Experimentally induced abutment
Kullar AS, Miller CS: Are there contraindications for placing dental im- strains in three types of single-molar implant restorations, J Prosthet
plants? Dent Clin North Am 63(3):345-362, 2019. doi:10.1016/j. Dent 84(3):318-326, 2000. doi:10.1067/mpr.2000.109124.
cden.2019.02.004. Tarnow DP, Cho SC, Wallace SS: The effect of inter-implant distance on
Kütük N, Gönen ZB, Yaşar MT, et al: Reliability of panoramic radiogra- the height of inter-implant bone crest, J Periodontol 71(4):546-549,
phy in determination of neurosensory disturbances related to dental 2000. doi:10.1902/jop.2000.71.4.546.

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33
Maxillary Implants
A L I H A S S ANI , O M I D R E Z A FAZL I S AL E H I , a n d S AL A R C H AYC H I S AL M A SI

CC There are no signs pertaining to a remaining or recurring pathol-

ogy. No apparent oroantral fistulas were detected at clinical in-
A 65-year-old female is referred to our clinic with the chief com- spection. The keratinized tissue was scarce, yet the soft tissue
plaint of missing teeth in her upper right jaw. seemed inflammation free.

HPI Imaging
The patient underwent surgery about 2 years ago to remove sev- Preoperative cone-beam computed tomography shows severe
eral radicular cysts along with all teeth in the upper right quadrant horizontal and vertical bone loss across the upper right alveolar
except for the incisors. No attempt to rehabilitate the occlusion in ridge. The sinus seems free of illness, and a thin sinus floor is the
the upper right quadrant has been made so far neither by a remov- only remaining bony structure in parts of the molar region
able nor a fixed prosthesis. The patient reports no signs and symp- (eFig. 33.2).
toms related to the previous pathology since the surgery.
Labs
PMH/PDHX/Medications/Allergies/SH/FH
The patient was prepared for an iliac–bone graft, so laboratory
Noncontributory except for the aforementioned surgery in the tests included a complete blood count, electrolyte check, and co-
upper right quadrant 2 years ago. agulation tests; the results were all normal.

Examination Assessment
General. The patient is healthy and well-nourished in general Severe horizontal and vertical hard and soft tissue loss because of re-
with no apparent distress. spective surgery requires three-dimensional (3D) augmentation. Con-
Maxillofacial. A severe vertical defect had remained after the sidering the size of the defect, the patient must be worked up for an
surgery with apparent loss in both hard and soft tissues (Fig. 33.1). autogenous iliac bone graft to augment the bone vertically (by both
sinus lifting and onlay grafting) and horizontally. Occlusal rehabili-
tation by dental implants is planned after the augmentation is
achieved.

Treatment
To restore soft and hard tissue three dimensionally, the patient
was prepared for a bone augmentation procedure by an autoge-
nous iliac graft under general anesthesia. After applying local an-
esthesia (lidocaine 2% and epinephrine 1/100,000) locally, a flap
was elevated with the incision placed near the vestibular depth in
mobile tissue (Fig. 33.3). This allows for easier closure with no
tension after the bone beneath has been augmented. It also places
the incision away from where the graft for vertical augmentation
is fixed. A mucoperiosteal flap was elevated.
A window in the lateral sinus wall was created using a dia-
mond bur. The schneiderian membrane was meticulously
elevated from the sinus floor. A small perforation in the schnei-
derian membrane in the superolateral aspect of the window was
repaired using sutures fixating the membrane to the lateral sinus
• Fig. 33.1 Severe vertical defect after the extraction surgery with loss in wall through two holes made by a small-diameter fissure bur
both hard and soft tissues. (Fig. 33.4).

153
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 CHAPTER 33 Maxillary Implants 153.e1

• eFig. 33.2 Preoperative cone-beam computed tomography scan showing severe horizontal and vertical
bone loss across the upper-right alveolar ridge. The sinus seems free of illness, and a thin sinus floor is
the only remaining bony structure in parts of the molar region.

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154 S E C TI O N Dental Implant Surgery

• Fig. 33.5 Autogenous corticocancellous graft harvested from the right

• Fig. 33.3 Flap design with the incision placed near the vestibular depth ileum.
in mobile tissue.

• Fig. 33.4 Repair of a small perforation in the schneiderian membrane in • Fig. 33.6 Cancellous bone chips mixed with autoplastic particulate bone
the superolateral aspect of the window using sutures fixating the mem- graft used to fill in the sinus floor where the membrane was elevated.
brane to the lateral sinus wall through two holes made by a small-diameter
fissure bur.

Then autogenous corticocancellous graft was harvested from

the right ileum (Fig. 33.5). Cancellous bone chips mixed with
autoplastic particulate bone graft were used to fill in the sinus
floor where the membrane was elevated (Fig. 33.6), and bone
blocks were used as overlay grafts to enhance both bone width and
height (Fig. 33.7). The remaining gaps between the bone grafts
were also filled with autoplastic bone material (Fig. 33.8). To
ensure two-layer closure, regain soft tissue volume, and boost
bone augmentation, a pedicled buccal fat graft was mobilized and
sutured to the palatal soft tissue over the bone grafts (Fig. 33.9).
This vascularized pedicle flap is a potent source of stem cells and
progenitor cells, which can potentially turn to osteoblasts and fi-
broblasts, contributing to bone and soft tissue formation. Finally,
the incision was sutured free of tension (Fig. 33.10). The postop-
erative radiograph shows proper bone healing with the sinus floor
elevated substantially, no evidence of sinus pathogenesis, and
proper vertical bone height (Fig. 33.11).
A minimum of 5 months is recommended before implant in-
sertion for the bone grafts in the sinus to mature before implant • Fig. 33.7 Bone blocks used as overlay grafts to enhance both bone
insertion. width and height.

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 CHAPTER 33 Maxillary Implants 155

• Fig. 33.11 Postoperative radiograph shows proper bone healing with

sinus floor elevated substantially. There is no evidence of sinus pathogen-
esis, and proper vertical bone height is seen.
• Fig. 33.8 Remaining gaps between the bone grafts filled with autoplastic
bone material.

• Fig. 33.12 Because of the prior surgery, there is reduced vestibular

• Fig. 33.9 Two-layer closure to regain soft tissue volume and boost bone depth and the amount of keratinized gingiva on the buccal aspect of the
augmentation using a pedicled buccal fat graft sutured to the palatal soft ridge is extremely limited.
tissue over the bone grafts.

mucosa with a bevel toward the buccal side (Fig. 33.13). This
helps mobilize the keratinized tissue to the buccal of the implants
and leave enough periosteal tissue under the beveled incision to
help with secondary healing when necessary. The central and lat-
eral incisors on the upper right maxilla were extracted because of
improper crown–root ratio, and four implants (Implantium,
Dentium) were inserted in the position of teeth #1, #3, #4, and
#6 in the upper right maxilla with the sizes of 4.0314, 4.0314,
4.0314, and 4.8312, respectively (Fig. 33.14). Insertion torque
for each implant was above 35 Ncm, which allowed for mounting
the healing abutments. The flap was sutured in a more buccal
position, mobilizing the keratinized tissue buccally. The buccal
bevel of the incision leaves the periosteum attached to the under-
lying bone in areas where primary closure was not possible, help-
ing with a smoother secondary healing.
Impressions were made 2 months after implant surgery, and
• Fig. 33.10 Tension-free closure of the incision. final restorations were delivered in 1 month (Fig. 33.15).

Complications
The surgery for implant insertion was carried out in the office
under local anesthesia. The prior surgery had decreased the ves- Like any augmentative process in the maxillofacial region and the
tibular depth and reduced the amount of keratinized gingiva on maxillary sinus, common symptoms such as mild to moderate
the buccal aspect of the ridge (Fig. 33.12). To counter this, the pain and swelling were expected but were ameliorated by prescrip-
incision for flap elevation was placed a few millimeters in palatal tion corticosteroids and nonsteroidal antiinflammatory drugs

t.me/Dr_Mouayyad_AlbtousH
156 S E C TI O N Dental Implant Surgery

along with antibiotics. The schneiderian membrane perforation

could have been repaired by only covering it with an absorbable
membrane, yet the suturing technique used in this case seems a
more reliable measure for completely separating the nasoanthral
flora from the sinus bone graft. For this technique to work, the
texture of the schneiderian membrane should be pliable and care-
fully elevated from all the surrounding sinus walls, and only
round-end needles should be used for suturing. The grafted bone
might go thorough resorption in the postoperative period, but
this can be minimized by proper rigid fixation of the grafts using
titanium screws, assuring nontension wound closure and close
follow-up of the patient to monitor the patient’s oral hygiene and
wound care.

• Fig. 33.13 The incision for flap elevation was placed a few millimeters in Discussion
palatal mucosa with a bevel toward the buccal side to help increase kera-
tinized tissue over the ridge. Dental implant treatment in the maxilla can be complicated for a
number of reasons, including limiting anatomic structures, such
as the maxillary sinus, nasal cavity, and the incisive canal, and D3
and D4 bone quality, which can jeopardize primary stability in
implant insertion. The buccal cortex of the maxilla is an area of
bone resorption after tooth extraction, and as time goes by, an
edentulous maxilla can be severely affected by horizontal and
vertical bone loss.
In this case discussed, a surgical intervention had caused a se-
vere 3D bone defect, rendering bone augmentation necessary
before implant insertion. Reconstruction of such defects solely by
the help of prosthetics often results in compromised function and
aesthetics; therefore, surgeons must brief patients calmly about
the whole aspect of the defect, which goes beyond only teeth.
A graft from the iliac crest is the gold standard for autogenous
bone graft augmentation in the maxillofacial region. Paying atten-
tion to soft tissue augmentation and proper distribution of kera-
tinized tissue is just as important as a proper harvest and fixating
• Fig. 33.14 Implant placement. a bone graft for obtaining optimal results in such a case. The
measures we took in this regard were distinctive placement of in-
cisions in different surgeries (a vestibular incision for augmenta-
tion and a palatal incision with a buccal bevel for implant inser-
tion) and a pedicled buccal fat graft for two-layered closure and
soft and hard tissue volume enhancement.

,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for

complete set of bibliography.

• Fig. 33.15 Postoperative radiograph (A) and clinical photograph (B) at

2 months.

t.me/Dr_Mouayyad_AlbtousH
 156.e1

Bibliography Ogle OE, Weinstock RJ, Friedman E: Surgical anatomy of the nasal cav-
ity and paranasal sinuses, Oral Maxillofac Surg Clin North Am
24(2):155-166, 2012.
Cosola S, Marconcini S, Giammarinaro E, et al: Oral health-related qual- Papadopoulou AM, Chrysikos D, Samolis A, et al: Anatomical variations
ity of life and clinical outcomes of immediately or delayed loaded of the nasal cavities and paranasal sinuses: a systematic review, Cureus
implants in the rehabilitation of edentulous jaws: a retrospective 13(1):e12727, 2021.
comparative study, Minerva Stomatol 67(5):189-195, 2018. Resnik R: Misch’s Contemporary Implant Dentistry e-book, 2020, Elsevier
Doornewaard R, De Bruyn H, Matthys C, et al: The long-term effect of Health Sciences.
adapting the vertical position of implants on peri-implant health: a Rodella LF, Buffoli B, Labanca M, et al: A review of the mandibular and
5-year intra-subject comparison in the edentulous mandible including maxillary nerve supplies and their clinical relevance, Arch Oral Biol
oral health-related quality of life, J Clin Med 9(10):3320, 2020. 57(4):323-334, 2012.
Ho CC: Practical Procedures in Implant Dentistry, Hoboken, New Jersey, Rysz M, Ciszek B, Rogowska M, et al: Arteries of the anterior wall of
the united states of America, 2021, John Wiley & Sons. the maxilla in sinus lift surgery, Int J Oral and Maxillofac Surg 43(9):
Iwanaga J, Wilson C, Lachkar S, et al: Clinical anatomy of the maxillary 1127-1130, 2014.
sinus: application to sinus floor augmentation, Anat Cell Biol Sadrameli M, Mupparapu M: Oral and maxillofacial anatomy, Radiol
52(1):17-24, 2019. Clin North Am 56(1):13-29, 2018.
Kageyama I, Maeda S, Takezawa K: Importance of anatomy in dental Tomaszewska I, Zwinczewska H, Gładysz T, et al: Anatomy and clinical
implant surgery, J Oral Biosci 63(2):142-152, 2021. significance of the maxillary nerve: a literature review, Folia Morphol
Kohal RJ, Spies BC, Vach K, et al: A prospective clinical cohort investiga- (Warsz) 74(2):150-156, 2015.
tion on zirconia implants: 5-year results, J Clin Med 9(8):2585, 2020. Wychowański P, Starzyńska A, Osiak M, et al: The anatomical conditions
MeshkatAlsadat M, Hassani A, Bitaraf T, et al: Dimensional changes of peri- of the alveolar process of the anterior maxilla in terms of immediate
implant tissue following immediate flapless implant placement and implantation—radiological retrospective case series study, J Clin Med
provisionalization with or without xenograft in the anterior maxilla: a 10(8):1688, 2021.
study protocol for a randomized controlled trial, Trials 23(1):960, 2022.

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34
Sinus Lift for Implants
AL I R E Z A J A H A N G I R N I A a n d S E Y E D A L I M O S A D DA D

CC and inflammatory debris associated with sinusitis create an unfa-

vorable environment for surgery and subsequent healing. Infec-
A 39-year-old male patient was referred to the authors’ outpatient tions of the maxillary sinus after sinus grafting surgery occur in a
clinic to restore the posterior right maxillary region. His chief small percentage of cases and are usually managed conservatively,
complaint was that he could not chew well. with preservation of uninfected graft and subsequent implant suc-
cess. The two most common bacteria involved in acute maxillary
HPI sinusitis are Haemophilus influenzae and Streptococcus pneumoniae.
Staphylococcus aureus, a-hemolytic streptococci, and Bacteroides
The patient is seeking treatment for replacement of his missing and Pseudomonas spp. are most frequently found in chronic bacte-
teeth, preferably a fixed type of dental restoration to improve rial sinusitis. Any form of sinus infection should be treated with
masticatory efficiency. He lost his upper right first premolar, sec- decongestants and antibiotics, and some infections require func-
ond premolar, and first molar about 4 years ago because of failed tional endoscopic sinus surgery before performance of a sinus
endodontic treatment. Early loss of posterior maxillary teeth is grafting procedure can be contemplated. A broad-spectrum antibi-
associated with increased pneumatization of the maxillary sinus, otic, such as amoxicillin with clavulanic acid (Augmentin), is often
and frequently inadequate bone for satisfactory implants does not the initial antibiotic used in the management of infections caused
exist below such a sinus. by nasal or sinus flora.

PMHX/PDHX/Medications/Allergies/SH/FH Examination
His medical history is noncontributory. Inadequately controlled The extraoral examination showed no abnormalities, including
conditions, such as diabetes mellitus, immunodeficiencies, or any swelling or facial asymmetry, and the tissue overlying the left sinus
condition interfering with implant integration, must be taken and the zygomatic area looked normal. The intraoral examination
into account. The patient’s main complaint and expectations of revealed edentulous right posterior maxilla with adequate oral
treatment are paramount. Social history (drinking, recreational hygiene. Only mild plaque-induced gingivitis was present, espe-
drug use, and smoking) should be addressed because they can cially in the anterior maxilla. Dental caries, soft tissue pathology,
increase implant failure. Cigarette smoking (nicotine) increases and occlusal problems were ruled out. The patient demonstrated
platelet adhesiveness, raises the risk of microvascular occlusion, a canine guidance occlusion on the left side with minimal signs of
and causes tissue ischemia. Tobacco smoking causes catechol- nocturnal bruxism. A comprehensive clinical dental and peri-
amine release and associated vasoconstriction, resulting in de- odontal assessment is necessary to rule out or identify all intraoral
creased tissue perfusion. Smoking is additionally believed to sup- diseases, including mucogingival issues, dental caries or other re-
press the immune responses by affecting the function of storative deficiencies, occlusal problems, periodontitis, hard or
neutrophils. A perioperative smoking cessation program has been soft tissue, and periapical pathologies.
shown to reduce respiratory and wound-healing complications.
Good health care mandates smoking cessation in any patient, and Imaging
the possibility of an increased risk of failure of osseointegration in
smokers should be discussed with the patient and included in the Initially, a preoperative panoramic radiograph was taken to have a
consent as a shared liability. Immunosuppressants and mediations general overview of the maxillary sinuses with the adjacent denti-
that affect bone healing can compromise integration. Dental hy- tion and bone structures. Panoramic radiographs could be used as
giene, including plaque management, should be addressed before preoperative imaging evaluation to plan maxillary implant reha-
implant surgery. bilitation. This technique is used to visualize the maxillary sinus
A history of acute or chronic sinusitis may be problematic for and evaluate the remaining alveolar bone. However, panoramic
an implant surgery with an associated sinus graft procedure radiographs have inherent limitations in the three-dimensional
planned. Prolonged inflammation or infection creates an inappro- visualization of the anatomic structures and related pathologies.
priate environment for the procedure. Maxillary sinusitis results A cone-beam computed tomography (CBCT) scan was or-
from a secondary bacterial infection of an obstructed sinus. Muco- dered for the posterior right maxillary region to evaluate factors
sal edema, increased mucous production, bacterial accumulation, related to the maxillary sinus lift surgery (MSLS) surgery,

157
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158 S E C TI O N Dental Implant Surgery

including the patency of the ostium, the presence of septa in the cortical bone (cortical shavings). Extraoral sites can provide suffi-
antral cavity, vascularization, the status of the Schneiderian mem- cient autogenous cancellous marrow for large, bilateral augmenta-
brane, mediolateral distance of the sinus cavity, residual bone tions. Some surgeons prefer to construct a composite graft by
height and width, residual bone quality, lateral wall thickness, and mixing autogenous bone with allogenic, alloplastic, or xenogenic
ruling out any pathological conditions of the sinus. graft materials, especially when inadequate autogenous bone is
The CBCT from the targeted site showed an inadequate verti- available.
cal height of the remaining alveolar bone caused by sinus pneu- Another alternative modality for maxillary sinus floor augmen-
matization; however, its width was adequate for placing regular tation is the use of recombinant human bone morphogenetic
implants. The lateral wall thickness was about 1 mm, and the re- protein 2 (rhBMP-2), which has been shown to induce de novo
sidual bone quality was measured as D3. The antral cavity was bone formation. rhBMP-2 in combination with a collagen sponge
devoid of sinus pathology, the ostium passage was clear, and the (Infuse, Medtronic) is placed on the sinus floor in a fashion simi-
sinus membrane appeared thin. Septa were also not present in the lar to bone graft material; it acts as an osteoinductive factor that
antral cavity. stimulates undifferentiated mesenchymal cells to transform into
osteoprogenitor cells and produce bone. De novo bone formation
Labs for sinus augmentation and placement of functional implants has
been shown to be predictable and comparable to that seen with
Unless explicitly required by the patient’s medical history, routine autogenous bone grafting; however, recent reports of increased
laboratory workup is not indicated before an MSLS or implant adverse events with this modality have been published.
surgery. For this patient, a fixed-type restoration of the posterior max-
illa is planned using a simultaneous implant placement with
Assessment MSLS via the lateral window approach was planned. The lateral
method was selected instead of the transcrestal approach because
The patient demonstrated a unilaterally resorbed edentulous pos- the residual bone height was 4 mm or less in the planned surgical
terior maxilla caused by increased maxillary sinus pneumatization sites.
and inadequate alveolar bone beneath the sinus for implant The patient was given a 0.2% chlorhexidine mouthwash to
placement. rinse his mouth before the surgery. This procedure can be done
under local or intravenous sedation anesthesia. A midcrestal bevel
Treatment horizontal incision was performed with a 15C blade on the kera-
tinized tissue of the alveolar ridge 4 mm away from the estimated
Maxillary sinus floor augmentation has become the most popular window design, which might allow for the simultaneous insertion
strategy among surgeons because of its predictability, low mor- of implants and MSLS. A vertical buccal incision was also done
bidity, and technical simplicity. Various methods can be used to on the anterior side of the horizontal incision 10 mm away from
augment the excessively pneumatized maxillary sinus to accom- the window outline as a releasing incision to improve the acces-
modate an implant of at least 10 mm in length. Sinus membrane sibility to the lateral sinus wall and ensure the presence of suffi-
elevation followed by implant placement without grafting also has cient soft tissue over the bone. The reflection of a full-thickness
its advocates. A lateral wall antrostomy, or window (open tech- buccal flap was performed to a position superior to the lateral
nique), is the most common technique used to expose the sinus window’s projected height. The flap needs to be reflected up to the
floor. Alternatively, the Summer osteotome technique (closed zygomaticomaxillary buttress for the surgeon to have complete
technique) can be used for selected cases when less than 4 mm of access to and visualize the lateral sinus wall. Primary closure can
sinus floor elevation is needed. The grafting material or materials be easily performed using this flap design. While elevating a full-
are selected based on the surgeon’s preference. If a decision is thickness flap, the elevator must adhere to the bone surface to
made to use autogenous bone, the harvest technique planned keep the periosteum unchanged.
must be explained to the patient so that informed consent can be The osteotomy stage commenced after the flap was raised to
obtained. The decision on simultaneous or staged augmentation the intended elevation. Because the lateral wall of the sinus was
and implant placement is made based on the quality and quantity 1 mm thick, the complete osteotomy technique was planned for
of host bone at the surgical site. creating the lateral window. A small round tungsten carbide surgi-
There are four primary types of grafting material available for cal bur (no. 4) was first used to create an oval outline. The crestal
sinus augmentation: border of the outline was 3 mm apical to the sinus floor to make
• Autogenous bone a reservoir to contain the graft material. The coronal edge of the
• Allogenic bone outline was created 10 mm apical to the crestal border, measured
• Alloplastic materials based on the length of the planned implants and the height of the
• Xenogenic materials graft. The mesial border was located just distal to the canine
These materials can be used alone or in combination (composite tooth, and the distal edge was placed on the imagined distal sur-
graft) for sinus augmentation. Autogenous bone (cancellous mar- face of the missed tooth #16. Then the remaining bony island was
row or cortical shavings) is a popular and predictable material for scraped away to a paper-thin bone lamella until the bluish color
sinus grafting. Donor sites for bone harvest include intraoral sites of the mucosal membrane was apparent beneath it (Fig. 34.1A).
(maxillary tuberosity, zygomatic buttress, mandibular ramus, poste- The sharp edges of the window were smoothed with a larger
rior body or symphysis) and extraoral sites (tibial plateau and ante- round diamond bur to avoid membrane perforation. The lateral
rior iliac crest are the most commonly used). Donor site selection is bony window can be removed and discarded, crushed to make
based on the clinical situation and the amount and type of bone bone chips, or returned to its original position after the comple-
needed. Intraoral sites must be considered a limited source of can- tion of the surgery (bone lid). It can also be scraped (complete
cellous marrow but are a good source of surface-derived autogenous antrostomy) or left intact and rotated inwardly and upwardly

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 CHAPTER 34 Sinus Lift for Implants 159

Full-thickness flap
Incision at the
Osteotomy design crestal ridge
A

Membrane elevation

B
Window access Membrane perforation

C
Introduction of the barrier membrane Sealing the perforation

Partially grafting the

medial wall of the sinus

D Implant placement

E Space filled with graft material

• Fig. 34.1 A graphical abstract demonstrating the entire procedure. A, The design of the window outline
and window osteotomy. B, Elevation of the Schneiderian membrane and the concurred membrane perfo-
ration. C, The introduction of the collagen membrane into the antral cavity to cover and seal the perforation.
D, Partially grafting the medial wall of the antral cavity with simultaneous implant placement. E, Grafting the
entire cavity after implant insertion, closure, and the healed view of the operative site.

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160 S E C TI O N Dental Implant Surgery

(top-hinge trapdoor technique). However, the complete antros- pericardium (Tutopatch, Tutogen GmbH) were first soaked in a
tomy procedure provides easier biomaterial grafting and better sterile saline solution for 5 minutes and then positioned on the
control of the sinus membrane’s structural integrity, minimizing perforated membrane near each other (Figs. 34.3 and 34.4), cover-
intra- and postoperative adverse events. Then membrane elevation ing beyond the margins of the perforation (Fig. 34.1C). Because
was started at the edges using a short blunt curette. When at least an effective seal was developed and the height of the residual al-
2 mm of membrane detachment was achieved along all borders, veolar ridge was sufficient to provide adequate primary stability for
the elevation gradually progressed from the superior aspect of the planned implants, it was decided to insert implants simultane-
the osteotomy, proceeding 2 to 3 mm mesially toward the mesio- ously with the bone graft materials. As a result, the osteotomy was
superior line angle. Finally, longer angled curettes were used to prepared using drills following the manufacturer’s instructions.
passively make more elevation in all directions, making the mem-
brane free in the cavity, especially from the medial sinus wall, to
provide a good blood supply for the bone material to regenerate.
In this way, the membrane was elevated coronally (Fig. 34.1B)
and to a level higher than the upper border of the window to
provide adequate space for a pressureless biomaterial placement.
To reduce membrane perforation, it is crucial to remember that
surgical curettes should always be in close touch with the underly-
ing bony walls.
When the patient was asked to breathe in and out to evaluate
the degree of the membrane release, a large perforation was ob-
served in the central part of the membrane. This was expected
anteriorly because the Schneiderian membrane was of a thin
biotype, diagnosed earlier on CBCT and confirmed visually at the
time of the surgery. Because the elevation of the membrane was
nearly completed, no more attempts were made, and neither
was allowed to elevate the membrane. The perforation’s size was
7 3 7 mm (Fig. 34.2), which is considered a large perforation.
Bioresorbable collagen membranes, autologous fibrin glue, de-
mineralized freeze-dried human lamellar bone sheets, oxidized
regenerated cellulose, sutures, and platelet-rich fibrin (PRF) can
all be used to repair Schneiderian membrane perforations. The
surgeon preferred the collagen membrane method. Two large
(15 3 20 mm) resorbable membranes of the freeze-dried bovine • Fig. 34.3 The first membrane was introduced in the antral cavity to seal
the perforation.

• Fig. 34.4 Introducing the second membrane to cover the entire perfora-
• Fig. 34.2 Membrane perforation disclosed intraoperatively. tion zone and beyond its margins.

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 CHAPTER 34 Sinus Lift for Implants 161

Before the implants were inserted in the prepared sites, the sinus
cavity was partially grafted by a xenograft material (bovine bone
granules; cerabone, 1.0–2.0 mm, Botiss Dental) soaked in a sterile
saline solution at the medial sinus wall with the help of a bone
carrier instrument. Afterward, implants (Neobiotech) were in-
serted according to the manufacturer’s protocol 0.5 mm subcrest-
ally (Fig. 34.5) with the implants’ tips exposed in the created
compartment in the maxillary sinus (Fig. 34.1D), and a torque
wrench was used to measure their primary stability (25 Ncm). Then
the rest of the biomaterial was densely packed around the exposed
implants with a condenser to facilitate de novo bone formation
(Fig. 34.1E). Overpacking was avoided because it prevents vascu-
larization and may cause necrosis of the biomaterials.
At the end of the surgery, the antrostomy was covered by di-
rectly suturing the mucoperiosteal flap over the grafting material.
For flap closure, the margins of the flaps were first passively ap-
proximated; single interrupted sutures were used for the releasing
incision; then continuous lock sutures were placed on top of the
crestal ridge (Fig. 34.6). The suture was 3/0 resorbable polygly-
colic acid. An immediate postoperative panoramic image was
taken to see the surgery results, including the position and angle
of the implants and the success of repairing the perforation. It was
observed that the bone graft material was not pushed into the • Fig. 34.6 Final clinical view of the surgical site.
antral cavity; otherwise, if there were an appearance of bony gran-
ules scattered in the sinus cavity, it would be the result of an un-
successful perforation repair. In addition, a confined dome-shaped
radiopaque appearance from the presence of the bone material in
the sinus cavity confirmed success. The implants also were in a
proper position and angulation for further prosthetic rehabilita-
tion (Fig. 34.7). Then postoperative instructions were given to the
patient verbally and in writing, including not blowing his nose;
not sneezing with his mouth closed; no swimming, scuba diving,

• Fig. 34.7 Postoperative panoramic image demonstrating placed

implants and the view of the grafted sinus.

or flying in pressured aircraft; no heavy lifting of weights; and no

playing a musical instrument that requires blowing for 1 week. In
addition, postoperative medications were prescribed for him, in-
cluding a nonsteroidal antiinflammatory drugs (ibuprofen 400 mg
every 6 to 8 hours for 3 days), painkiller (paracetamol 500 mg
orally, every 4 to 6 hours for 3 days or the shortest duration pos-
sible), antibiotics (amoxicillin–clavulanic acid 625 mg orally, ev-
ery 8 hours for 7 days), decongestant (oxymetazoline HCl 0.05%
nasal spray, every 10 to 12 hours for 3 days), and chlorhexidine
0.2% mouthwash (10 mL rinsed in the mouth for 1 minute and
then spat out, every 8 to 12 hours for 5–10 days).
A postoperative follow-up was done for the first time
48 hours after the procedure, again at 14 days for removing
sutures, and finally at 6 months for the next stage. However, the
patient was advised to return immediately if there were any
symptoms of bleeding, epistaxis, hematoma, the expulsion of
graft debris through the nostrils, wound opening, infection
(intraoral swelling, redness, fistulation, suppuration, tender-
ness, excruciating pain, swelling of the face, abscess, increased
body temperature, or discharge of graft materials through the
• Fig. 34.5 Simultaneous implant placement after partially grafting the fistula), and sinusitis (nasal congestion, purulent secretion, and
medial antral wall. headaches). The patient did not have any complaint at any

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162 S E C TI O N Dental Implant Surgery

follow-up sessions on any of the earlier-mentioned symptoms, damages, and implant dislodgement into the sinus. Postoperative
providing evidence that the surgery was untroublesome. Six complications include bleeding, graft leak, wound dehiscence,
months later, the patient returned for the prosthetic rehabilita- infections associated with MSLS (including surgical site or graft
tion of the submerged implants. He was reevaluated clinically infection), and postoperative sinusitis. Typical postoperative man-
and radiographically at this session. The visual examination and ifestations include edema, ecchymosis, and mild to moderate pain
the second CBCT confirmed no complications, full recovery of that typically subsides within 3 weeks and is rarely spontaneous in
the tissues, and graft integration. The implant stability was the first few days. There may also be a slight nosebleed. The reso-
ideal as assessed using the resonance frequency analysis tech- lution of symptoms 3 weeks later points to a typical postoperative
nique by the Osstell device. healing phase. Although acute spontaneous pain is typically ab-
sent, its presence should trigger an immediate investigation by the
Complications clinician. The management of sinus membrane perforation, its
contributing variables, and prevention strategies make up a sizable
Complications may arise intra- or postoperatively. The former portion of the discussion section. Additionally, Table 34.1 pro-
includes Schneiderian membrane perforation, bleeding, inade- vides a summary of the factors to take into account for other
quacy in the primary stability, surgical complications, neurosensory adverse events.

TABLE
34.1 Intra- and Postoperative Complications Regarding Maxillary Sinus Lift Surgery
INTRAOPERATIVE COMPLICATIONS
Contributing Factors Prevention Management
Bleeding • Injury to AAA • Preoperative evaluations localizing the trajectory • Head elevation 1 direct firm
• Traumatizing the surgical flap of intraosseous arteries pressure with sterile gauze soaked in
• Damage to intraosseous arteries • Modifying the osteotomy design epinephrine contained anesthetic
• Consider an alternative approach solution or tranexamic acid
• Dissecting the artery from the bone • Cauterization with lasers or
• Using piezoelectric surgery electrocautery
• Dissection of the artery and ligation
with resorbable sutures
Inadequacy • Inadequate bone quantity and quality • Proper case selection • Using condensation methods such
in the • Overtreatment with drills or osteotomes • Adequate consolidation of the bone graft as osteotomes or osseodensification
primary • Underpreparation of the osteotomy site • If not successful, implant placement
stability • Appropriate fixture selection regarding geometry at a later stage must be considered
(tapered), surface modifications (rough surfaces),
and thread design
Damage to • Direct trauma: • Make oblique rather than vertical incisions at the The neurosensory changes (mild pares-
the infra- • Cutting the nerves caused by a canine region toward the anterior segment thesia, dysesthesia, or anesthesia)
orbital high-releasing incision at the site of • Avoiding elevation to the infraorbital foramen are primarily temporary and pass
nerve the maxillary canines • Lifting a full-thickness flap to position the within 6 months
and the • Elevating the flap up to the infraor- retractor on the bony surface
superior bital foramen • Considering the more approximate position of
alveolar • Squeezing the retractor the infraorbital nerve to the bony crest in atro-
nerve • Indirect trauma: phic ridges
branches • Hematoma
• Postoperative edema
Implant • Insufficient bone quality • Using condensation methods to improve bone Immediate removal of the implant via
dislodge- • Insufficient bone height quality surgical approaches:
ment into • Unrepaired membrane perforation • Management of sinus perforation if needed • Transnasal
the sinus • Excessive force or torque in implant • Placing implants according to the manufactur- • Transoral
placement er's protocol with minimal pressure • Through the osteotomy site
• Widened osteotomy caused by
overdrilling
Postoperative Complications
Bleeding • Inappropriate flap closure • Instructing patients to apply pressure over the • Prescribing decongestants
• Medication related operated site immediately after suturing • Monitoring the patient until hemo-
• Undiagnosed bleeding disorders • Ensuring adequate hemostasis before closure stasis is achieved
• Sinus membrane perforation • Consulting the patient’s physician in case of tak- • Consulting the patient's physician to
• Damage to the AAA ing medications or suspecting bleeding disorders manage systemic causes
Hematoma • When hemostasis is not sufficiently Same as for bleeding • Same as for bleeding
achieved before flap closure • Prescribing amoxicillin–clavulanate
• Injury to the posterior superior alveolar (875 mg/125 mg twice daily) for
artery or inferior orbital artery 7–10 days to prevent postoperative
infection

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 CHAPTER 34 Sinus Lift for Implants 163

TABLE
34.1 Intra- and Postoperative Complications Regarding Maxillary Sinus Lift Surgery—cont’d
INTRAOPERATIVE COMPLICATIONS
Contributing Factors Prevention Management
Graft • Defective membrane perforation repair • Evaluation of the membrane before applying • Reentry and applying proper surgi-
leakage • Undiagnosed membrane perforation graft material cal approaches are needed to repair
• Secondary membrane perforation • Proper selection of the repair technique the membrane perforation
caused by excessive packing forces • Ensuring adequate seal in repairing the perfora- • Prescribing decongestants
during graft placement tion • Flushing the sinus cavity before re-
• Necrosis of the Schneiderian mem- • Avoiding excessive condensation forces pairing the membrane
brane caused by an overfilled cavity • Avoiding overfilling the antral cavity
Wound de- • Flap and suture tension • A tension-free closure by: • Within the first 24–48 hours: pri-
hiscence • Mechanical trauma: • Anterior or posterior releasing incisions mary closure can be achieved
• Mastication • Elevating a full-thickness flap or releasing • After 48 hours have passed, or the
• Denture the periosteum wound opening is greater than
• Poor tissue management by the clini- • Mattress sutures 2–3 cm: excise wound margins and
cian • Denture adjustments: resuture
• Postoperative infection • Relieving dentures to prevent pressure from • If the wound cannot be closed pri-
• Increase in intrasinus pressure being placed on the surgical field marily: consider prescribing
• Removing the flange of the dentures in the chlorhexidine mouthwash and anti-
corresponding mucobuccal fold biotics to obtain secondary healing
• Consider using tissue conditioners or soft liners
• When esthetic is not a concern, consider not
wearing the denture during the healing phase
Surgical site • Poor oral care • Reducing bacterial introduction into the surgical • A minor superficial infection: antibi-
or graft • Graft or implant contamination site during the operation otic therapy with
infection • Membrane perforation • Treating any existing periodontal or endodontic • Amoxicillin–clavulanate
• Wound dehiscence condition first (875 mg/125 mg twice daily) or
• Insufficiency in performing an aseptic • Oral hygiene instruction at the first session of ex- • Clindamycin (300 mg three
surgery amining the patient to improve periodontal indices times daily)
• Preexisting sinus disease • Pre- and postoperative use of chlorhexidine • Unresponsive or resistant infections
mouthwash (persist .3 weeks) that are well
• Disinfection of the perioral skin with an antisep- contained under the membrane:
tic solution before the surgery • Antibiotic therapy 1 surgical
• Following strict infection control protocol drainage 1 removal of the
• Using sterile drapes and instruments implants and the graft material
• Preventing biomaterial contamination with saliva partially or totally
• Using two sterile surgical sets: one for the surgi- • Unresponsive or resistant infections
cal phase and the other for the grafting stage (persist .3 weeks) that are dis-
• Performing the incision away from the window persed in the sinus cavity:
preparation • Consider FESS 1 removal of the
• Rinsing the surgical area with sterile saline solution implants and the graft material
• Minimizing the surgery time totally 1 systemic antibiotic
• Adequate postoperative antibiotic prescription therapy
• Regular follow-ups
• Smoking cessation advice
Postopera- • Hematoma or seroma in the antral cavity • Postoperative antibiotics: amoxicillin, ciprofloxa- • In acute rhinosinusitis:
tive • Edema of the Schneiderian membrane cin–clindamycin (in allergic patients) • Postoperative antibiotics (amoxi-
sinusitis • Air-flow blockage after reduced intra- • Ensuring the patency of the osteomeatal com- cillin or ciprofloxacin–
sinus volume plex through: clindamycin [in allergic pa-
• Impaired ciliary activity caused by intra- • Systemic decongestants: pseudoephedrine tients]) 1 systemic
operative membrane perforations, lac- • Nasal decongestant sprays: phenylephrine– decongestants (pseudoephed-
erations, or displacement or overfilling oxymetazoline rine) 1 nasal decongestant
of the graft material sprays (phenylephrine–
• Obliteration of the osteomeatal complex oxymetazoline)
• Preexisting sinus disease • In chronic rhinosinusitis:
• Allergic patients • Considering removal of the
• Graft contamination implants and graft materials
• Anatomic factors predisposing patients: 1 nasal irrigation with saline
• Septal deviation solution 1 nasal steroid sprays
• Oversized turbinates 1 oral antihistamine 1 systemic
• Ostium stenosis antibiotics 1 surgical endoscopy
(if necessary)

AAA, Alveoloantral artery; FESS, functional endoscopic sinus surgery.

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164 S E C TI O N Dental Implant Surgery

Discussion the transcrestal technique, osteotomes of different diameters are

used in the osteotomy sites of the crestal bone to lift the sinus
Primary bone resorption in a buccal–palatal direction happens membrane. Then implants are directly inserted within the areas
after tooth extraction in the posterior maxilla caused by the dis- prepared using these instruments. This technique is considered a
rupted blood supply to the bone and the absence of functional less invasive and straightforward method. TCSL results in an in-
loads. Progressive loss of alveolar ridge in an apical direction is a creased bone quantity and quality at the sinus floor when placing
prevalent clinical finding in this area for the surgeon while plan- the implants. In addition, it has been shown that in the case of
ning for implant placement. It is defined by progressive sinus applying the indirect method, the implant survival is high and
pneumatization as a result of intrasinus positive pressure that re- ranges between 92.7% and 97.2%, and the annual failure rate is
duces the alveolar bone volume, thus affecting the appropriate 2.48% approximately. Based on the currently available evidence,
treatment plan in patients who require osseointegrated implants. transcrestal and lateral MSLS approaches are both safe and pre-
When there is an inadequate residual bone in the resorbed dictable, and they bring about favorable outcomes in terms of the
posterior maxilla for implant placement, MSLS with concurrent long-term success rate of the implant and grafting method. In
or delayed implant placement is a highly effective surgical method. addition, no difference between the transcrestal and lateral proce-
The MSLS aims to heighten the residual alveolar ridge in the dures has been reported for implant failure or survival rate. Simul-
posterior maxilla by elevating the maxillary sinus floor. As a result, taneous implant placement using both approaches maintains
an optimal bone height is established, which can effectively facili- peri-implant bone support; peri-implant mucositis shows a simi-
tate the placement of dental implants. Implant survival rates with lar prevalence.
MSLS are on par with healthy bone. The survival rate of implants Nonetheless, it has been reported that the apical implant bone
is considered high, regardless of whether implants are placed si- height and the augmented sinus bone gain are much higher in
multaneously or at a later stage, whether the patient has a partial LWSL compared with the TCSL technique, but the reported
or complete edentulism, or if autogenic bone or other graft mate- crestal bone level and bone-to-implant contact (BIC) parameters
rials are used as a bone substitute. in both approaches are nearly the same. The TCSL and LWSL
The principal indication for MSLS is implant-based rehabilita- methods do not show any noticeable differences in the quality of
tion of the partially or totally edentulous posterior maxilla expe- the newly generated bone. The primary deficiency of the LWSL
riencing severe postextraction sinus pneumatization and alveolar technique is that a large flap must be raised for surgical accessibil-
ridge resorption. It is possible to distinguish between general im- ity purposes. This method is time-consuming and more procedure
plant contraindications, absolute contraindications, and relative sensitive while necessitating higher surgical skills. Because the
contraindications when discussing the contraindications to TCSL technique uses an osteotome compared with the LWSL
MSLS. An MSLS procedure is not a suitable treatment for pa- approach, it is less invasive and has several advantages, such as
tients with general implant contraindications (Box 34.1). minimum postsurgical complications and a shorter surgical dura-
The two primary techniques used to carry out the MSLS are tion. In addition, the TCSL method can condense the low-quality
the transcrestal (indirect, osteotome-mediated, or TCSL) and maxillary bone (i.e., bone types III and IV) and increase the BIC
lateral approaches (direct or LWSL). In the direct technique, sinus area, which improves the primary stability. In addition, it is note-
mucosa is accessed directly by creating an osteotomy window worthy that when the crestal zone is used to access the sinus, a
within the lateral sinus wall, which is then released to adopt a smaller socket is required to pave the way for significantly decreas-
superior position. This process provides enough room for sinus ing the healing period. From another perspective, it is noteworthy
grafting and the placement of the planned implants. The overall that in the TCSL approach, the graft materials are blindly placed
survival rate of the implants with this technique exceeds 90%. In beneath the Schneiderian membrane. As a result, the primary

BOX 34.1 Indications and Contraindications of Sinus Lift Surgery at a Glance

Indications Contraindications
Inadequate residual bone height General contraindications Absolute Relative
(,9 mm of vertical bone height) to implant surgery
Atrophic posterior maxillary Severe or unmanageable systemic condition Localized soft or hard tissue lesions (sinus in-
alveolar bone (e.g., uncontrolled diabetes mellitus) fection and acute infections of dental origin)
Maxillary high-dose radiotherapy Stenosis of the drainage–ventilation pathways
in the maxillary sinus
Mental disorders (e.g., psychosis) A pathological sinus condition (cyst, polyp, or
tumor)
Sepsis Sinusitis and allergic rhinitis
Heavy smoking Previous sinus surgery
Severe drug or alcohol abuse Maxillary low-dose radiotherapy
Using alcohol, tobacco, and narcotics recre-
ationally
Limitations in mouth opening
Malocclusion
Severe bruxism

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 CHAPTER 34 Sinus Lift for Implants 165

drawback of this method is the uncertainty related to the poten- during graft introduction, incorrect surgical instrument use, and
tial membrane perforation. Comparing the TCSL and LWSL uncontrolled pressure on the membrane. The latter comprises
methods concerning the pain levels and the incidence of bruising, decreased membrane thickness, decreased membrane elasticity
edema, and nasal bleeding or discharge during the first 24 hours, and friability, increased bone surface adhesion, the presence of
reports show that the pain levels in the LWSL method are much Underwood’s septa (bony blades that divide the sinus cavity), the
lower than with the TCSL method. Nonetheless, over time, the antral cavity’s buccal–palatal angle, inconsistencies in the sinus
morbidity levels of all scrutinized parameters reverse in favor of floor caused by the root profiles protruding, prior sinus surgery,
the TCSL technique, which leads to much faster recovery. Con- chronic sinus pathology, and a decreased height of the remnant
cerning edema and inflammation, the two methods show no sig- alveolar ridge. Moreover, smoking has been acknowledged as an
nificant differences. Instead, the most suitable MSLS strategy additional risk factor raising the likelihood of membrane perfora-
should be chosen based on the initial clinical scenario, as revealed tion. In contrast to piezosurgery for osteotomy, which reduces the
in Table 34.2 and Fig. 34.8, because various factors affect the risk of perforation to 8%, rotary instruments have a higher risk of
therapy spectrum. perforation. The rate of sinus membrane perforation is also associ-
Among intraoperative complications, sinus membrane perfo- ated with its thickness. The perforation risk increases when the
ration is the most frequent in MSLS, and incidence rates range thickness is less than 0.8 mm or greater than 2 mm. The sinus
from 7% to 60%. The integrity of this membrane, as a protection mucosal perforation risk is lowest when the thickness is between
for the sinus cavity, will improve graft stability by enabling suffi- 1 and 2 mm. When elevating the Schneiderian membrane, addi-
cient vascularization during the initial healing phase. Perforations tional factors can influence the perforation incidence, such as:
of the sinus membrane can arise intraoperatively at any point in 1. The size of the window: When it is too narrow to be conserva-
the process, including when preparing the osteotomy, trimming tive, mechanical and visual accessibility to the sinus is con-
or turning over the bony window, lifting the membrane, or plac- strained, curette motions are constrained, and the recognition
ing bone substitutes. However, sinus perforation occurs more of a perforation is more challenging.
frequently during the osteotomy process when forming the win- 2. The window shape: The window is typically oval in shape, and
dow rather than separating the mucosa from the bony wall. It may its corners should not be sharp to prevent the membrane from
be caused by either iatrogenic factors resulting from improper being perforated.
surgical handling or patient-specific anatomic issues, making 3. The position of the window: The ideal location for lateral win-
the procedure challenging. The former includes excessive filling dow opening should be 3 mm above the sinus floor and 3 mm

TABLE
34.2 Timetable of Various Maxillary Sinus Lift Surgery Approaches

Residual Bone Height First-Stage Surgery Second-Stage Surgery Restorative Phase

.9 mm Standard implant placement Not needed 3 months after first surgery
No MSLS needed
.5 mm and #9 mm MSLS with transcrestal or lateral window approach Not needed 3 months after first surgery
Simultaneous implant placement
Graft options • Autograft bone
• Autograft or bone substitute (1:1)
• Bone substitute alone
.3 mm and #5 mm MSLS with lateral window approach Not needed
Simultaneous implant placement
Graft options • Autograft bone • 3–4 months after first surgery
• Autograft or bone substitute (1:1) • 3–4 months after first surgery
• Bone substitute alone • 6 months after first surgery
Primary stability not obtainable
Delayed implant placement
Graft options • Autograft bone • 4–6 months after first surgery • 3 months after second surgery
• Autograft or bone substitute (1:1) • 6 months after first surgery • 3 months after second surgery
• Bone substitute alone • 9–12 months after first surgery • 3 months after second surgery
#3 mm MSLS with lateral window approach
Delayed implant placement
Graft options • Autograft bone • 6 months after first surgery • 3 months after second surgery
• Autograft or bone substitute (1:1) • 6–8 months after first surgery • 3 months after second surgery
• Bone substitute alone • 9–12 months after first surgery • 3 months after second surgery

MSLS, Maxillary sinus lift surgery.

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166 S E C TI O N Dental Implant Surgery

Residual bone height

3–5 mm, adequate ,3 mm, no

5–8 mm primary stability
primary stability

Buccopalatal sinus width Buccopalatal sinus width

(measured at a height of (measured at a height of
Short implants
10 mm, comprising the 10 mm, comprising the
alveolar crest) alveolar crest)

Narrow sinus Wide sinus Narrow sinus Wide sinus

(,12 mm) (.12 mm) (,12 mm) (.12 mm)

One-stage One-stage lateral Two-stage Two-stage lateral

transcrestal MSLS MSLS transcrestal MSLS MSLS

• Fig. 34.8 A decision-making tree for selecting the proper maxillary sinus lift surgery (MSLS) approach.

away from the anterior wall’s inclination because it is impera- volume. There is also no noticeable difference between mem-
tive to create the lateral window’s contour as closely as possible branes that have been repaired and those left intact in terms of
to the anterior wall and the sinus floor to prevent perforations. subsequent implant survival rates.
4. The sinus width: Long-neck curettes must be used in sinuses However, as the size of the perforations increases, a higher
with a wide buccopalatal width to gain access to the medial/ percentage of implant failures is anticipated. Furthermore, pa-
palatonasal wall; therefore, to avoid membrane tearing, it is criti- tients with membrane perforation during MSLS experienced
cal to maintain the instrument in close contact with the bone. more postoperative complications. Infection is the most common
5. The angle formed by the floor of the sinus with its medial and related complication with the perforated membrane. Compared
lateral walls: When this angle is less than 30 degrees, the risk with nonperforated membranes, perforated ones were shown to
of membrane perforations is highest, but the most common have a sixfold higher risk of infection or sinusitis and a threefold
situations (angle between 30 and 60 degrees) are correlated with higher chance of bone graft failure. Nevertheless, membrane per-
a usual perforation rate. The safest values are when the angle is foration does not affect graft or marginal bone loss surrounding
greater than 60 degrees; in this case, membrane laceration risk implants.
is almost 0%. Acute angles are more common in second pre- Many repair strategies suggested in the literature for treating
molar areas than in first and second molar areas. Therefore, it Schneiderian membrane perforation have been studied, including
is believed that the risk for perforation during MSLS is higher demineralized laminar bone, block grafts, oxidized cellulose, bio-
in the proximity of the second premolar area and hence in the logical adhesives, hemostatic compounds, PRF membranes, and
anterior part of the sinus. absorbable collagen membranes. The size and position of the
6. The existence of septa in the maxillary sinus: Because the membrane perforation determine the therapeutic approach.
membrane tightly adheres along the septa, there is an increased It has been recommended that superiorly positioned perfora-
risk for perforation during the lifting procedure. tions smaller than 5 mm be addressed by folding the membrane
Although Schneiderian membrane perforation during MSLS is directly or using absorbable sutures. The perforation could be
not considered to compromise the implant survival rate, disconti- sutured within the membrane, or it could also be sutured to the
nuities in this membrane compromise the antral cavity’s func- window’s superior osseous border. For the membrane to be with-
tional homeostasis and have a negative impact on the surgical out tension after suturing, the membrane must first be carefully
outcome by contaminating the graft with bacteria and dispersing separated from the bone and made loose. Additionally, specialized
particulate that can lead to postoperative sinusitis or graft infec- tools such as magnification loupes with lights, microsurgical pli-
tion. The formation of new bone may be negatively impacted by ers, scissors, and microsurgical needle holders for 6.0 to 8.0 su-
membrane perforation, especially in the vicinity of the perforation. tures are required. Nevertheless, it is typically quite challenging to
Nevertheless, there is no discernible difference between the do so without applying tension at the membrane level because the
undamaged and perforated groups in the total augmented bone membrane is situated behind the bone window. Because of the

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 CHAPTER 34 Sinus Lift for Implants 167

extreme delicacy and friability of the sinus membrane, suturing it the use of centrifugation and special instruments to extract the
is not advised because doing so will almost invariably widen any PRF membrane for surgical use, making it not available for all
existing perforations or cause new ones. techniques.
When perforations are small (,5 mm) or medium (5–10 mm), A slow-resorption collagen membrane in conjunction with a
multiple perforations exist, or perforations are medially or inferi- laminar bone has been suggested when perforations are larger
orly positioned within the window access, using a collagen mem- than 10 mm. The medial wall will receive this membrane, which
brane with slow resorption rate is the most frequently advised will then be folded from the superior and inferior parts to form a
treatment method because it enables regeneration while enhancing new roof and floor over the border lines of the bony window. This
perforation closure. In sinus-lifting surgery, because of their several pouch, known as the Loma Linda technique, surrounds and iso-
biological properties, collagen membranes are commonly used for lates the bone graft. Sinus bony walls are the primary sources of
membrane perforations. Transforming growth factor-b1, a growth new bone formation because they provide the required blood
factor responsible for bone remodeling, is secreted more frequently supply. Because the lateral wall is disturbed by creating the access
by collagen bioabsorbable membranes. Additionally, it is asserted window, the medial wall and the basal bone are two primary
that collagen membranes’ influence on osteoblastic activities may sources of blood supply in MSLS. Because in this technique, the
help to facilitate bone regeneration. With this method, the bony graft material is completely isolated from the blood source pro-
walls are left intact because the resorbable membrane is placed just vided by sinus walls (infraorbital, posterior superior alveolar, and
on the surface of the sinus membrane, allowing the bone’s blood posterior lateral nasal arteries), it may decrease the rate of remod-
supply to promote vascularization and bone regeneration. Besides, eling process in the graft material by temporarily isolating it from
this technique is quite simple, devoid of the need for advanced the blood supply; thus, placing implants at a later stage is recom-
equipment; it is performed rapidly and effectively; the material is mended. One of this method’s most common detrimental effects
widely available; and it reduces the costs and morbidity for the is the dislocation of the collagen membrane, which allows graft
patient. It also controls bleeding, stabilizes blood clots, and pro- particles to escape to the sinus cavity, resulting in surgical failure.
tects the membrane. This usually happens because in large perforations, using mem-
Platelet-rich fibrin may be used as an adjuvant therapeutic in- branes causes them to become shapeless and soft when wet. For
tervention. PRF stimulates angiogenesis through the activation of this reason, using absorbable sutures or fixing pins is suggested to
the vascular system. PRF can prohibit graft particle penetration stabilize this membrane on the adjacent bony wall. On the other
into the sinus because of its high-strength fibrin network. Direct hand, this would complicate the procedure, increasing the cost for
communication of PRF with the nonsterile environment of the the patient and requiring more advanced instruments and surgical
maxillary sinus has been recommended to behave as a barrier skills. Besides, in most cases, the thin lateral wall does not allow a
membrane against the unsealed perforation, thereby accelerating proper fixation.
the recovery process. PRF is thought to combat bacterial infec- Furthermore, in the case of large perforations (.10 mm),
tions in addition to secreting growth factors. However, histologic stopping the procedure may be a more viable option when repair-
analyses have shown no statistically substantial differences be- ing a perforation seems complicated. Because an appropriately
tween the collagen and the PRF membranes in the recovery of restored perforation does not result in a corresponding implant
sinus perforation. In addition, regarding the percentage of soft failure, it is not necessary to stop an MSLS in the instance of a
tissue area, the height of the augmented bone, implant stability, complete tear. However, acquiring a naturally repaired membrane
and survival rate, the findings suggest that using PRF in MSLS in might be much simpler and safer by deterring the augmentation
addition to other grafting biomaterials does not appear to have procedure and scheduling reentry at least 6 weeks later.
any adjunct positive impacts. It should be noted that this tech-
nique also requires taking blood samples from patients before the ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
surgery, which increases the patient’s discomfort and necessitates complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 167.e1

Bibliography Farina R, Simonelli A, Franceschetti G, et al: Peri-implant tissue condi-

tions following transcrestal and lateral sinus floor elevation: 3-year
Almeida de Ferreira CE, Martinelli CB, Novaes AB, et al: Effect of max- results of a bi-center, randomized trial, Clin Oral Investig 26(5):
illary sinus membrane perforation on implant survival rate: a retro- 3975-3986, 2022. doi:10.1007/s00784-021-04364-y.
spective study, Int J Oral Maxillofac Implants 32(2):401-407, 2017. Guo T, Gulati K, Shen Z, et al: Therapeutic outcomes of non-grafted and
doi:10.11607/jomi.4419. platelet concentrations-grafted transcrestal maxillary sinus elevation
Al-Moraissi E, Elsharkawy A, Abotaleb B, et al: Does intraoperative per- (TSFE): a systematic review and meta-analysis, Sci Rep 10(1):5935,
foration of Schneiderian membrane during sinus lift surgery causes an 2020. doi:10.1038/s41598-020-62407-y.
increased the risk of implants failure? A systematic review and meta Hernández-Alfaro F, Torradeflot MM, Marti C: Prevalence and manage-
regression analysis, Clin Implant Dent Relat Res 20(5):882-889, 2018. ment of Schneiderian membrane perforations during sinus-lift proce-
doi:10.1111/cid.12660. dures, Clin Oral Implants Res 19(1):91-98, 2008.
Altiparmak N, Akdeniz SS, Diker N, et al: Comparison of success rate of Hirota A, Lang NP, Ferri M, et al: Tomographic evaluation of the influ-
dental implants placed in autogenous bone graft regenerated areas and ence of the placement of a collagen membrane subjacent to the sinus
pristine bone, J Craniofac Surg 31(6):1572-1577, 2020. mucosa during maxillary sinus floor augmentation: a randomized
Aricioglu C, Dolanmaz D, Esen A, et al: Histological evaluation of clinical trial, Int J Implant Dent 5(1):31, 2019. doi:10.1186/s40729-
effectiveness of platelet-rich fibrin on healing of sinus membrane 019-0183-5.
perforations: a preclinical animal study, J Craniomaxillofac Surg Jordi C, Mukaddam K, Lambrecht JT, et al: Membrane perforation rate
45(8):1150-1157, 2017. doi:10.1016/j.jcms.2017.05.005. in lateral maxillary sinus floor augmentation using conventional
Barbu HM, Iancu SA, Hancu V, et al: PRF-solution in large sinus mem- rotating instruments and piezoelectric device—a meta-analysis, Int J
brane perforation with simultaneous implant placement-micro CT Implant Dent 4(1):3, 2018. doi:10.1186/s40729-017-0114-2.
and histological analysis, Membranes (Basel) 11(6):438, 2021. doi:10. Kezys J: Impact of early complications of sinus floor elevation and individ-
3390/membranes11060438. ual factors of the body on the long-term treatment results, Stomatologija
Barbu HM, Iancu SA, Jarjour Mirea I, et al: Management of Schneide- 18(4):122-127, 2016.
rian membrane perforations during sinus augmentation procedures: a Kim GS, Lee JW, Chong JH, et al: Evaluation of clinical outcomes of
preliminary comparison of two different approaches, J Clin Med implants placed into the maxillary sinus with a perforated sinus mem-
8(9):1491, 2019. doi:10.3390/jcm8091491. brane: a retrospective study, Maxillofac Plast Reconstr Surg 38(1):50,
Bathla SC, Fry RR, Majumdar K: Maxillary sinus augmentation, J Indian 2016. doi:10.1186/s40902-016-0097-6.
Soc Periodontol 22(6):468-473, 2018. doi:10.4103/jisp.jisp_236_18. Kim J, Jang H: A review of complications of maxillary sinus augmenta-
Beck-Broichsitter BE, Gerle M, Wiltfang J, et al: Perforation of the tion and available treatment methods, J Korean Assoc Oral Maxillofac
Schneiderian membrane during sinus floor elevation: a risk factor for Surg 45(4):220-224, 2019. doi:10.5125/jkaoms.2019.45.4.220.
long-term success of dental implants? Oral and Maxillofac Surg Lin YH, Yang YC, Wen SC, et al: The influence of sinus membrane
24(2):151-156, 2020. doi:10.1007/s10006-020-00829-8. thickness upon membrane perforation during lateral window sinus
Becker ST, Terheyden H, Steinriede A, et al: Prospective observation of augmentation, Clin Oral Implants Res 27(5):612-617, 2016.
41 perforations of the Schneiderian membrane during sinus floor el- doi:10.1111/clr.12646.
evation, Clin Oral Implants Res 19(12):1285-1289, 2008. doi:10.1111/ Molina A, Sanz-Sánchez I, Sanz-Martín I, et al: Complications in sinus
j.1600-0501.2008.01612.x. lifting procedures: classification and management, Periodontology
Burkhardt R, Lang NP: Fundamental principles in periodontal plastic 2000 88(1):103-115, 2022. doi:10.1111/prd.12414.
surgery and mucosal augmentation—a narrative review, J Clin Munakata M, Yamaguchi K, Sato D, et al: Factors influencing the sinus
Periodontol 41(Suppl 15):S98-S107, 2014. doi:10.1111/jcpe.12193. membrane thickness in edentulous regions: a cone-beam computed
Chen MH, Shi JY: Clinical and radiological outcomes of implants in tomography study, Int J Implant Dent 7(1):16, 2021. doi:10.1186/
osteotome sinus floor elevation with and without grafting: a system- s40729-021-00298-y.
atic review and a meta-analysis, J Prosthodont 27(5):394-401, 2018. Nasr S, Slot DE, Bahaa S, et al: Dental implants combined with sinus
doi:10.1111/jopr.12576. augmentation: what is the merit of bone grafting? A systematic review,
Danesh-Sani SA, Loomer PM, Wallace SS: A comprehensive clinical re- J Craniomaxillofac Surg 44(10):1607-1617, 2016. doi:10.1016/j.
view of maxillary sinus floor elevation: anatomy, techniques, bioma- jcms.2016.06.022.
terials and complications, Br J Oral Maxillofac Surg 54(7):724-730, Ortega-Mejia H, Estrugo-Devesa A, Saka-Herrán C, et al: Platelet-rich
2016. doi:10.1016/j.bjoms.2016.05.008. plasma in maxillary sinus augmentation: systematic review, Materials
de Oliveira H, de Moraes RPF, Limirio P, et al: Repair of a perforated (Basel) 13(3):622, 2020. doi:10.3390/ma13030622.
sinus membrane with an autogenous periosteal graft: a study in 24 Otero AIP, Fernandes JCH, Borges T, et al: Sinus lift associated with
patients, Br J Oral Maxillofac Surg 56(4):299-303, 2018. doi:10.1016/j. leucocyte-platelet-rich fibrin (second generation) for bone gain: a
bjoms.2017.12.020. systematic review, J Clin Med 11(7):1888, 2022. doi:10.3390/
Díaz-Olivares LA, Cortés-Bretón Brinkmann J, Martínez-Rodríguez N, jcm11071888.
et al: Management of Schneiderian membrane perforations during max- Paik JW, Cha JK, Song YW, et al: Effect of Schneiderian membrane integ-
illary sinus floor augmentation with lateral approach in relation to sub- rity on bone formation in sinus augmentation: an experimental study in
sequent implant survival rates: a systematic review and meta-analysis, Int rabbits, J Clin Periodontol 49(1):76-83, 2022. doi:10.1111/jcpe.13562. Park
J Implant Dent 7(1):91, 2021. doi:10.1186/s40729-021-00346-7. WB, Han JY, Kang P, et al: The clinical and radiographic outcomes of
Ekhlasmandkermani M, Amid R, Kadkhodazadeh M, et al: Sinus floor Schneiderian membrane perforation without repair in sinus eleva- tion
elevation and simultaneous implant placement in fresh extraction sockets: surgery, Clin Implant Dent Relat Res 21(5):931-937, 2019.
a systematic review of clinical data, J Korean Assoc Oral Maxillofac Surg doi:10.1111/cid.12752.
47(6):411-426, 2021. doi:10.5125/jkaoms.2021.47.6.411. Proussaefs P, Lozada J: The “Loma Linda pouch”: a technique for repair-
Esfahanizadeh N, Rokn AR, Paknejad M, et al: Comparison of lateral ing the perforated sinus membrane, Int J Periodontics Restorative Dent
window and osteotome techniques in sinus augmentation: histologi- 23(6):593-597, 2003.
cal and histomorphometric evaluation, J Dent (Tehran) 9(3):237-246, Scarano A, De Oliveira PS, Traini T, et al: Sinus membrane elevation
2012. with heterologous cortical lamina: a randomized study of a new surgi-
Farina R, Franceschetti G, Travaglini D, et al: Morbidity following tran- cal technique for maxillary sinus floor augmentation without bone
screstal and lateral sinus floor elevation: a randomized trial, J Clin graft, Materials 11(8):1457, 2018. Available at: https://www.mdpi.
Periodontol 45(9):1128-1139, 2018. doi:10.1111/jcpe.12985. com/1996-1944/11/8/1457.

t.me/Dr_Mouayyad_AlbtousH
December 04, 2024. For personal use onB
lya
.Ngoheotrhi er uses w9it7h8
ou-t0p-e4r4
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gh0t0©423024. Elsevier Inc. All rights reserved.
167.e2

Schiavon L, Perini A, Brunello G, et al: The bone lid technique in lateral Tavelli L, Borgonovo AE, Re D, et al: Sinus presurgical evaluation: a
sinus lift: a systematic review and meta-analysis, Int J Implant Dent literature review and a new classification proposal, Minerva Stomatol
8(1):33, 2022. doi:10.1186/s40729-022-00433-3. 66(3):115-131, 2017. doi:10.23736/s0026-4970.17.04027-4.
Schwarz L, Schiebel V, Hof M, et al: Risk factors of membrane perfora- Testori T, Drago L, Wallace SS, et al: Prevention and treatment of post-
tion and postoperative complications in sinus floor elevation surgery: operative infections after sinus elevation surgery: clinical consensus
review of 407 augmentation procedures, J Oral Maxillofac Surg and recommendations, Int J Dent 2012:365809, 2012. doi:10.
73(7):1275-1282, 2015. doi:10.1016/j.joms.2015.01.039. 1155/2012/365809.
Shiffler K, Lee D, Aghaloo T, et al: Sinus membrane perforations and the Testori T, Wallace SS, Del Fabbro M, et al: Repair of large sinus mem-
incidence of complications: a retrospective study from a residency brane perforations using stabilized collagen barrier membranes: surgi-
program, Oral Surg Oral Med Oral Pathol Oral Radiol 120(1):10-14, cal techniques with histologic and radiographic evidence of success,
2015. doi:10.1016/j.oooo.2015.02.477. Int J Periodontics Restorative Dent 28(1):9-17, 2008.
Silva LD, de Lima VN, Faverani LP, et al: Maxillary sinus lift surgery— Xin L, Yuan S, Mu Z, et al: Histological and histomorphometric evalua-
with or without graft material? A systematic review, Int J Oral Maxil- tion of applying a bioactive advanced platelet-rich fibrin to a perfo-
lofac Surg 45(12):1570-1576, 2016. doi:10.1016/j.ijom.2016.09.023. rated Schneiderian membrane in a maxillary sinus elevation model,
Stacchi C, Andolsek F, Berton F, et al: Intraoperative complications during Front Bioeng Biotechnol 8:600032, 2020. doi:10.3389/fbioe.2020.
sinus floor elevation with lateral approach: a systematic review, Int J Oral 600032.
Maxillofac Implants 32(3):e107-e118, 2017. doi:10.11607/jomi.4884. Yilmaz HG, Tözüm TF: Are gingival phenotype, residual ridge height,
Starch-Jensen T, Jensen JD: Maxillary sinus floor augmentation: a review and membrane thickness critical for the perforation of maxillary sinus?
of selected treatment modalities, J Oral Maxillofac Res 8(3):e3, 2017. J Periodontol 83(4):420-425, 2012. doi:10.1902/jop.2011.110110.
doi:10.5037/jomr.2017.8303. Zhang Y, Tangl S, Huber CD, et al: Effects of Choukroun’s platelet-rich
Starch-Jensen T, Aludden H, Hallman M, et al: A systematic review and fibrin on bone regeneration in combination with deproteinized bo-
meta-analysis of long-term studies (five or more years) assessing max- vine bone mineral in maxillary sinus augmentation: a histological and
illary sinus floor augmentation, Int J Oral Maxillofac Surg 47(1): histomorphometric study, J Craniomaxillofac Surg 40(4):321-328,
103-116, 2018. doi:10.1016/j.ijom.2017.05.001. 2012.
Talo Yildirim T, Güncü GN, Colak M, et al: Evaluation of maxillary si- Zhou Y, Shi Y, Si M, et al: The comparative evaluation of transcrestal and
nus septa: a retrospective clinical study with cone beam computerized lateral sinus floor elevation in sites with residual bone height #6 mm:
tomography (CBCT), Eur Rev Med Pharmacol Sci 21(23):5306-5314, a two-year prospective randomized study, Clin Oral Implants Res
2017. doi:10.26355/eurrev_201712_13912. 32(2):180-191, 2021. doi:10.1111/clr.13688.

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herri uses with9o7u8t -p0
er-m
4i4s3
si-o1
n.1C0o3p0y-ri6g/h0t 0
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0234. Elsevier Inc. All rights reserved.
35
Zygoma Implants
C E S A R A . G U E R R E R O, M A R I A NE L A G O N Z A L E Z C A R R A N Z A , a n d B AB E R K HAT IB

Case 1 dental bridge and the soft tissues. The desired vertical dimension
was obtained, and there was no request for bone reduction for the
CC maxilla. A provisional teeth prosthesis was obtained using the
dental scan and it was digitally printed from the three-dimen-
A 55-year-old female, who used to be a heavy smoker and had loss sional (3D) scanner. An unrestricted surgical guide was provided
of her teeth in her early 20s, presents for dental implants and fixed with a groove behind the teeth to allocate the implant abutments
hybrids. (Fig. 35.1, eFig. 35.2, Figs. 35.3 and 35.4).
Under general anesthesia in our clinic, five zygoma implants
HPI were inserted in the piriform rims and body of the zygomas. All
implants were 45 Ncm or more, four of the implants had bone at
The patient was treated in our center 13 years earlier for lower the alveolar site and bone above, and one zygoma presented no
All-on-4 implants with success; however, her severe maxillary bone around the neck of the implant at the alveolar bone level.
atrophy limited the treatment to just her lower jaw, and she The latter implant was grafted using a sandwich technique, col-
declined the option of sinus lifts and staged surgeries. lagen membrane, and the lateral fat pad around the implant. The
same technique was also used on the other maxillary side to pre-
PMH vent lateral implant exposure and oroantral communication. The
fifth implant was to be uncovered 6 months later to deliver the
The PMH was unremarkable, but the smoking and chronic ob- final prosthesis. The prosthodontist performed the conversion,
structive pulmonary disease have improved since the patient and temporary teeth were delivered the day of the surgery, follow-
stopped smoking 7 years ago. She has no allergies and is not tak- ing the teeth in a day protocol (Figs. 35.5 and 35.6).
ing medications other than vitamins. The fifth implant was uncovered 6 months later under local
anesthesia. It is important to mention that the abutment was se-
Clinical Evaluation lected during the time of surgery, showing adequate parallelism
with the others. This implant will not rotate during the second
Alert and in no distress; anxious about the possible treatment. stage because of the osseointegration. A temporary cap was
Vital signs. Vital signs are within normal limits. placed, and 2 weeks later, final impressions were made. The final
Maxillofacial. Unremarkable. teeth were delivered a few days later (Figs. 35.7–8, eFig. 35.9 and
Oral. Maxillary edentulous with signs of pressure because of the Fig. 35.10).
upper denture; she has never removed the denture except to clean
it. The lower jaw shows All-on-4 hybrid teeth in perfect condition. Case 2
Imaging CC
Images show severe maxillary atrophy in zones 1, 2, and 3. The A 65-year-old female presents for dental implants and fixed
only bone available is in the piriform rims, zygomas, and ptery- bridges. She has visited several dentists and surgeons who did not
goids areas. recommend maxillary implants because of her severe atrophy.

Assessment HPI
Severe maxillary atrophy with Class I skeletal relationship between The patient presents with a severe maxillary atrophy in zones 1,
the upper and lower jaws. 2, and 3 on clinical examination. The prosthodontist predicts
bone reduction of her maxillary bone to make her transitional
Treatment line higher. Part of her cortical bone will be lost after the reduc-
tion of the maxillary bone when using the surgical reduction
The prosthodontist evaluated the patient, and the remaining max- guide.
illary alveolar bone was well above the smile transitional line; the The patient is wearing ill-fitting upper total dentures and
upper lip would cover in excess the junction between the hybrid partial removable dentures in the mandible. The inferior teeth

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168.e1 S EC TI O N Dental Implant Surgery

• eFig. 35.2 Three-dimensional reconstruction of the midface to obtain a file that can be printed for the
surgeon and prosthodontist to plan the number of implants and the direction of the implants and to avoid
palatal or lateral positioning.

• eFig. 35.9 Cone-beam computed tomography showing five implants, two on each zygoma and one by
the pyriform.

168
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 CHAPTER 35 Zygoma Implants 169

B C D
• Fig. 35.1 Panoramic (A), lateral cephalic (B), posteroanterior (C), and axial (D) views extracted from the
cone-beam computed tomography examination to analyze bony structures, skeletal relationships, and
maxillary and mandibular atrophy.

18.086 mm

18.16 mm

B
• Fig. 35.3 A and B, Stereolithographic model with a depth gauge to plan • Fig. 35.4 Digital impressions to estimate the amount of surgical
for the length of the zygoma implants. reduction.

are seen well above the lower lip level; progressive extrusion Examination
secondary to maxillary edentulism is present. These patients
have a very high transition smile line for the mandible; there- The patient is alert and in no distress. She is anxious about the
fore, the patient needs 5 mm or more of bone reduction in her possible treatment.
atrophic maxillary arch and mandibular arch, leaving less bone Vital signs. Blood pressure is 130/85 mm Hg, heart rate is
in height and less cortical bone for implant placement. This 70 bpm, and respirations are 13 breaths per minute.
makes conventional implant placement more challenging Maxillofacial. Unremarkable.
(eFigs. 35.11 and 35.12). Oral. The patient is completely edentulous wearing dentures.
The dentures have become progressively more unstable, and the
PMH patient was only wearing them socially.
On smile evaluation, she shows no maxillary or mandibular
The patient has controlled hypertension. She has no allergies and alveolar ridges. She shows healthy mucosa and normal temporo-
is not taking medications other than hormones and vitamins. mandibular joint function.

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170 S E C TI O N Dental Implant Surgery

• Fig. 35.6 Patient under general anesthesia during the conversion.

• Fig. 35.7 Implants placed. Direction indicators in all abutments need

to be placed at the time of surgery; they need to be as parallel as pos-
sible, even if one of them remains asleep for a future second stage.

Imaging
The patient has severe maxillary atrophy in zones 1, 2, and 3.
The only bone available left after bone reduction was the piri-
form rims, zygomas, and pterygoids areas. A short implant in the
C maxillary midline was considered (eFig. 35.13).

• Fig. 35.5 A–C, Grafting using the sandwich technique of demineralized Assessment
bone rolled in a collagen membrane and covered by the buccal fat pad.
The buccal fat pad is sutured around the head of the abutment and zygo- Severe maxillomandibular atrophy with Class I skeletal relationship
matic implant. Temporary caps are seen here. between the upper and lower jaws.

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 CHAPTER 35 Zygoma Implants 171

we proceeded to insert an 8-mm-long straight implant in the

maxillary midline. The mandibular implants were performed un-
eventfully using the All-on-4 concept (Fig. 35.16, eFig. 35.17,
Figs. 35.18 and 35.19).
The prosthodontist proceeded with the conversion, and upper
and lower hybrid dentures were screwed in. Four months later, all
implants were osseointegrated without complications. Two weeks
later, the final impressions were made, and the final prosthesis was
fabricated with a very narrow platform to help with hygiene. Final
prostheses were delivered a few days later (eFigs. 35.20–22 and
Fig. 35.23).

Case 3
CC
A 19-year-old male with oligodontia presents to discuss his failing
maxillary bridge. He is interested in keeping as many teeth as pos-
• Fig. 35.8 Incision is made at the end of the vestibule for a better closure. sible. He has been told that “he does not have enough bone for
The abutments are exposed through the alveolar mucosa using a small implants.”
tissue punch if necessary.

HPI
Treatment The patient is congenitally missing his maxillary laterals and ca-
nines, and his central incisors are pegged. He has had a bridge for
The prosthodontist evaluated the patient and found no maxil- more than 2 years, but there are now mobility and caries to his
lary cant; a Class I intermaxillary relationship; and severe central incisors. He is in college and does not want to be without
maxillary atrophy in zones 1, 2, and 3. The desired vertical teeth. Additionally, he is a competitive athlete and wants minimal
dimension was obtained, and no bone reduction was indicated down time related to any surgical interventions.
because there was 34-mm intermaxillary distance anteriorly
and posteriorly, and the transitional smiling line was at PMHX/PDHX/Medications/Allergies/SH/FH
13 mm. A provisional teeth prosthesis was fabricated using the
dental scanner, and it was printed from the 3D scan. An unre- He is an otherwise healthy male and has undergone dental im-
stricted surgical guide was provided with a groove behind the plants and grafting on his mandible previously. He has no history
teeth to guide the implants and the abutments (eFigs. 35.14 of paranasal sinus pathology and specifically denies chronic and
and 35.15). recurrent rhinosinusitis and nasal breathing difficulties. On com-
The surgical plan included the insertion of titanium fixtures at puted tomography, no obvious polyps or septal deviation are seen;
the piriform, zygoma, and pterygoid sites bilaterally. After the benign skeletal conditions do not necessarily preclude the applica-
implants were inserted and all were 45 Ncm of torque or beyond, tion of a zygomatic implant.

A B
• Fig. 35.10 The patient before (A) and after (B).

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 CHAPTER 35 Zygoma Implants 171.e1

• eFig. 35.13 Stereolithographic model printed from the cone-beam com-

• eFig. 35.11 Panoramic view from cone-beam computed tomography puted tomography three-dimensional reconstruction, showing extreme
showing severe maxillary atrophy at zones 1, 2, and 3. atrophy or the maxilla.

• eFig. 35.12 Lateral view showing a skeletal Class III malocclusion

caused by severe maxillary atrophy.

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 CHAPTER 35 Zygoma Implants 171.e2

• eFig. 35.15 Printed denture from the scanner and printer without the
need for conventional impression from the mouth.

• eFig. 35.17 Axial view of all seven implants on this atrophic maxilla. The
implant in the midline is to avoid an anterior cantilever.

Anteroposterior
cantilever

C
• eFig. 35.14 Printed unrestricted surgical guide and maxillary denture to
guide the surgeon during the implant placement, especially to keep the
• eFig. 35.20 Maxillary prosthesis showing a large anteroposterior cantile-
implants from being too lateral or too palatal. ver that will create prosthetic failures and ultimately implant failures.

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 35 Zygoma Implants 171.e3

Anteroposterior
cantilever

• eFig. 35.21 Same prosthesis from eFig. 35.2 showing the abutments • eFig. 35.22 Immediately after placement of seven implants in the
and the same amount of posteroanterior cantilever. This is not recom- maxilla.
mended because of biomechanical problems.

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172 S E C TI O N Dental Implant Surgery

• Fig. 35.16 Panorex showing two pterygoids, two zygomas, two piriform,
and one conventional implant in the midline.

• Fig. 35.23 The patient after upper and lower treatment with the concept
of “All-on 4.” Four implants in the mandible and seven implants in the
severe atrophic maxilla.

Vital signs. Blood pressure is 124/850 mm Hg, pulse is

65 bpm, are respirations are 14 breaths per minute.
Maxillofacial. Evidence of “cauliflower ear” bilaterally.
Intraoral. Oral examination reveals the range of opening to be
at least 40 mm. The maxillary arch has peg central incisors, evi-
dence of cervical decay, and a grossly atrophic ridge in the region
of his congenitally missing canines and premolars. His first molars
have crown preps on them from the previous failed large-span
bridge. The mandibular dentition is in good repair with missing
premolars and central and lateral incisors. There is a six-unit
bridge between his mandibular canines. Previously placed dental
• Fig. 35.18 Three-dimensional reconstruction showing the mandibular implants in the premolar region appear to be healing appropri-
implants placed tilted to the lingual and the maxillary implants straight or ately. They are unrestored.
somehow tilted more palatal to help with the Class III malocclusion.

Imaging
A Panorex reformatted from the patient’s cone-beam computed
tomography (CBCT) scan shows clear maxillary sinuses without
evidence of pathology. Maxillary third molars are present. A large-
span bridge from the maxillary first molars to the central incisors
bilaterally is seen. Mandibular third molars are present, and there
are four dental implants in the premolar regions that are currently
unrestored.

Labs
No routine laboratory testing is specifically necessary for the
placement of zygomatic implants other than studies deemed pru-
dent for a specific patient before the administration of intrave-
nous (IV) sedation or general anesthesia.

Assessment
• Fig. 35.19 New technology merging soft and hard tissue with the
planned implant in one image. Atrophic maxilla in the setting of congenital oligodontia and failed
large-span maxillary bridge.

Examination Treatment
General. Alert and in no distress; noticeably anxious about the The goal of treatment for this patient is to restore a functional
examination. occlusion with adequate stability and retention of his prostheses

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 CHAPTER 35 Zygoma Implants 173

and to do so with a minimum number of operations at a reason- the base of the zygomatic body. External digital pressure is used to
able cost. Reconstruction of the atrophic maxillary in the setting identify the zygomatic notch; the implant drills are oriented to
of trauma, pathology, caries, or congenital absence requires thor- the zygomatic body, and retraction is optimized. The 2.9-mm-
ough planning and interdisciplinary care between the reconstruc- diameter drill bit is used first, and the surgeon drills obliquely
tive and restorative team. until the tip of the drill bit is palpated as it exits the zygomatic
Zygomatic implants are technically challenging from both body near the zygomatic arch. This is followed by a transitional
surgical and restorative standpoints. drill. Last, the 3.5-mm drill bit is passed. The depth gauge is used
In many cases of mild to moderate maxillary atrophy, the max- to determine the length of implant needed. Upon removal of the
illary dentition can be restored with standard endosseous implants implant from its container, the screw retaining the transfer abut-
using shorter implants versus sinus augmentation. Grafting of the ment should be preemptively loosened and retightened before
maxillary sinus through a lateral or vertical approach is reliable placement of the implant. The zygoma implant is threaded into
and predictable. However, this introduces a time delay before position without tapping. The long axis of the screw that retains
implant placement, and in patients with a severely atrophic max- the transfer abutment is aligned with the long axis of the anterior
illa, sufficient grafting can obstruct drainage through the natural implants by placing the driver into its hex and assessing the long
ostium. Zygomatic implants can provide an effective, predictable axis of the driver. The transfer abutment is removed, exposing the
option that allows implant placement in a single surgical proce- 45-degree orientation of the external hex implant platform, which
dure without preliminary sinus lift bone grafting. These can be now parallels the fixture surfaces of the anterior implants. In some
placed in conjunction with standard endosseous implants, as an patients, the sinus slot technique results in the exposure of im-
individual rescue implant, or bilaterally as the only structural sup- plant threads outside the maxillary sinus wall rather than within
port for future restorations. Additionally, one can often immedi- the sinus.
ately load a provisional prosthesis. This is expected and does not affect stability. Closure is per-
We prefer to perform the procedure under general endotra- formed with 4-0 polyglactin sutures placed in a horizontal mat-
cheal anesthesia on an outpatient basis. The placement of zygo- tress fashion.
matic implants under IV sedation and local anesthesia has been Zygoma implants range in length from 30 to 55 mm. The shaft
described and is an option for healthy patients who can open their diameter tapers from 4 mm superiorly to 5 mm at the fixture level.
mouths widely. As was done in the current patient, an appropriate Implant integration occurs within the thick bone in the body of
preoperative antibiotic is administered intravenously. After induc- the zygoma, which produces an integrated length in the range of
tion and nasal intubation, the mouth and face undergo a standard 15 to 20 mm. The acquisition of an additional zone of integration
antiseptic prep. The oral surgical sites and nasal floor as well as at the level of the alveolus is welcome but unnecessary. The fixture
zygomaticotemporal and infraorbital regions (transcutaneous) are is angulated at 0 or 45 degrees (Nobel Biocare) or 55 degrees
injected with 0.5% bupivacaine (Marcaine) containing 1:200,000 (Straumann Holding AG Basel) and oriented roughly parallel to
epinephrine. The nose is packed with 0.05% oxymetazoline- the occlusal plane. The long arm of the zygoma implant makes it
soaked cottonoid sponges to vasoconstrict and shrink the mucosa. inappropriate to use without cross-arch stabilization to other con-
Additionally, liposomal bupivacaine is injected at the end of sur- ventional implants or to anterior conventional implants plus a
gery for prolonged pain control. zygoma implant on the opposite side.
The mouth is opened maximally to allow both visualization
and access for the necessarily long instrumentation of the zygo-
matic implants. A palatal favored crestal incision is created with Applications of Point-of-Care Three-
an anterior midline and bilateral posterolateral releasing inci- Dimensional Printing
sions to aid in tissue reflection. Subperiosteal exposure of the
anterior maxillary sinus wall to the zygomatic buttress is com- With severe maxillary atrophy, the native alveolus become pala-
pleted. When conventional implants are placed in conjunction tal in reference to the native dentition before removal. This
with zygomatic implants, short standard root form implants can needs to be factored in placement implant emergence palatal to
be placed in the region of the piriform and incisive foramen into the alveolus can result in an unfavorably large palatal ridge, a
the base of the nasal crest. Zygomatic implants are placed ac- bulky prosthesis, and a potentially disgruntled patient and re-
cording to the sinus slot technique described by Stella and storative doctor. Point-of care (POC) 3D printing facilitates
Warner, which allows emergence of the fixture at the alveolar preoperative planning and affords reasonable expectations from
crest rather than on the palatal aspect of the alveolus, as in the the surgeon, restorative dentist, and patient.
original Brånemark technique. In this case, intraoral scans were merged with a CBCT in
The “slot” refers to the access slot through the maxillary sinus open-source planning software (BlueSky Bio) and converted from
wall that is created to allow visualization of the trajectory of the a DICOM (Digital Imaging and Communications in Medicine)
implant. An emergence hole is drilled at the crest of the alveolus to an STL (stereolithography) file. The maxilla and zygomas were
in the second premolar or first molar area. The slot then begins segmented out and printed on a POC printer (Sprintray). Addi-
above the alveolus superior and lateral to this hole and extends tionally, a clear duplicate of the patient’s denture was printed after
along the crest of the zygomaticomaxillary buttress toward the being fabricated by scanning the patient’s complete upper denture
body of the zygoma. Side-cutting zygomatic implant burrs prove that was to be used in the conversion process. Predictive holes
very helpful at this step. The apex of the slot is flattened horizon- were placed in the lateral and second premolar region bilaterally.
tally with a round bur, and a dimple is drilled into this flat area to This was then sterilized and used intraoperatively to demarcate
allow drilling of the hole into the body of the zygoma for the ideal positioning of the dental implants. Additionally, the clear
implant. Attention is paid to adequate retraction and protection stent facilitated conversion and the restorative dentist simply mir-
of the lips before drilling. The implant drill is then placed through rored the access channel openings from the clear stent into the
the access hole and into the “slot,” terminating in the dimple at provisional denture.

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174 S E C TI O N Dental Implant Surgery

The patient was extubated and recovered without incident. Using the Bedrossian and Aparicio classifications helps the
Postoperative medications include analgesics and chlorhexidine clinicians to either use standard implants or zygoma implants
oral rinse. A postoperative antibiotic was prescribed for this pa- in that particular maxillary area, either trans- or extra-sinus.
tient considering the anterior maxillary and nasal floor bone graft- Most patients can be treated with the All-on-4 technique, but
ing. The use of nasal decongestants and antibiotics is optional. some patients require five or six implants, still with the All-
Postoperative CBCT is routinely obtained. Restoration of the on-4 Concept. The amount and quality of bone, anatomy,
zygoma implants can be initiated immediately after placement or presence of bruxism, and maxillomandibular relationship may
after waiting for a period of integration. If restoration is delayed, alter the surgical planning and anchorage for the immediate
an interim denture can be worn over the zygoma implants. loading complete maxillary rehabilitation. The ideal surgical
implant insertion design is based on minimal cantilever in any
Complications direction. The surgeon and prosthodontist must analyze in a
3D fashion to avoid prosthesis or teeth from fracturing and
Complications of zygomatic implants can be divided into surgical screws from loosening or fracturing. The prosthetic platform
failures and prosthetic failures. Infection is no more likely than size is also of paramount importance because problems in
with conventional root-form implants. Sinus pathology after im- speech and hygiene are severe issues that can be avoided with
plant placement is not expected, and although there may be ra- smaller platforms and an ideal relationship between the maxil-
diographic mucosal thickening in up to 20% of cases, this does lae and the prosthesis. Similarly, neglecting anchorage in the
not affect the stability of the implant or necessitate intervention anterior maxilla can lead to a large anteroposterior cantilever
by an otolaryngologist. Ecchymosis is less common with the sinus with a resultant risk of continues screw loosening and frac-
slot technique than with the traditional Brånemark approach be- tures. The anterior forces need to be balanced accordingly us-
cause of the limited soft tissue dissection. The surgeon should ing anterior anchorage.
avoid placing the implant emergence point too lateral because this Patients with bruxism and clenching will fracture the pros-
may predispose to mucosal dehiscence over the threads. Prosthetic thetic screws. The use of botulism toxin 25 units per temporalis
failures are more likely to be related to inadequate cross-arch sta- muscles and 25 units for each masseter muscle, for a total of 100
bilization, with resultant loosening of the fixture. Even using units every 6 months for 3 years or based on each case, will pre-
polished surface zygoma implants that only have threads at the vent prosthesis or prosthetic screw fractures.
body of the zygoma, the smooth surface will get exposed through Angle’s Class II or III malocclusions present a real challenge for
the soft tissue if the implant is placed too laterally. edentulous patients requiring dental rehabilitation anchorage on
dental implants. Severe deformities should be corrected simulta-
Discussion neously with orthognathic surgery, or the dental occlusion could
be improved but maintaining an anterior crossbite in patients
Bedrossian’s classification of maxillary atrophy identifies three with Class III malocclusions. For patients with Class II malocclu-
zones of potential atrophy. Zone 1 corresponds to the alveolus in sions, a major overjet is created in the dental rehabilitation and
the incisor region of the arch, zone 2 to the premolars, and zone needs to be avoided.
3 to the molars. Inadequate bone in zone 3 is a contraindication Patients with moderate deformities could be treated by tilt-
to conventional implants. Although a combination of sinus aug- ing the maxillary implants anteriorly to compensate for the
mentation and bone grafting before implant placement is an op- Class III malocclusion. For those with Class II malocclusions,
tion, the success of implants in this situation is not what can be the anterior maxillary implants should be more straight up.
expected under other circumstances. The 1994 Academy of Os- Considering the central incisor is usually 102 degrees 6 5 de-
seointegration Sinus Graft Consensus Conference reviewed the grees, the surgeon could play with the inclination a few degrees,
results of 2997 implants placed among 1007 grafted sinuses. After keeping the posterior implants with a limited anterior inclina-
a minimum 3-year follow-up after restoration, a 61% failure rate tion for the prosthesis draw into the abutments to be fixated
was found when implants were placed simultaneously with sinus with the mini-screws.
lift bone grafts. The success of zygomatic implants has been well For patients who already have a hybrid and who want surgery
established when the critical aspects of the techniques are fol- of the other arch, consider sending the patient to the prosthodon-
lowed. In a prospective 16-center evaluation with 3-year follow- tist to remove the present hybrid to have more space and better
up, Kahnberg and colleagues reported a 96.3% survival rate. opening while you work on the new implant placement for a
Malevez and coworkers published a 100% survival rate with hybrid.
103 zygoma implants in 55 patients, retrospectively, after 6 to 48 In summary, the zygomatic implant is an underused resource
months of loading. Brånemark described his outcome results for that provides a cost-effective, single-stage solution to the problem
28 consecutive patients with severely resorbed edentulous maxil- of inadequate posterior maxillary bone. It merits careful consider-
lae involving 52 zygoma implants followed for 5 to 10 years with ation in the treatment planning for patients with atrophic maxilla
a survival rate of 94% with no significant complications. who require multiple implants.
When restoring the edentulous maxillary arch, the clinician
must understand the many variables involved to facilitate a pre- ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
dictable and stable long-term outcome. complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 174.e1

Bibliography Garg A: Augmentation grafting of the maxillary sinus for placement of

dental implants: anatomy, physiology, and procedures, Implant Dent
8:36-46, 1999.
Aparicio C: A proposed classification for zygomatic implant patients Granström G, Tjellströn A, Brånemark P: Osseointegrated implants in
based on the zygoma anatomy guided approach (ZAGA): a cross- irradiated bone: a case- controlled study using adjunctive hyperbaric
sectional survey, Euro J Oral Implantology 4(3):269-275, 2011. oxygen therapy, J Oral Maxillofac Surg 57:493- 499, 1999.
Balshi S, Wolfinger G, Balshi T: A retrospective analysis of 110 zygomatic Guerrero C, Sabogal A: Zygoma implants. Atlas of surgery and prosthetics.
implants in a single-stage immediate loading protocol, Int J Oral Chapter 7. Pentagonal design - Five zygomatic implants 145-165,
Maxillofac Implants 24:335-341, 2009. Madrid, 2010, Ripano.
Becktor J, Isaksson S, Abrahamsson P, et al: Evaluation of 31 zygomatic Guerrero CA, Sader G, Henriquez M, et al: Implantes Zigomaticos com
implants and 74 regular dental implants used in 16 patients for pros- Desenho Pentagonal para a Reabilitacao Inmediata da Maxila, Implant
thetic reconstruction of the atrophic maxilla with cross-arch fixed News 9(6a):49-64, 2012.
bridges, Clin Implant Dent Relat Res 7(3):159-165, 2005. Hirsch J, Öhrnell L, Henry P, et al: A clinical evaluation of the zygoma
Bedrossian E, Stumpel L III, Beckely M, et al: The zygomatic implant: fixture: one year of follow-up at 16 clinics, J Oral Maxillofac Surg
preliminary data on treatment of severely resorbed maxillae. A clinical 62(Suppl 2):22-29, 2004.
report, Int J Oral Maxillofac Implants 17: 861-865, 2002. Jensen O, Adams M, Cottam J, et al: The All-on-4 shelf: maxilla, J Oral
Bedrossian E, Stumpel L, Indresano T: Immediate function with the zy- Maxillofac Surg 68:2520- 2527, 2010.
gomatic implant: A graftless solution for the patient with mild to Jensen OT, Cottam J, Ringeman J, et al: Trans-sinus dental implants,
advanced atrophy of the maxilla, Int J Oral Maxillofac Implants bone morphogenetic protein 2, and immediate function for All-on-4
21:937-942, 2006. treatment of severe maxillary atrophy, J Oral Maxillofac Surg
Bedrossian E, Stumpel L: Immediate stabilization at stage II of zygomatic 70(1):141-148, 2012.
implants: rationale and technique, J Prosthet Dent 86:10-14, 2001. Kahnberg K, Henry PJ, Hirsch J, et al: Clinical evaluation of the zygoma
Bedrossian E, Sullivan R, Malo P: Fixed-prosthetic implant restoration of implant: 3-year follow-up at 16 clinics, J Oral Maxillofac Surg
the edentulous maxilla: a systematic pretreatment evaluation method, 65:2033-2038, 2007.
J Oral Maxillofac Surg 66:112-122, 2008. Kahnberg KE, Henry P, Hirsch JM, et al: Clinical evaluation of the zy-
Bedrossian E, Sullivan RM, Fortin Y, et al: Fixed-prosthetic implant res- goma implant: 3-year follow- up at 16 clinics, J Oral Maxillofac Surg
toration of the edentulous maxilla: a systematic pretreatment evalua- 65:2033-2038, 2007.
tion method, J Oral Maxillofac Surg 66:112-122, 2008. Kreissl M, Heydecke G, Metzger M, et al: Zygoma implant-supported
Block M, Haggerty C, Fisher R: Nongrafting implant options for restora- prosthetic rehabilitation after partial maxillectomy using surgical
tion of the edentulous maxilla, J Oral Maxillofac Surg 67:872-881, 2009. navigation: a clinical report, J Prosthet Dent 97:121-128, 2007.
Bothur S, Jonsson G, Sandahl L: Modified technique using multiple zy- Malevez C, Abarca M, Durdu F, et al: The zygomatic implant: a 6–48
gomatic implants in reconstruction of the atrophic maxilla: a techni- month follow-up study, Clin Oral Implants Res 15(1):15-18, 2004.
cal note, Int J Oral Maxillofac Implants 18:902- 904, 2003. Malevez C, Abarca M, Durdu F, et al: Clinical outcome of 103 consecu-
Boyes VJ, Howes D, Lownie J, et al: Surgical modifications to the Brånemark tive zygomatic implants: a 6-48 months follow-up study, Clin Oral
zygomaticus protocol in the treatment of the severely resorbed maxilla: a Implants Res 15:18-22, 2004.
clinical report, Int J Oral Maxillofac Implants 18:232-237, 2003. Malik N, Kumar V, Bora P: Le Fort 1 distraction osteogenesis of the
Brånemark PI: The osseointegration book. From calvarium to calcaneus. edentulous maxilla, Int J Oral Maxillofac Surg 40:430-433, 2011.
Chapter 15. Prosthetic treatment of atrophic maxillae and maxillectomized Parel S, Brånemark P, Öhrnell L, et al: Remote implant anchorage for the
patients based on osseointegration, Berlin, 2005, Quintessence Books. rehabilitation of maxillary defects, J Prosthet Dent 86:377-381, 2001.
Brånemark PI, Gröndahl K, Öhrnell LO, et al: Zygoma fixture in the Petruson B: Sinuscopy in patients with titanium implants in the nose and
management of advanced atrophy of the maxilla: technique and long- sinuses, Scand J Plast Reconstr Surg Hand Surg 38(2):86-93, 2004.
term results, Scand J Plast Reconstr Surg Hand Surg 38:70-85, 2004. Schmidt B, Pogrel M, Young C, et al: Reconstruction of extensive maxil-
Brånemark PI, Svensson B, Van Steenberghe D: Ten- year survival rates lary defects using zygomaticus implants, J Oral Maxillofac Surg
of fixed prosthesis on four of six implants ad modum Brånemark in 62(Suppl 2):82-89, 2004.
full edentulism, Clin Oral Implants Res 6:227-231, 1995. Shulman LB, Jensen OT: Academy of Osseointegration: Sinus Graft
Chiapasco M, Zanibon M: Methods to treat the edentulous posterior Consensus Conference, Int J Oral Maxillofac Implants 13(Suppl):4,
maxilla: implants with sinus grafting, J Oral Maxillofac Surg 67: 1998.
867-871, 2009. Stella JP, Warner MR: Sinus slot technique for simplification and im-
Chow J, Hui E, Lee P, et al: Zygomatic implants - protocol for immediate proved orientation of zygomaticus dental implants; a technical note,
occlusal loading: a preliminary report, J Oral Maxillofac Surg 64: Int J Oral Maxillofac Implants 15:889-893, 2000.
804-811, 2006. Uchida Y, Goto M, Katsuki T, et al: Measurement of the maxilla and
Chow J, Hui E, Lee PK, et al: Zygomaticus implants: a new treatment zygoma as an aid in installing zygomatic implants, J Oral Maxillofac
modality for the edentulous maxilla, J Oral Maxillofac Surg 64:804- Surg 59:1193-1198, 2001.
811, 2006. Ujigawa K, Kato Y, Kizu Y, et al: Three-dimensional finite elemental
Darle C. The zygomaticus fixture – Minimized treatment for maximal pre- analysis of zygomatic implants in craniofacial structures, Int J Oral
dictability. A new procedure for rehabilitating the severely resorbed maxil- Maxillofac Surg 36:620-625, 2007.
lary. Gotebörg Sweden, 2000, Nobel Biocare AB. Vrielinck L, Politis C, Schepers S, et al: Image-based planning and clini-
Davó R, Malevez C, López-Orellana C, et al: Sinus reactions to immedi- cal validation of zygoma and pterygoid implant placement in patients
ately loaded zygoma implants: a clinical and radiographic study, Eur J with severe bone atrophy using customized drill guides. Preliminary
Oral Implantol 1:53-60, 2008. results from a prospective clinical follow-up study, Int J Oral Maxil-
Davó R, Malevez C, Rojas J: Immediate function in the atrophic maxilla lofac Surg 32:7-14, 2003.
using zygoma implants: a preliminary study, J Prosthet Dent 97(Suppl 6): Xiaojuna C, Minga Y, Yanpinga L, et al: Image guided oral implantology
44-51, 2007. and its application in the placement of zygoma implants, Comput
Ferrara E, Stella J: Restoration of the edentulous maxilla: the case for the Methods Programs Biomed 93:162-173, 2009.
zygomatic implants, J Oral Maxillofac Surg 62:1418-1422, 2004.

t.me/Dr_Mouayyad_AlbtousH
36
Contemporary Treatment Options for
Edentulism
K U M A R J . PAT E L a n d S H A H R O K H C . B AG H ER I

CC (see chapters on bone grafting elsewhere in this text) before surgi-

cal placement of implants or consideration for zygoma implants
A 66-year-old female is referred to a prosthodontist for implant (see the discussion of zygoma implants in this chapter). There was
restoration with complaints that her “dentures are old and loose.” adequate bone in the maxilla to place four conventional implants.
However, the mandible required significant grafting for placement
HPI of implants to stabilize the prosthesis and prevent the mandible
from the risk of fracture. Cone-beam computed tomography
The patient has been wearing prosthesis for 30 years and has been (CBCT) imaging and additional prosthetic planning are helpful. A
wearing existing prosthesis for the past 10 years. It has progres- team approach involving an oral and maxillofacial surgeon and a
sively become loose, and it is functionally inadequate. prosthodontist or restorative dentist is helpful, and proper com-
munication is a must. The following treatment options were pre-
PMHX/PSHX/Medications/Allergies/SH/FH sented to the patient by referring to a prosthodontist.
1. Conventional upper and lower full dentures at correct occlusal
Noncontributory. vertical dimension. Shortfalls of instability, discomfort, and fur-
ther mandibular and maxillary ridge resorption were discussed.
Examination 2. Conventional maxillary denture with mandibular overdenture
after mandibular ridge augmentation with two implants or
General. Very petite. four implants was presented.
Maxillofacial. Opening, temporomandibular joint and muscles 3. Maxillary overdenture with four implants along with man-
are with in normal limits. Collapsed vertical with existing prosthesis; dibular ridge augmentation with four implants to stabilize
inadequate facial support for tissues and reduced height. At correct dentures and prevent further fracture of the mandible.
vertical, the patient demonstrated a class 1 skeletal relationship. 4. Zygomatic implants with combination of conventional im-
plants for fixed upper prosthesis against mandibular fixed pros-
Intraoral Examination thesis with five implants after mandibular ridge augmentation.
5. Maxillary and mandibular augmentation along with eight im-
Overclosure and reduced vertical dimension of occlusion. Ex- plants in the maxilla and six in mandible to restore dentition with
tremely atrophic ridges. Soft tissues are within normal limits. The an implant-supported crown and bridge (Figs. 36.1 and 36.2).
patient has significant resorption of the mandibular ridge and virtu-
ally no sulcus. Existing prosthesis was unstable and extremely worn. Treatment
Labs The patient chose option 3, four implants in the maxilla with
mandibular ridge augmentation and four implants to stabilize the
No laboratory studies were indicated. denture. This option in the author’s opinion was best because a
removable prosthesis provides the option of adding a flange and
Assessment bulk necessary to support facial tissue and adequately restore ver-
tical dimension of occlusion. This option presents an excellent
Edentulous atrophic maxilla and mandible with poorly fitting den- balance of cost, practicality, bore regeneration, and ease of post-
tures requiring prosthetic rehabilitation. treatment prosthetic maintenance.

Treatment Phase 1 : Preprosthetic Phase

Several options are available for patients with adequate bone The new interim prosthesis was fabricated at the correct vertical
height and width. Patients with inadequate bone require grafting dimension, and the patient was allowed to function for 4 weeks so

175
t.me/Dr_Mouayyad_AlbtousH
176 S E C TI O N Dental Implant Surgery

were placed in the maxillary arch. Final impressions were made. Jaw
registration was recorded, and teeth setup was done. The mandibu-
lar bar with four locator abutments was fabricated using a com-
puter-aided design and computer-aided manufacturing approach,
and a maxillary cast Co–Cr framework was fabricated. Processed
bases were made, and attachments were picked up in the bases so
that more accurate occlusal records could be made. The teeth were
set to satisfy esthetic and phonetic requirements. The final prosthe-
sis was processed and delivered to the patient. Maintenance instruc-
tions were given, and the patient was followed up with every 6
months for hygiene follow-up. Once a year, the bar was removed,
and maintenance was performed. The patient has been followed up
with for 6 years with no complications. Locator matrices (nylon
inserts) were changed every other year to maintain appropriate re-
tention. Teeth wear has been minimal.

Complications
Complications can be divided into those related to surgery or to the
• Fig. 36.1 Edentulous patient with collapsed occlusal vertical dimension. prosthetic. Surgical complications of implant-related surgery and
bone grafting are discussed elsewhere in the text. Most common
prosthetic complications involve soreness at the surgical site. The
patient did not wear any prosthesis for 6 weeks because changes in
oral tissue after surgery were substantial, and a new prosthesis was
needed. The new mandibular prothesis was fabricated 6 weeks after
surgery. Soreness was addressed with a soft tissue conditioner,
which was changed every 4 weeks (Figs. 36.3 to 36.8).

Discussion
Edentulism can be classified as a form of disability. Edentulous
patients demonstrate relatively lower intake of dietary fibers and
food with folate and vitamin C. Lin and colleagues investigated
• Fig. 36.2 Panoramic radiograph. Note the extreme resorption of the the relationship between chewing ability and diet among older
mandible and maxilla.
adult edentulous patients: approximately 58% of the these
patients reported dissatisfaction with their dentures, and 51%
centric relation could be determined accurately. A preoperative reported discomfort on chewing. A 6-year study on institutional-
CBCT scan was obtained with the prosthesis and markers for better ized older adult patients compared physical activity and mortality
understanding of the existing bone. Treatment was planned for four rate between groups of edentulous patients without dentures and
implants in the mandible with bone graft harvested from the hip those who were partially edentulous. The study suggested that
and four implants in the maxilla. A mandibular prosthesis was there is a decline in physical ability and an increase in mortality
planned to be retained and supported with a bar. The maxillary rates for patients with no replacement dentures.
prothesis was planned to be retained with four locator attachments. Extractions of teeth are followed by resorption of the residual
ridge. Bone loss is a continuing process, and the mandibular ridge
Phase 2 : Surgical Phase may resorb at approximately four times the rate of the maxillary
ridge. Although conventional dentures are prescribed to many
Under general anesthesia, the maxillofacial surgeon harvested bone patients as a form of replacement for teeth, increasing evidence
from the hip. With chin incision, the mandibular ridge was aug- suggests that the first choice of treatment should include at least
mented, and four endosteal implants were placed. The mandible was
plated with plates to prevent future fracture. Four implants were
placed in the maxillary arch. The patient did not wear the mandibu-
lar denture for 6 weeks. A new mandibular denture was fabricated
after 6 weeks. The patient was followed up at 1-, 2-, and 4-week
intervals. Bone and implants were allowed to integrate for 4 months.
Upon completion of healing, the mandibular and maxillary im-
plants were uncovered, and the prosthesis was relined so the patient
could function while the definitive prosthesis was being fabricated.

Phase 3 : Prosthetic Phase

Four weeks after the implants were uncovered, multiunit abutments
were placed on the mandibular implants, and locator abutments • Fig. 36.3 Postoperative panoramic radiograph.

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 CHAPTER 36 Contemporary Treatment Options for Edentulism 177

A B

C D
• Figure 36.4 A, Postoperative maxilla. B, Postoperative mandibular bar. C and D, The final prosthesis.

A B

C D
• Fig. 36.5 A–D, Conventional maxillary dentures and implant-retained mandibular denture.

t.me/Dr_Mouayyad_AlbtousH
178 S E C TI O N Dental Implant Surgery

A B

C D

E F
• Figs. 36.6 Atrophic maxillary rehabilitation with zygomatic implants and a bar-supported prosthesis. A,
Atrophic maxilla. B, Atrophic maxilla. C, Use of zygomatic implants. D, Bar to retain and support the
prosthesis. E, Prostheses with adequate flange to support the lips. F, The final prosthesis.

two implants in the mandibular arch to stabilize the mandibular favorable; however, they typically require more interocclusal room
prosthesis. The McGill Consensus Statement Report (2002) rec- and should not be recommended without a full prosthetic evalua-
ommended that implant-retained mandibular overdentures should tion. In general, 12 to 15 mm of vertical space is needed from the
be the first choice standard of care for patients who are edentulous. implant platform to the occlusal plane for fabrication of the bar.
This statement was supported by the British Society for the Study They are good option in situations when significant resorption has
of Prosthetic Dentistry in 2009. Dental implants provide stability occurred. Additionally, they splint implants together, increasing
and retention for the prostheses, and they help maintain bone anchorage and favorable load distribution on implants specially in
volume. Endosseous implants are thought to maintain width and grafted sites or poor bone quality. All attachments come with
height as long as the implant remains anchored in bone with maintenance and require follow-up visits. Attachment retention
healthy, biologic attachments. The high levels of patient satisfaction forces from 5 to 7 N should be sufficient to stabilize overdentures.
have been reported for implant-retained and implant-supported Most attachment systems suffer from wear during insertion and
prostheses. Edentulism still remains a widely prevalent condition removal. In the authors’ opinion, resilient independent attachment
and requires proper treatment (Box 36.1). with nylon inserts are cost-effective and easy to maintain.
The best choice of attachments between implant and denture Few studies have justified the use of four implants in the maxil-
base remains controversial. Use of more implants and bars is lary arch to retain a maxillary prosthesis. Mills et al. reported an
associated with more retention. However, Bruns and colleagues implant survival rate of 93.8% and a denture success rates of 95.8%.
reported that patients preferred the independent implant attach- Krennmaire and colleagues reported a success rate of 97% in 179
ment. Bars are also used when implant angulation are not implants followed up for up to 5 years. Fend et al. reported a success

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 CHAPTER 36 Contemporary Treatment Options for Edentulism 179

A B

C D
• Figs. 36.7 All-on-4 concept to rehabilitate edentulous arches. A, Preoperative image. B, Axial and tilted
implants. C and D, The prostheses.

A B

C
• Figs. 36.8 A–D, The implant-supported crown and bridge.

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180 S E C TI O N Dental Implant Surgery

• BOX 36.1 Consequences of Tooth Loss and 88.9% at 10 years. Some of the complications were peri-im-
plantitis (5.4%), veneer fracture (10.3%), screw loosening (8.2%),
Deterioration of orofacial tissues such as ridges, nerves, receptors, or muscu- and abutment or screw fractures (2.1%). Although framework
lature fracture was not reported, it is known to be a complication.
Loss of chewing efficiency The use of four to six implants for maxillary rehabilitation with
Reduced intake of food specially fruits and vegetables a fixed prosthesis has been well reported. Capelli and coworkers
Increase intake of sugar- and fat-rich foods reported a success rate of 97.6% for immediately loaded maxillary
Higher risk of malnutrition implants followed up for 40 months. The study included 246
implants in 41 maxilla restored with a six implant-supported hy-
brid prosthesis. The same study reported 100% success rates for
mandibular prostheses supported by four implants. Slutzkey et al.
rate of 95.2% over a period of 46 months for maxillary overden- reported a survival rate of 97.8% for implants and a 100% sur-
tures after 104 implants in 26 patients. Chan et al. reported in their vival rate for prostheses for full-arch maxillary rehabilitation.
systemic review that maxillary implant-supported overdentures Ample evidence suggests immediate loading of implants for
have similar survival rates to those of fixed implant prostheses when treatment of full arch edentulous arches. In 2012, Ghoual and
matched for bone quality and quantity. High failure rates are associ- coworkers reported that to load immediately, three important
ated with extreme atrophy, poor bone quality, and use of short clinical criteria must be met: (1) micromotion must be reduced to
implants. 50 to 150 mm, (2) connecting several implants reduces the mo-
Ghiasi et al. conducted systemic review of 131 studies (1478 tion and provides cross-arch stabilization to counteract the bend-
overdentures, 668 implants) with a follow-up period ranging 1 to 9 ing effect of lateral forces, and (3) insertion torque values of im-
years for maxillary overdentures. Their findings found a 6% implant plants should exceed at least 30 N-cm2 at the time of placement.
failure rate and a 3.7% prosthesis failure rate. Most failures occurred Malo et al. 2017 reported a success rate of 97.8% for 7 years with
in the first year. In an in vitro evaluation, Damghani and colleagues marginal bone loss of 1.3 mm. Peñarrocha-Oltr et al. conducted
concluded that using four locator attachments produced signifi- a systemic review of 13 studies following 2484 immediately
cantly less force on the palate compared with using zero or two loca- loaded implants in 365 patients; the review reported survival rates
tor attachments. There was a significant reduction in the force of 87.5% to 100% when the patients were followed for 7 years.
measured when the distance between four locator attachments in- When adequate bone is present and the patient does not need
creased from 8 to 16 mm. Lewis and colleagues (1992) and Mericske- lip support, consideration should be given to an implant-
Stern et al. (2011) concluded that there appears to be consensus that supported crown and bridge (see Fig. 36.8). A screw-retained or
a minimum of four implants yields a favorable long-term prognosis cement-retained prosthesis can be used. They are easy to maintain
for prosthetic treatment options without palatal coverage. but costly to fabricate. This procedure may be performed using an
In the opinion of the authors, the use of partial palatal cover- interim fixed prosthesis to provide interim function or a delayed
age with four well-distributed implants provides a retentive maxil- loading protocol. An atrophic maxilla and mandible, as discussed
lary overdenture to improve function. Partial palatal coverage us- in this case, requires special consideration and use of a removable
ing a metal base provides for additional support and strength and prosthesis retained and supported by implants. Attachment
reduced thickness. The decision to use a fixed or removable pros- choices depend on available interarch space as discussed earlier.
thesis requires evaluation of numerous factors. Anteroposterior Zirconia has been widely used in rehabilitation of maxillary
resorption of more than 10 mm in the maxilla may be an indica- and mandibular fixed prosthesis. Full discussion of this material
tion for the use of an implant-retained and removable prosthesis. and its limitation is beyond the scope of this text and requires
The patient may require a flange for lip support; however, the special discussion. In the opinion of the authors, restoring maxil-
procedures still can be accomplished if adequate lip support is lary arch with six implants and no cantilever is very favorable with
available and the ridge overlap is modified. zirconia; a solid monolithic prosthesis provides protection against
Success rates of mandibular implants are well documented. In chipping. Tissue health and plaque control are very favorable with
this case, the grafted site was allowed to heal first before any attempt zirconia. Cantilevers should be avoided. A mandibular arch where
was made to load the implants. In a systemic review, Kern et al. re- cantilever is present (a resin prothesis wrapped around a titanium
ported a success rate of 98.9% with bar-retained mandibular im- bar) is very favorable. When a fixed prosthesis is considered for
plants. Prasad et al. conducted a systemic review and concluded that edentulous rehabilitation in the maxillary arch with no cantilever
although success rates with bar-type attachments was 95%, the most or cantilever of just one tooth against the resin prosthesis wrapped
favorable attachment system was the Locator. This attachment sys- around a titanium bar, zirconia is a treatment of choice.
tem was shown to be associated with the fewest prosthetic complica-
tions. Sutaria et al., in their systemic review, concluded that bar at- Conclusion
tachments provided superior retention. They further concluded that
when interarch space is limited, a solitary attachment is favorable. The first choice of treatment for an edentulous patient should be
Mandibular fixed hybrid prosthesis has shown very predictable at least an implant-retained mandibular denture. When the bone
success rates. Rodriguez and coworkers reported a success rate of level is adequate, a fixed implant–supported prosthesis should be
98.1% for mandibular fixed hybrid prosthesis followed up for 36 given consideration. When bone level is not adequate, an attach-
months. Fallucci and colleagues reported implant survival rates of ment retained or bar-retained and bar-supported removable pros-
100% and prosthesis survival rates of 95.5% for mandibular fixed thesis should be considered. All treatment modalities have ample
hybrid prosthesis on four to six implants with and average canti- evidence to support consideration. Teamwork and proper pros-
lever of 15.6 mm followed up for 5 years. Aglietta and colleagues thetic preplanning are vital for any edentulism rehabilitation.
conducted a systemic review to assess the survival rates of im-
plant-supported, cantilevered fixed prostheses after and observa- ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
tion of 5 years. They reported success rates of 94.3% at 5 years complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 180.e1

Bibliography versus maxillary posterior concept–a retrospective study, Int J Oral

Maxillofac Implants 23:343-353, 2008.
Ageliardi E, Clerico M, Ciancio P, et al: Immediate loading of full arch Kronstrom M, Widbom C, Soderfeldt B: Patient evaluation after treat-
fixed prostheses supported by axial and tilted implants for the treat- ment with maxillary implant-supported overdentures, Clin Implant
ment of edentulous atrophic mandible, Quitnessence Int 41:285-293, Dent Relat Res 8(1):39-43, 2006.
2010. Lewis S, Sharma A, Nishimura R: Treatment of edentulous maxilla with
Agliardi E, Panigatti S, Clerico M, et al: Immediate rehabilitation of the osseointegrated implants, J Prosthet Dent 68:503-508, 1992.
edentulous jaws with full fixed prostheses supported by four implants: Lian M, Zhao K, Wang F, et al: Stud vs. bar attachment for maxillary
interim results of a single cohort prospective study, Clin Oral Implants four implant supported overdentures: 3-9 year results from pro-
Res 21:459-465, 2010. spective study, Int J Oral Maxillofac Implants 34(4):936-946, 2019.
Aglietta M, Siciliano VI, Zwanhlen M, et al: A systemic review of the Lopes A, Maló P, de Araújo Nobre M, et al: The NobelGuide All-on-4
survival and complication rates of implant supported fixed dental Treatment concept for rehabilitation of edentulous jaws: a retrospec-
prosthesis with cantilever extension after an observation period of at tive report on the 7-years clinical and 5-years radiographic outcome,
least 5 years, Clin Oral Implants Res 20(5):441-451, 2009. Clin Implant Dent Relt Res 19(2):233-244, 2017.
Ahlan-Abdunabi, Morris M, Nader SA, et al: Impact of immediately Maló P, Rangert B, Nobre M: All-on-4 immediate-function concept
loaded implants-supported maxillary full-arch dental prosthesis; a with Brånemark system implants for completely edentulous maxil-
systemic review, J Appl Oral Sci 27:e20180600, 2019. lae: a 1-year retrospective clinical study, Clin Implant Dent 79:
Attard NJ, Zarb GA: Long-treatment outcomes in Edentulous patients 66-72, 1998.
with implant overdentures: the Toronto Study, Int J Prosthodont Mericske-Stern et al. (2011)
17:425-433, 2004. Mills S: How successful are maxillary implant retained overdentures on
Atwood DA: Reduction of residual ridge: a major oral disease entity, two or four implants?, Evid Based Dent 22(4):146-147, 2021.
Prosthet Dent 26:266-279, 1971. Naert I, Gizani S, Van Steenbergh D: Rigidly splinted implants in the
Bergkvist G, Nilner K, Sahlholm S, et al: Immediate loading of implants resorbed maxilla to retain hinging overdenture: a series of clinical re-
in the edentulous maxilla: use of an interim fixed prothesis followed ports for up to 4 years, J Prosthet Dent 79:66-73, 1998.
by permanent fixed prosthesis—a 32-month prospective radiological Peñarrocha-Oltr D, Covani U, Peñarrocha-Diago M, et al: Immediate
and clinical study, Clin Implant Dent Relat Res 11:1-10, 2009. loading in maxilla: review of the literature, Med Oral Patol Oral Cir
Borges AF, Dias Pereira L, Thome G, et al: Prostheses removal for suture Bucal 19(5):e512-e517, 2014.
removal after immediate load: success of implants, Clin Implant Dent Prasad S, Faverani LP, Santiago Junior JF, et al: Attachment systems for
Relat Res 12:244-248, 2010. mandibular implant supported overdentures: a systemic review and
Burns DR, Unger J, Coffey JP, et al: Randomized, prospective clinical meta-analysis of randomized controlled trials, J Prosthet Dent S0022-
evaluation of prosthodontic modalities for mandibular implant over- 3913(22)00485-1, 2022.
denture treatment, J Prosthet Dent 106(1)12-21, 2011. Raghoebar GM, Meijer HJ, Slot W, et al: A systemic review of implant-
Capelli M, Zuffett F, Del Fabbro M, et al: Immediate rehabilitation of supported overdentures in edentulous maxilla, compared to mandi-
completely edentulous jaw with fixed prostheses supported by either ble: how many implants, Eur J Oral Implantol 7(Suppl 2):S191-S201,
upright or tilted implants: a multicenter clinical study, Int J Oral 2014.
Maxillofac Implants 22(4):639-644, 2007. Rodriguez AM, Orenstein IH, Morris HF, et al: Survival of various implant-
Cavallaro JS Jr, Tarnow DP: Unsplinted implants retaining maxillary supported prosthesis designs following 36 months of clinical function: five
overdentures with partial palatal coverage: reports of 5 consecutive year results of fixed implant-supported rehabilitations with distal cantile-
cases, Int J Oral Maxillofac Implants 22(5):808-814, 2007. vers for edentulous mandible, Ann Periodontol 5(1):101-108, 2000.
Chan MF, Närhi TO, de Baat C, et al: Treatment of the atrophic eden- Romeo E, Lops D, Margutti E, et al: Long term survival and success of
tulous maxilla with implant supported overdentures: a review of lit- oral implants in the treatment of full and partial arches: a 7-year pro-
erature, Int J Prosthodon 11(1):7-15, 1998. spective study with the ITI dental implant system, Int J Oral Maxil-
Das K, Jahngiri L, Katz R: The first choice standard of care for edentu- lofac Implants 19:257-259, 2004.
lous mandible, J Am Dent Assoc 143(8):881-889, 2012. Shimazaki Y, Soh I, Saito T, et al: Influence of dentition status on physi-
Degidi M, Piatelli A: Comparative analysis study of 702 dental implants cal disability, mental impairment and mortality in institutionalized
subjected to immediate functional loading and immediate non func- elderly people, J Dent Res 80:340-245, 2001.
tion loading to traditional healing periods with follow-up of 24 Slutzkey GS, Cohen O, Chaushu L, et al: Immediate maxillary full arch
months, Int J Oral Maxillofac Implants 20:99-107, 2004. rehabilitation of periodontal patients with terminal dentition using
Drago C, Carpentieri J: Treatment of maxillary jaws with dental im- tilted implants and bone augmentation: a 5-year retrospective study,
plants: guidelines for treatment, J Prosthod 20:336-346, 2012. J Clin Med 11(10):2902, 2022.
Ekfeldt A, Christiansson U, Eriksson T, et al: A retrospective analysis of Sutaria PV, Shah HM, Patel SD, et al: Mandibular implant-supported
factors associated with multiple implant failures in maxilla, Clin Oral overdentures: a systemic review and meta-analysis for optimum selec-
Implants Res 12:462-467, 2001. tion of attachment system, J Indian Prosthodont Soc 21(4):319-327,
El Ghoul W, Chidiac JJ: Prosthetic requirements for immediate implant 2021.
loading: a review, J Prosthodont 21(2):141-154, 2012. Tealdo T, Bevilacqua M, Pera F, et al: Immediate function with fixed
Feine JS, Carlsson GE, Awad MA, et al: The McGill consensus statement implant–supported dentures: a 12-month pilot study, J Prostht Dent
on overdentures, Int J Prosthodont 15(4):413-414, 2002. 99(5):352-360, 2008.
Felton D: Edentulism and comorbid factors, J Prosthodont 18:88-96, Tellgren A: The continuing reduction of the residual alveolar ridges in
2009. complete denture wearer, a mixed longitudinal study covering 25
Gallucci GO, Doughtie CB, Hwang JW, et al: Five year results of fixed years, J Prosthet Dent 89:427-435, 2003.
implant-supported rehabilitation with distal cantilevers for the eden- Thomason JM, Feine J, Exleay C, et al: Mandibular two-implant sup-
tulous mandible, Clin Oral Implants Res 20(6):601-607, 2009. ported overdentures as the first choice standard of care for edentulous
Ghiasi P, Ahlgren C, Larsson C, et al: Implant and prosthesis failure rates patients—the York consensus statement, Br Dent J 207(4):185-186,
with Implant supported maxillary overdentures: a systemic review, Int 2009.
J Prosthodont 34(4):482-491, 2021. Weinstein R, Agliardi E, Fabbro M, et al: Immediate rehabilitation of
Krennmair G, Kranninhofner M, Peihslinger E: Implant–supported extremely atrophic mandible with fixed full-prosthesis supported by
maxillary overdentures retained with milled bars: maxillary anterior four implants, Clin Implant Dent Relat Res 14(3):434-441, 2010.

t.me/Dr_Mouayyad_AlbtousH
180.e2

World Health Organization: WHO International Classification of Func- Zhou H, Jiao Y, Ma CF, et al: Clinical outcome of implant-retained man-
tioning, Disability and Health. Available at: www.who.int/classifica- dibular overdentures using the bar and magnetic attachment systems:
tion. Accessed June 20, 2012. an up to 5-year retrospective study, An Transl Med 8(21):1360, 2020.
Zarb G, Schmidt A: Edentulous predicament. Part 1, a prospective study
of the effectiveness of implant supported fixed prosthesis, J Am Dent
Assoc 127:59-72, 1996.

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37
Using a Dynamic Navigation System
for Placing Dental Implants
M A Z I A R S H A H Z A D D OW L AT S H AH I a n d R A H U L M A N H A R S H A H

CC
A cone-beam computed tomography (CBCT) scan was ob-
A 47-year-old male was referred for consultation regarding the tained on a well-calibrated machine.
periodontal condition and implant placement in the upper and
lower jaws. The patient had bleeding during brushing and re- Investigations
ported pain and discomfort in the gums when eating. He wanted
to replace his missing tooth as well. Basic laboratory investigations were made, and the patient did
not give any specific medical history, complete blood count,
HPI prothrombin time with international normalized ratio, or blood
sugar levels.
The patient has a history of removal of teeth for orthodontic rea-
sons. He has no history of bruxism, smoking, diabetes, use of Assessment
bisphosphonates, immune-compromised diseases, chemotherapy,
or radiotherapy. Stage III, grade B periodontitis.

Examination Treatment
Extraoral. Upon inspection of the maxilla and mandible, there is
no evidence of lumps or swelling. The maximum incisal opening
Phase I: Cause-Related Therapy
is 58 mm. Initial treatment included oral hygiene, scaling, root planing, ex-
The intraoral examination reveals bleeding on probing and traction of the hopeless teeth, and repairing caries. Follow-up and
deep pockets in multiple sites. The patient’s oral hygiene is good. maintenance treatment were carried out after 3 weeks.
No other soft or hard tissue abnormalities are seen.
Phase II: Surgical Phase
Imaging
Periodontal surgery was performed for the upper and lower jaws
A panoramic radiograph revealed missing teeth in the upper and with follow-up after 3 weeks. The patient was scheduled for im-
lower jaws with horizontal and vertical bone loss (Fig. 37.1). plant placement surgery for teeth #47, #37, and #17.
The risks, benefits, alternative treatment plans, cost, and treat-
ment time were thoroughly discussed with the patient. He chose
treatment with implants. CBCT DICOM (Digital Imaging and
Communications in Medicine) files were imported to dynamic
navigation software (Navident, Claronav Inc.) (eFig. 37.2).
The treatment plan involved placing a 4.5-mm 3 8.5-mm
implant (AnyRidge implant, MegaGen Co.) as a single-stage flap-
less approach for tooth #47. To control the drilling depth and use
live navigation, a digital implant was placed in the ideal location,
biologically and prosthetically, with respect to the planned digital
crown (Fig. 37.3).
The restorative dentist approved the virtual prosthetic design
and positioning of the implant.
• Fig. 37.1 Panoramic radiograph revealing missing teeth in the upper and Local anesthesia was performed with infiltration technique on
lower jaws with horizontal and vertical bone loss. the buccal and lingual of the lower right second molar area.

181
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 CHAPTER 37 Using a Dynamic Navigation System for Placing Dental Implants 181.e1

• eFig. 37.2 Cone-beam computed tomography DICOM (Digital Imaging

and Communications in Medicine) files imported to dynamic navigation
software (Navident, Claronav Inc.).

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182 S E C TI O N Dental Implant Surgery

• Fig. 37.3 To control the drilling depth and use live navigation, a digital
implant was placed in the ideal location, biologically and prosthetically,
with respect to the planned digital crown.

To accurately guide the drilling process, the navigation system

must map the drill tip to a computed tomography (CT) scan im-
age of the jaw, which consists of three steps: registration, calibra-
tion, and tracking (eFig. 37.4). Registration is the process of
mapping the CBCT image to the patient’s physical jaw structures.
First, the Jaw Tracker, a tag used for real-time tracking of the pa-
tient’s jaw, was fitted onto the incisal surfaces of the mandibular • Fig. 37.5 Using the Jaw Tracker, a tag used for real-time tracking of the
incisors; then it was fixed in position with impression material patient’s jaw was fitted onto the incisal surfaces of the mandibular incisors
and then fixed in position with impression material.
(Fig. 37.5). The system’s tracking camera (Micron Tracker, Claro-
Nav Inc.) tracked the Jaw Tracker in the physical three-dimensional
(3D) space, allowing continuous tracking of the patient’s mandibu-
lar anatomic structures. Next the trace registration procedure was
performed (eFig. 37.6).
Trace registration was performed by marking four landmarks
on teeth using a panoramic 3D presentation of the jaw and then
tracing these landmark regions with the tracer tool while the cam-
era and software collected 100 points on each tooth (Fig. 37.7 and
eFig. 37.8). The software automatically registered the Jaw Tracker
with the patient’s mandibular CBCT scan based on the collected
points. Therefore, the computer can map the patient’s anatomic
structures to the CBCT scan images, accurately maintaining this
mapping during the surgery regardless of the patient’s possible
movement.
After the tracing was completed, its accuracy was verified on • Fig. 37.7 Trace registration is performed by marking four landmarks on
the computer screen by touching the surfaces of teeth with the teeth using a panoramic three-dimensional presentation of the jaw and
tracer tool and evaluating whether the corresponding images on then tracing these landmark regions with the tracer tool while the camera
the computer screen were correct. and software collect 100 points on each tooth.
The DrillTag was already placed on the surgical handpiece ac-
cording to the company’s instructions so the system could identify
the axis of the handpiece during the surgery (eFig. 37.9). The dimple at the center of the calibrator, which is a multitool calibra-
navigation machine was positioned in the operatory to visualize tion device that enables the calibration of low-speed handpiece-
the Jaw Tracker tag and the handpiece tag to detect them during driven drills, fixtures, and other rigid instruments for determining
surgery. After the camera detects the CT markers, they become the drill tip position and location in relation to the optical track-
visible on the side panel of the monitor. The next step was cali- ing tag installed on the handpiece. With calibration, the naviga-
brating the handpiece head by placing the handpiece head into tion system can adapt to the particular angulation and length of
the calibration peg on top of the calibrator device (eFig. 37.10). the drill to be used when drilling and have it represented correctly
The handpiece was then rotated clockwise and counterclockwise on the navigation screen so the surgeon can see the drill depth and
around the peg to calibrate and register (eFig. 37.11). The system angulation in 3D in real time. After the drill tip was calibrated, it
then prompts calibration of the drill. The drill was then placed became visible on the monitor and the CT image when it came
into the handpiece and calibrated by placing the drill tip into the into the surgical field. The next step was to verify the drill tip

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182.e1 S EC TI O N Dental Implant Surgery

Calibration: Mapping the

drill trip to the tracking
marker for the drill
Tracking:
Mapping the
tracking
marker for
the drill to the
tracking marker
for the jaw
(dynamic
throughout
operation) • eFig. 37.9 The drill tag is placed on the surgical handpiece according to
the manufacturer’s instructions so the system could identify the axis of the
handpiece during the surgery.

Registration: Mapping the tracking marker for

the jaw to the CT image and planning the drill site
• eFig. 37.4 To accurately guide the drilling process, the navigation system
must map the drill tip to a computed tomography (CT) scan image of the
jaw, which consists of three steps: registration, calibration, and tracking.

• eFig. 37.10 Calibrating the handpiece head by placing the handpiece

head into the calibration peg on top of the calibrator device.

• eFig. 37.6 The registration procedure device for the Jaw Tracker.

• eFig. 37.11 The handpiece is rotated clockwise and counterclockwise

• eFig. 37.8 around the peg to calibrate and register.

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 CHAPTER 37 Using a Dynamic Navigation System for Placing Dental Implants 183

• Fig. 37.12 Operator in action on the computer monitor in real time.

position. This was done quickly by placing the bur tip on a land-
mark in the jaw to verify its positioning accuracy.
The last step is tracking. When the DrillTag and the JawTag
were in the tracking camera’s field of view, the position of the drill • Fig. 37.14 Postoperative posteroanterior radiography performed to
tip and the patient’s anatomic structures were mapped together by evaluate the accuracy of the implant placement compared with the pre-
the software. This step relates the drills to the jaw structures, al- operative planning.
lowing the operator to see them in motion on the computer
monitor in real time (Fig. 37.12)
The drill was then brought to the surgical site, and the navi- and inaccurate patient registration and calibration. Despite these
gated drilling screen showed a targeted view and cross-sectional factors, when used with careful planning, this technology has
CT images with the drill image visualized in its real-time position. proven to have substantial benefits in treating simple to complex
The target and cross-sectional views allow the positioning of the cases, leading to improved outcomes and reduced risks.
drill into the ideal digitally planned implant position based on the
live view of the drill over the CT images. Discussion
Then insertion point was marked, and soft tissue was punched
considering at least 3 mm of keratinized gingiva in the buccal side Computer-guided placement of dental implants is significantly
of the punch. To place the implant in the digitally preplanned more accurate than freehand surgery.
path, the implant drills were calibrated with the calibrator and The main goals of implant dentistry are function and the es-
used to create osteotomies in a sequence that could be seen three thetics that can be achieved with prosthetically or biologically
dimensionally all the way on the screen (eFig. 37.13). The im- driven planning and placement. Osseointegration is necessary but
plant (AnyRidge implant, 4.5 mm 3 8.5 mm, MegaGen Co.) insufficient for a successful result. Accuracy in implant dentistry
was also calibrated before placing it into the osteotomy. Then is another important factor because misplaced or inaccurate os-
implant was placed according to the plan with 35-N and 6-mm seointegrated implants can cause esthetic and biologic complica-
3 4-mm healing abutment installed. tions, which can be considered a failure.
Postoperative posteroanterior radiography was performed to Using advanced technologies to increase length, position, and
evaluate the accuracy of the implant placement compared with angulation accuracy in 3D dental implant planning and place-
the preoperative planning (Fig. 37.14). ment is essential for increasing the success rate. Using CBCT
(scans and intraoral scanners has led to a significant advance in
Complications 3D presurgical planning and placing dental implants in their ideal
position through various software programs.
Educating patients about the risks and benefits of these proce- There are two methods for computer-assisted surgery: (1) static,
dures is paramount. The risks can be failing or failed implants, in which stereolithographic templates are used during the osteot-
peri-implantitis, nerve injury (despite the use of CBCT technol- omy and placement of the dental implant; and (2) dynamic navi-
ogy), or damage to the roots of adjacent teeth. gation, in which a microtracker device is used to monitor the drills
The success of dental implants depends on three factors, which and implants are following the planned insertion path in real time.
are the clinician’s knowledge and experience, patient-related fac- In areas of complex anatomy, computer-guided navigational
tors, and implant characteristics; however, complications may surgery is superior to conventional implant surgery to prevent
occur even with correct surgical technique and meticulous surgi- iatrogenic injuries. This technology can significantly improve the
cal and medical preparation of the patient. The overall success rate quality and accuracy of dental implant placement, offers an opti-
for dental implants is greater than 95%. The failure rate further mum approach for the placement of implants because of the
decreases when these three factors are considered precisely. effective mechanism of controlling the drilling pathway and a
Some inherent factors can lead to complications with dynamic significant margin of safety, and reduces the risks of intraoperative
navigation surgery, and understanding the possible pitfalls can and postoperative complications.
minimize the additive effect of these factors that can lead to un- Stefanelli et al. studied the present study’s positional and angu-
desirable outcomes. These pitfalls include errors from the CT lation accuracy using the same dynamic navigation system (Navi-
scanner caused by lack of calibration, incorrect mapping of vital dent, ClaroNav Inc.). The discrepancies between the actual and
structures or treatment planning on the software by the surgeon, planned implant positions were 0.71 (0.40) mm at the entry

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 CHAPTER 37 Using a Dynamic Navigation System for Placing Dental Implants 183.e1

• eFig. 37.13 To place the implant in the digitally preplanned path, the
implant drills are calibrated with the calibrator and used to create osteoto-
mies in a sequence that could be seen three dimensionally all the way on
the screen.

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184 S E C TI O N Dental Implant Surgery

point and 1.00 (0.49) mm at the apex. The mean angular discrep- guides. However, the dynamic navigation system has a learning
ancy was 2.26 degrees (1.62). Studies using different navigation curve. In the study by Stefanelli et al., one surgeon placed 231
systems also showed similar positional and angular accuracies. implants, and the results showed that the last 50 implants placed
These studies indicated that the dynamic navigation system had were significantly more accurate than the first 50 implants. In an-
comparable accuracy to the static computer-generated surgical other study by Block et al., significant improvements in placement
guides, and both were more accurate than the freehand drilling accuracy were achieved when surgeons performed more than 20
method. The dynamic navigation system has several advantages cases. The system requires the operator to look at a computer
over static surgical stents. The dynamic navigation system can be screen while drilling osteotomies, which can be challenging for
used in sites with limited vertical spaces, such as the second molar inexperienced users. Practice is needed to develop the necessary
sites, or in patients with limited mouth openings. Computer- hand–eye coordination to operate the dynamic navigation system.
generated surgical guides are more challenging because they are The margin of inaccuracies associated with the placement of
bulky and require extended implant drills and special instrumen- implants guided with dynamic navigation reported in the litera-
tations. The dynamic system allows for direct visualization of the ture and noted in this study could be attributed to several factors,
surgical field, whereas the static surgical guides block the direct including imaging errors, registration, calibration inaccuracies,
view of the surgical sites. The drills and implant movements can and human factors. The accuracy of the captured images depends
be monitored in real time, and accuracy can be verified through- on the voxel size and the viewed pixel size. The registration pro-
out the procedure. cess, which links the digital coordinate system of the 3D image to
The guide cylinders of static surgical guides have specific di- the physical patient coordinate system through the teeth land-
mensions and may be too wide for tight mesiodistal space sites. It marks, and the calibration process, which links the surgical instru-
is challenging to judge bone density during the drilling process ments, handpiece, and surgical instruments to the Jaw Tracker, are
because friction between implant drills and guide cylinders of subjected to errors. The combined effect of these registration er-
static surgical guides interferes with tactile sensation. The dynamic rors has been considered acceptable in image-guided surgery
navigation system provides better tactile sensation during osteot- when kept below 1.5 mm.
omy preparations, allowing surgical plan modifications during
operations. The dynamic navigation system allows surgery on the ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
same day as CBCT scanning, which is impossible with static complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 184.e1

Bibliography in zygomatic implant surgery, Clin Implant Dent Relat Res 22(6):747-
755, 2020.
Wu Y, Tao B, Lan K, et al: Reliability and accuracy of dynamic navigation
Gracher AHP, de Moura MB, da Silva Peres P, et al: Full arch rehabilita- for zygomatic implant placement, Clin Oral Implantol Res 33(4):362-
tion in patients with atrophic upper jaws with zygomatic implants: a 376, 2022.
systematic review, Int J Implant Dent 7(1):17, 2021. Wu Y, Wang F, Huang W, et al: Real-time navigation in zygomatic im-
Hung K, Huang W, Wang F, et al: Real-time surgical navigation system plant placement: workflow, Oral Maxillofac Surg Clin North Am
for the placement of zygomatic implants with severe bone Deficiency, 31(3):357-367, 2019.
Int J Oral Maxillofac Implants 31(6):1444-1449, 2016. Xiaojun C, Ming Y, Yanping L, et al: Image guided oral implantology
Hung KF, Wang F, Wang HW, et al: Accuracy of a real-time surgical and its application in the placement of zygoma implants, Comput
navigation system for the placement of quad zygomatic implants in Methods Programs Biomed 93(2):162-173, 2009.
the severe atrophic maxilla: a pilot clinical study, Clin Implant Dent Xing Gao B, Iglesias-Velázquez O, G F Tresguerres F, et al: Accuracy of
Relat Res 19(3):458-465, 2017. digital planning in zygomatic implants, Int J Implant Dent 7(1):65,
Stefanelli LV, DeGroot BS, Lipton DI, et al: Accuracy of a dynamic 2021.
dental implant navigation system in a private practice, Int J Oral Zhou M, Zhou H, Li SY, et al: Comparison of the accuracy of dental im-
Maxillofac Implants 34(1):205-213, 2019. plant placement using static and dynamic computer-assisted systems:
Tao B, Shen Y, Sun Y, et al: Comparative accuracy of cone-beam CT and an in vitro study, J Stomatol Oral Maxillofac Surg 122:343-348, 2021.
conventional multislice computed tomography for real-time navigation

t.me/Dr_Mouayyad_AlbtousH
38
Alveolar Ridge Preservation Following
Extraction for Implant Placement
C LA IR E M ILLS, PIYU SHK U MAR PAT EL , A. MIC H AE L SODE IF I, a nd SHA H RO K H C. B AGHERI

CC
A 37-year-old female is referred by her general dentist for consulta-
tion to have tooth #19 extracted. She is interested in a dental implant.

HPI
Tooth #19 has had previous endodontic therapy. Recently, the
patient started to have pain while chewing. Endodontic evalua-
tion found a poor prognosis because of root fracture. She denies
any swelling or other symptoms.

PMH/PDH/Medications/Allergies/SH/FS
The medical history is not contributory. The patient has had rou-
tine dental care by her general dentist.
• Fig. 38.1 Preoperative photograph showing the missing crown and de-
Examination fective temporary restoration on tooth #19.

Examination of the temporomandibular joint is within normal

limits. (Good range of motion is important in placement of pos-
terior dental implants.) There are no extraoral or intraoral soft
tissue lesions, swelling, or masses. Tooth #19 is missing the crown
and has a temporary restoration (Fig. 38.1).

Imaging
On the panoramic radiograph, a periapical radiolucency can be
seen associated with mesial and distal roots of the endodontically
treated tooth #19. The radiolucency appears to be a few millime-
ters away from the inferior alveolar nerve (Fig. 38.2).
• Fig. 38.2 Preoperative panoramic radiograph.
Assessment
Failed root canal therapy and nonrestorable tooth #19 with a periapi-
cal abscess. Treatment
The patient is interested in a dental implant. The clinical and
radiographic findings are fully explained to the patient. The risks, Under intravenous sedation anesthesia, a sulcular incision is made,
benefits, and alternative treatment considerations are discussed. and a buccal mucoperiosteal flap is elevated (Fig. 38.3A) to visual-
Alternative options include extracting the tooth without replace- ize and protect the buccal cortical plate. Vignoletti and colleagues
ment or receiving a bridge or a partial denture. The plan for ridge report better outcomes when the flap is elevated for alveolar ridge
preservation (with human allograft) and delayed implant place- preservation (ARP) than with a flapless technique. Clinical studies
ment is presented and accepted by the patient. by Siu et al. (2022) and a meta-analysis by Lee et al. (2018) found

185
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186 S E C TI O N Dental Implant Surgery

that both flap and flapless alveolar ridge preservation techniques decortication. Several case reports and clinical studies have found
had similar crestal ridge width, height, and percentages of vital success with this approach, but other studies found no improvement.
bone at 4- to 6-month follow-up, which is in agreement with pre- A mineralized corticocancellous allograft was prepared with
vious animal studies conducted by Araujo and Lindhe. the use of leukocyte, and platelet-rich fibrin (L-PRF) to make
A 1702 bur is used under loupe magnification, and the tooth “sticky bone.” As described by Cortellini et al., two 9-mL glass-
structure is removed from the buccal aspects of the roots under coated plastic tubes (red cap) and one 9-mL plastic tube without
copious sterile saline irrigation (to prevent overheating of the coating (white top) were collected from the patient. These were
bone, which can lead to further bone loss). In essence, instead of centrifuged immediately at 408 g RCF. The centrifugation was
a buccal trough alveolectomy, a buccal odontotomy is performed interrupted after 3 minutes, and the white cap tube was removed.
to keep the buccal cortical bone fully intact. The crown and the The remaining red cap tubes were centrifuged for 9 additional
roots are sectioned from buccal to lingual (Fig. 38.3B). minutes (completing the cycle of 12 minutes). Immediately after
Next, a periotome (Fig. 38.3C) is used on the mesial and distal of removing the white cap tube, the yellow liquid (liquid fibrinogen)
each root to loosen the segment (Fig. 38.3D). The roots are com- above the red blood cell layer was collected with a sterile syringe.
pletely removed (Fig. 38.3E), and the granulation tissue in the apex The red cap tubes were removed after completion of centrifuga-
is fully cleaned with a curette. Throughout the process, care is taken tion (12 minutes), and the L-PRF membranes were prepared
not to damage the cortical buccal plate. The extraction site is irrigated following the protocol described by Temmerman et al. The PRF
with copious sterile saline. A round bur is used to decorticate the clot was transformed into a membrane by gentle compression in
inside of the socket to induce bleeding. This leads to better early the PRF box. These membranes were sliced into small fragments
vascularization and release of osteoprogenitor cells. At this time, no using scissors and mixed with the graft particles. The liquid fi-
human clinical trials have been conducted to study the benefit of brinogen was then added. After gentle modeling, the graft was

B
C

E D
• Fig. 38.3 A, Sulcular incision and an elevated buccal mucoperiosteal flap. B, The crown and the roots
are sectioned from buccal to lingual. C, Periotome and mallet. D, Periotome used on the mesial and
distal of each root to loosen the segment. E, The roots are completely removed.

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 CHAPTER 38 Alveolar Ridge Preservation Following Extraction for Implant Placement 187

J K

• Figure 38.3, cont’d F, Demineralized freeze-dried bone cortical allograft is prepared in advance. G–I,
Preparation of the platelet-rich fibrin gel for socket preservation. J, Bone is grafted in the extraction
socket. K, Flaps are sutured closed.

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188 S E C TI O N Dental Implant Surgery

ready to use. Fig. 38.3F to I describe this process. Alveolar ridge Tension-free closure of the flap and appropriate use of mem-
preservation through grafting reduces the amount of horizontal brane can reduce the incidence of flap retraction or dehiscence
and vertical bone resorption after tooth extraction by providing a and subsequent loss of grafted bone granules. Wound healing can
scaffold for additional bone to regenerate and fill the space. be compromised secondary to pressure applied by a removable
L-PRF can be used as a grafting material in alveolar ridge preser- partial denture. All attempts should be made to minimize pressure
vation because of its high concentration of platelets, leukocytes on the grafted site from a removable prostheses. Patients need to
(white blood cells), and lymphocytes (T cells, B cells, natural be taught to modify their diets to avoid function on the surgical
killer cells), which contribute to developing a strong mesh matrix site for 4 weeks and to undertake appropriate hygiene measures.
that releases growth factors and proteins to help stimulate the
wound healing and cell proliferation process. Studies of the Discussion
changes in bone height and width found improved soft tissue
healing, increased bone formation, and slightly reduced loss of Preservation of hard and soft tissue at the time of extraction is
alveolar width in the PRF group. Clark et al. (2018) conducted a essential in achieving better esthetic and long-term results for
randomized clinical trial of PRF and allografting on ridge preser- dental implants. The alveolar process is a tooth-dependent tissue.
vation and found that PRF1 allografting demonstrated signifi- The shape and volume of the ridge is dictated by the tooth shape,
cantly less ridge loss both for height (1 6 2.3 mm) and width axis, anatomy, and position. After dental tooth extraction, bone
(1.9 6 1.1 mm) compared with spontaneous healing (3.8 6 remodeling and shrinkage often occur because the alveolar process
2.0 mm height). The combination was superior to both PRF (1.8 6 and bundle (lamellar) bone that support the teeth resorb. Most of
2.1 mm height) and allograft (2.2 6 1.8 mm height) placement the resorption (typically in an apical and lingual direction) takes
alone as well. However, studies of changes in bone volume found place in the first 3 months; however, changes are seen up to 1 year
little difference in outcomes between grafting with L-PRF and nor- after surgery, resulting in approximately 50% reduction in the
mal healing with blood clotting. In addition, studies of new bone buccolingual dimensions of the alveolar ridge, according to
percentage and bone density both saw improvement in the PRF Schropp and colleagues.
treatment groups. Although there may not be significant difference The process of wound healing after extraction involves four
in bone loss after tooth extraction, L-PRF can provide overall ARP main stages: hemostasis and coagulation, inflammation, prolifera-
benefits for many patients. tion, and modeling and remodeling. Hemostasis and coagulation
The bone is grafted in the extraction socket (Fig. 38.3J). A 5-mm occur in the first 24 hours after extraction when a blood clot fills
subperiosteal pocket is made on the buccal and lingual to allow the the socket. The clot consists of red and white blood cells and
membrane to be tucked underneath the flaps. Studies have demon- platelets in a matrix of fibrin. The clot has two functions, to pro-
strated a statistically significant difference in favor of use of mem- tect the denuded tissues and to serve as a provisional matrix for
brane (Lekovic and colleagues). In the current case, a nonresorbable, cell migration. Next, after 2 to 3 days, inflammatory cells (neutro-
high-density polytetrafluoroethylene (d-PTFE) membrane is chosen phils and monocytes) migrate to the site and cleanse the wound
and used to cover the graft. d-PTFE membrane does not need pri- of bacteria and necrotic tissue through phagocytosis. As healing
mary closer over it; this minimizes displacement of the keratinized progresses, macrophages migrate into the area and continue de-
tissue, which is beneficial for keeping better-attached gingiva around bridement but also release growth factors. These growth factors
the future implant. d-PTFE has extensive cardiovascular applica- promote the proliferation of fibroblasts (produce collagen) and
tions in heart valves and vascular grafts. It does not induce secondary endothelial cells (produce blood vessels), and granulation tissue
inflammation. The flaps are sutured closed (Fig. 38.3K). forms (cellular and vascular rich tissue). After 14 to 21 days, the
After recovery, the patient was discharged to her husband. She proliferative phase occurs marked by rapid deposition of a provi-
was provided detailed instructions and prescribed amoxicillin sional collagen matrix and subsequent woven bone. Woven bone
(500 mg) three times per day for 3 days. The d-PTFE membrane is a type of provisional bone that is not capable of load bearing
will be removed in 3 weeks, and the site should be ready for place- and needs to be replaced with a more mature bone type. The
ment of the dental implant in 4 months. proliferative phase is also marked by development of the primary
osteon when bone completely surrounds individual blood vessels.
Complications Last, at around 30 days after the tooth extraction, the modeling
and remodeling phase occurs. This involves replacing woven bone
The main complication of ARP is infection (which also causes loss with lamellar or bone marrow and takes several months. The final
of graft). Fortunately, infections are rare (appearing in ,5% of phase of healing is quite variable among individuals and the de-
cases); however, when they occur, removal of the graft material gree of modeling (changing shape and height of bone) versus re-
typically is required. Optimizing the patient’s oral hygiene and modeling (bone changes without alterations in shape or architec-
appropriate use of perioperative antibiotics may help decrease the ture of bone) varies as well.
incidence of infection. Most often, teeth removed during the ex- A systematic review conducted by Moslemi et al. (2018) found
traction are very compromised and endodontically treated. There- that addition of a growth factor called recombinant human bone
fore, it is common for the roots to break into small segments. morphogenetic protein 2 (rhBMP-2) to an absorbable collagen
Remnants of roots accidentally left in place can lead to delayed sponge (ACS) is more effective in preserving the alveolar ridge
infection or can compromise the future implant. compared with ACS alone, especially in cases with more than
Periotomes can be driven into adjacent vital structure, such as 50% buccal bone dehiscence. These results are likely because of
the inferior alveolar nerve or sinus cavity, or can damage the adja- rhBMP-2’s ability to stimulate angiogenesis (blood vessel forma-
cent teeth. It is essential that the periotomes be navigated with the tion) and stem cell proliferation, migration, and differentiation.
utmost care and control. Copious irrigation is mandatory during However, the cost-to-benefit analysis of ridge preservation with
the odontotomy to minimize heat generation. Excessive heat can rhBMP-2 must be carefully considered because the research re-
damage the buccal plate and lead to unfavorable bone resorption. sults do not necessarily translate to improved clinical outcomes.

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 CHAPTER 38 Alveolar Ridge Preservation Following Extraction for Implant Placement 189

In addition, Tonetti et al. conducted a study to compare spon- The potential benefits of the different materials and techniques
taneous bone healing to ARP with bone grafting alone after extrac- used for ARP are still debatable, and very few well-designed stud-
tions. They found that 1.5 to 2.4 mm of horizontal, 1 to 2.5 mm ies address these issues. No scientific guidelines have been estab-
vertical buccal, and 0.8 to 1.5 mm of vertical lingual ridge resorp- lished with regard to biomaterials or surgical techniques to date.
tion can be avoided using ARP via bone grafting. A systematic Several studies have compared different methods of grafting for
review by Vignoletti and colleagues reports that the changes in the ARP, including autologous, allograft, xenograft, and alloplastic
horizontal dimension have benefited the most by the ARP tech- materials, generally showing similar results. In particular, xeno-
niques evaluated. They found the bone loss in the horizontal di- grafts and allografts were associated with superior ridge preserva-
mension to be the most important consequence during the first 3 tion. It is the authors’ opinion that the technique used at the time
to 6 months of healing after tooth extraction; this loss ranged from of extraction to keep the buccal bone intact is the most important
20.16 to 24.50 mm. The results of their meta-regression analysis step taken, when possible. Araujo and Lindhe also report that
of nine studies concluded that some degree of bone modeling and resorption of the buccal bone plate is a main cause of the bone
remodeling occurs after tooth extraction; however, different ridge loss. The buccal plate generally experiences greater bone modeling
preservation procedures resulted in significantly less vertical and and resorption than the lingual because the buccal crest is made
horizontal alveolar bone contraction. This review could not make of bundle bone, and the lingual is made of both bundle (alveolar)
a recommendation for the type of biomaterial or surgical proce- and cortical (stronger, compact) bone.
dure used, but the use of barrier membranes and flap (rather than
flapless) surgical procedures demonstrated better results. In con- Autograft
clusion, these researchers found a difference (D) of 21.47 mm in
height and 21.83 mm in width, with more significant bone loss Autograft refers to viable cortical or cancellous bone grafting
seen in the control group without bone grafting. A study by De when the source of the graft is the patient. This is the gold stan-
Angelis et al. (2022) used digital three-dimensional models to dard, and it has osteoconductive, osteoinductive, and osteogene-
compare the quantity of bone filling extraction sockets in ARP sic benefits. Autogenous grafts include cortical, cancellous, and
with a bovine graft compared with standard healing. They found a corticocancellous bone with cancellous bone providing rapid re-
significant different (P 5 .004) in bone loss between the standard vascularization and integration in the socket. However, a second
(106.41 6 24 mm3) and ARP groups (62.66 6 17.5 mm3), sup- surgical site usually is required to obtain the bone from sites such
porting the use of bone grafting for ARP. as the symphysis, external oblique ridge, maxillary tuberosity,
The approach used to remove the tooth and preserve the site edentulous ridges, and exostoses, and this can lead to increases in
substantially affects the quality of the bone and soft tissue at the morbidity and recovery time for the patient. At times, it is possi-
time of implant placement. The rationale behind extraction site ble to simply harvest bone from adjacent bony tissue without a
preservation with bone grafting is to provide a stable environment significant increase in morbidity.
for osteoconduction to take its natural course. Allograft used in
this case is just a scaffold, which still requires the natural turnover Allograft
of bone as the adjacent osteocytes migrate from the native tissue
to lay new vital bone within the graft and ultimately replace it. Allograft refers to bone graft from cadavers in the same species.
This cannot effectively take place without having healthy and vital These are available from licensed tissue banks. The cadavers are
neighboring bone. The ultimate goal is preservation of the soft screened for malignancy, hepatitis B and C viruses, HIV, and
tissue volume and architecture at the site by having a stable bony lifestyle factors that may place the donor at a higher risk category
foundation to support it. for transmittable diseases. The bone is obtained in an aseptic set-
There is no one graft material that can be recommended over ting in the operating room. Patients should be advised of the re-
others for every case. An understanding of the physical and bio- mote possibility of disease transmission despite the lack of any
logic properties of the graft material and individualization of documented cases. The patient’s religious preference also needs to
treatment planning are necessary in choosing the most appropri- be considered. The graft material is available in the demineralized
ate material in each case. freeze-dried bone allograft form, mineralized freeze-dried form, or
a mixture of the two forms. It can also be selected in cortical or
Graft Material Classification cancellous forms. These differ in the time it takes for the grafted
bone to remodel and be replaced by the patient’s own vital bone.
Bone grafting is a technique designed to aid alveolar ridge (The process of turnover starts with osteoblasts surrounding the
augmentation and reduce bone loss after tooth extraction by pro- graft particles with formation of osteoid (nonmineralized bone)
viding a scaffold to enhance hard and soft tissue growth. Bone around the particles with osteoclasts starting to resorb the parti-
grafting with different materials is a form of tissue engineering cle. As the process continues (over a few months), the particles are
designed to repair and improve structural deficiencies. For engi- turned over with the replacement of the graft particles with host
neering functional tissues capable of providing long-term clinical bone. In general, demineralized bone is remodeled faster, and
benefit, the tissue cells must have sufficient spatial and temporal mineralized cortical bone takes longest to turn over. Therefore,
signals to promote growth, differentiation, and synthesis of an the surgeon’s understanding of these properties is important in
extracellular matrix (ECM) capable of supporting structural, choosing the right graft for a particular case (Table 38.1).
functional, and mechanical needs. Tissue engineering approaches
are based on cells, the ECM, and signaling systems. Biomaterials Alloplast
are central to tissue engineering in ridge augmentation and differ-
ent scaffold materials have been developed as ECM analogues to Alloplast refers to synthetic biomaterials that function as scaffold-
support cell attachment and provide cues for spatial and temporal ing for osteoconduction and volume expanders. Examples of allo-
bone development (induction). plast include hydroxyapatite, calcium phosphate, calcium sulfate,

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190 S E C TI O N Dental Implant Surgery

TABLE
38.1 Allograft Properties

Mineralized (FDBA) Demineralized (DFDBA) Cortical Cancellous Cortico-cancellous

• More dimensionally • The process of demineralization exposes BMP; thus, • Denser • More porous • Different ratios
stable there is more potential for osteoinduction • Turns over more • Easier incorpo- available
• Mineralization of bone • Available BMP in commercially available allografts slowly ration and faster
easier than deminer- vary between tissue banks and batches within the • Better for space remodeling
alized because it con- same bank maintenance
tains calcium • Age of the donor also affects the amount of BMP and stability
• More radiopaque • The clinical significance of its osteoinduction has
been questioned

BMP, Bone morphogenetic protein; DFDBA, demineralized freeze-dried bone allograft; FDBA, mineralized freeze-dried bone allograft.

and bioactive glass. Hydroxyapatite resorbs slowly and can be Membrane Material Classification
beneficial for long-lasting ridge preservation. Tricalcium phosphate
provides beneficial calcium and magnesium ions, creating an envi- Several types of membranes can be used to help contain grafting
ronment similar to human bone, and because it resorbs quickly, material and act as an independent scaffold. Guarnieri et al. show
hydroxyapatite is often added to the grafting material in a 60/40 that membranes alone result in improved bone healing compared
ratio to improve scaffold longevity. Calcium sulfate provides angio- with no preservation adjuncts. However, the major benefit of
genic and hemostatic benefits in addition to osteoconductive membranes is their ability to hold the graft material in place while
properties. Bioactive glass is a bone substitute made of sodium preventing faster growing soft tissue cells from migrating into the
oxide, calcium oxide, phosphorous pentoxide, silicon dioxide, and defect. This allows the slower moving osteoprogenitor cells to
silica. A biologically active calcium phosphate layer forms on the populate the defect and allow bony regeneration. A meta-analysis
surface of the glass, playing an integral role in forming the bone– conducted by Troiano et al. (2018) of seven independent studies
graft bond. found that the combination of graft material (xenograft or al-
lograft) covered by a resorbable membrane significantly reduced
horizontal (2.19 mm) and vertical (1.72 mm) ridge resorption
Xenograft compared with spontaneous healing. Several of the primary indi-
Xenograft represents naturally derived hydroxylapatite from bovine, cations for using membranes include inhibition of epithelial
porcine, equine, and coralline sources and is generally biocompati- ingrowth, maintenance of a biological space (if rigid), graft con-
ble and structurally similar to human bone. Bovine xenografts are tainment, a thin buccal plate (,1.5–2 mm), and sites where there
the most commonly used in practice. Even though there are no has been damage to the bony wall(s). The major counter indica-
reported cases of transmittable disease from a bovine source, some tion to using membranes and grafts is acute infection.
have expressed concern about the possible risk of transmission of
bovine spongiform encephalopathy. However, this risk is thought to Resorbable
be extremely low.
Just as does an allograft, a xenograft provides scaffolding for Resorbable membranes are a commonly used type of membrane
osteoconduction. Turnover of these grafts can be very long (years). that do not require additional procedures to remove them in addi-
They are often used when dimensional stability over time is re- tion to the tooth extraction. Collagen, oxidized cellulose, lactic acid
quired (e.g., veneer grafting over minor exposed threads of im- polymers, and synthetic polymers are the most commonly used
plants at time of placement). Rodrigues and colleagues found that types of resorbable membranes. The most common synthetic poly-
xenografts placement with free gingival grafting had significantly mer materials are polyglycolide and polylactide. Whereas the natu-
reduced alveolar ridge loss width measured on CBCT compared ral membranes such as collagen resorb through enzymatic degrada-
with natural socket healing and platelet rich fibrin grafting. tion, the synthetic materials resorb via hydrolysis of peptide bonds
Bovine xenografts are dried either at room temperature, into pyruvic and lactic acid. Type 1 collagen membranes are the
300°C, or 600° to 800°C. The higher temperatures offer the most commonly used resorbable membranes. The benefits they
benefit of increased crystallinity and reduced surface microporos- provide include improved hemostasis, minimal immune reaction,
ity, aiding in reduced resorption over time. However, osteocon- chemotaxis of periodontal ligament and fibroblast cells, ease of
ductivity can be reduced. A study by Block (2020) found that manipulation, physiologic degradation, and minimal morbidity if
high-temperate preprocessed xenografts result in long-term hori- exposed. Noncrosslinked collagen (e.g., colla tape or plugs) resorbs
zontal stability in both arches and sufficient bone for implant in 7 to 10 days. Cross-linked membranes (membranes can be cross-
placement. After 7 years of follow-up, maxillary and mandibular linked by various methods such as physical [ultraviolet light, dehy-
augmentations decreased by about 1 mm with the majority of the drothermal, chemical [glutaraldehyde, carbodiimide-succinimide
shrinkage occurring in the first 6 months. Implants placed within (EDC-NHS)] or enzymatic [transglutaminase ribose crosslinking]
6 to 9 months after augmentation had a success rate of 95%. processes) extend the resorption time. The method of crosslinking
These results support the use of heat-pretreated bovine xenograft can increase the time of resorption. A densely structured ribose
for augmentation width maintenance and subsequent implant (enzymatic processed) crosslinked membrane can have a resorption
placement. time of 6 to 8 months. Type 1 bovine collagen is currently the most

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 CHAPTER 38 Alveolar Ridge Preservation Following Extraction for Implant Placement 191

commonly used membrane that is crosslinked; it has a resorption similar benefits yet is not as prone to bacterial infection because
time of 3 months. Crosslinking inhibits sliding between collagen of its smaller pore size. Titanium mesh membranes provide supe-
molecules under pressure by introducing intra- and intermolecular rior rigidity and space maintenance while minimizing membrane
covalent or noncovalent bonds, which increase the stiffness, tensile collapse and graft displacement. There is also a low risk of infec-
strength, and compressive modulus and reduce the extensibility of tion with titanium membranes.
collagen fibers. Intermolecular crosslinking also improves the resis- Dental extraction is one of the oldest surgical procedures in den-
tance of collagen against enzymatic degradation by masking the tistry. Alveolar ridge preservation is a recently developed, evidence-
cleavage site of collagen. based, additional technique that supports maintaining bony structure
for future restorative treatments such as implant placement. Ridge
Nonresorbable preservation is aimed at maintaining the bony walls when possible.
However, many factors play a role in healing after dental extraction
The nonresorbable membranes are also used to provide strong that can influence alveolar ridge shape such as medical history, surgi-
graft stability, space maintenance, and adaptation to bony defects. cal technique, and infection. Grafting cannot always overcome these
The most common nonresorbable membranes include expanded- challenges in maintaining strong alveolar ridge integrity. In certain
polytetrafluoroethylene (e-PTFE), dense polytetrafluoroethylene cases, such as infection, it can be beneficial to extract teeth without
(d-PTFE), titanium mesh, and titanium-reinforced PTFE. E-PTFEs immediate graft placement and monitor bone levels for future
are beneficial because their small pores improve tissue attachment, implant placement. The benefits of grafting must be weighed against
stabilize the wound, and restrict migration of connective tissue. the costs for each individual patient and tooth site.
However, e-PTFE membranes are prone to oral cavity exposure
and bacterial infection, and they have been discontinued. Recently, ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
d-PTFE has become more widely accepted because it provides complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 191.e1

Bibliography Jung RE, Ioannidis A, Hämmerle CH, et al: Alveolar ridge preservation
in the esthetic zone, Periodontology 2000 77(1):165-175, 2018.
Lee J, Lee JB, Koo KT, et al: Flap management in alveolar ridge preserva-
Araujo M, Linder E, Wennstrom J, et al: The influence of Bio-Oss col- tion: a systematic review and meta-analysis, Int J Oral Maxillofac
lagen on healing of an extraction socket: an experimental study in the Implants 33(3):613-621, 2018.
dog, Int J Periodontics Restorative Dent 28:123-135, 2008. Lekovic V, Camargo PM, Klokkevold PR, et al: Preservation of alveolar
Araujo MG, Lindhe J: Dimensional ridge alterations following tooth bone in extraction sockets using bioabsorbable membranes,
extraction: an experimental study in the dog, J Clin Periodontol J Periodontol 69:1044-1049, 1998.
32:212-218, 2005. Lekovic V, Kenney EB, Weinlaender M, et al: A bone regenerative
Araujo MG, Lindhe J: Ridge alterations following tooth extraction with approach to alveolar ridge maintenance following tooth extraction:
and without flap elevation: an experimental study in the dog, Clin report of 10 cases, J Periodontol 68:563-570, 1997.
Oral Implants Res 20:545-549, 2009. Moslemi N, Khoshkam V, Rafiei SC, et al: Outcomes of alveolar ridge
Araujo MG, Lindhe J: Socket grafting with the use of autologous bone: an preservation with recombinant human bone morphogenetic protein-2:
experimental study in the dog, Clin Oral Implants Res 22:9-13, 2011. a systematic review, Implant Dent 27(3):351-362, 2018.
Araújo MG, Silva CO, Misawa M, et al: Alveolar socket healing: what Ren Y, Fan L, Alkildani S, et al: Barrier membranes for guided bone re-
can we learn? Periodontology 2000 68(1):122-134, 2015. generation (GBR): a focus on recent advances in collagen membranes,
Aravena PC, Sandoval SP, Pizarro FE, et al: Leukocyte and platelet-rich Int J Mol Sci 23(23):14987, 2022. doi:10.3390/ijms232314987.
fibrin have same effect as blood clot in the 3-dimensional alveolar Rodrigues MTV, Guillen GA, Macêdo FGC, et al: Comparative effects
ridge preservation. A split-mouth randomized clinical trial, J Oral of different materials on alveolar preservation, J Oral Maxillofac Surg
Maxillofac Surg 79(3):575-584, 2021. 81(2):213-223, 2023.
Bartee B: Implant Site Development and Extraction Site Grafting, Lubbock, Scheller EL, Krebsbach PH, Kohn DH: Tissue engineering: state of the
TX, Osteogenics Clinical Education, Osteogenics Biomedical, Inc. art in oral rehabilitation, J Oral Rehabil 36(5):368-389, 2009.
2011. Schropp L, Wenzel A, Kostopoulos L, et al: Bone healing and soft tissue
Bartee BK, Carr JA: Evaluation of a high-density polytetrafluoroethylene contour changes following single-tooth extraction: a clinical and ra-
(nPTFE) membrane as a barrier material to facilitate guided bone diographic 12-month prospective study, Int J Periodontics Restorative
regeneration in the rat mandible, J Oral Implantol 21:88-95, 1995. Dent 23:313-323, 2003.
Bartee BK: The use of high density polytetrafluoroethylene to treat osse- Sclar A: Soft Tissue and Esthetic Considerations in Implant Therapy,
ous defects: clinical reports, Implant Dent 4:21-26, 1995. Hanover Park, Ill, 2003, Quintessence.
Block MS: Does the use of high-temperature–processed xenografts for Siu TL, Dukka H, Saleh MH, et al: Flap versus flapless alveolar ridge
ridge augmentation result in ridge width stability over time? J Oral preservation: a clinical and histological single-blinded, randomized
Maxillofac Surg 78(10):1717-1725, 2020. controlled trial, J Periodontol 94(2):184-192, 2023.
Clark D, Rajendran Y, Paydar S, et al: Advanced platelet-rich fibrin and Soldatos NK, Stylianou P, Koidou VP, et al: Limitations and options us-
freeze-dried bone allograft for ridge preservation: a randomized con- ing resorbable versus nonresorbable membranes for successful guided
trolled clinical trial, J Periodontol 89(4):379-387, 2018. bone regeneration, Quintessence Int 48(2):131-147, 2017.
Cortellini S, Castro AB, Temmerman A, et al: Leucocyte-and platelet- Temmerman A, Vandessel J, Castro A, et al: The use of leucocyte and
rich fibrin block for bone augmentation procedure: a proof-of- platelet-rich fibrin in socket management and ridge preservation: a
concept study, J Clin Periodontol 45(5):624-634, 2018. split-mouth, randomized, controlled clinical trial, J Clin Periodontol
De Angelis P, et al: Hard and soft tissue evaluation of alveolar ridge pres- 43(11):990-999, 2016.
ervation compared to spontaneous healing: a retrospective clinical and Tonetti MS, Jung RE, Avila-Ortiz G, et al: Management of the extraction
volumetric analysis, Int J Implant Dent 2022:62. APA, 8.1. socket and timing of implant placement: consensus report and clinical
Del Fabbro M, Bucchi C, Lolato A, et al: Healing of postextraction sockets recommendations of group 3 of the XV European Workshop in Peri-
preserved with autologous platelet concentrates. A systematic review odontology, J Clin Periodontol 46:183-194, 2019.
and meta-analysis, J Oral Maxillofac Surg 75(8):1601-1615, 2017. Troiano G, Zhurakivska K, Lo Muzio L, et al: Combination of bone graft
Greenstein G, Greenstein B, Cavallaro J, et al: The role of bone decortica- and resorbable membrane for alveolar ridge preservation: a systematic
tion in enhancing the results of guided bone regeneration: a literature review, meta-analysis, and trial sequential analysis, J Periodontol
review, J Periodontol 80(2):175-189, 2009. 89(1):46-57, 2018.
Guarnieri R, Testarelli L, Stefanelli L, et al: Bone healing in extraction Vignoletti F, Matesanz P, Rodrigo D, et al: Surgical protocols for ridge
sockets covered with collagen membrane alone or associated with preservation after tooth extraction. A systematic review, Clin Oral
porcine-derived bone graft: a comparative histological and histomor- Implants Res 23:22-38, 2012.
phometric analysis, J Oral Maxillofac Res 8(4):e4, 2017. Zhang Y, Ruan Z, Shen M, et al: Clinical effect of platelet-rich fibrin on
Jamjoom A, Cohen RE: Grafts for ridge preservation, J Funct Biomater the preservation of the alveolar ridge following tooth extraction, Exp
6(3):833-848, 2015. Ther Med 15(3):2277-2286, 2018.

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39
Implants in the Esthetic Zone
E DWAR D R. S C H L I S S E L

CASE 1

CC
A 42-year-old female presents to the dental office complaining of
a fractured maxillary incisor. She states that she suffered the injury
in an automobile accident 2 days earlier and that she is not in
pain.
Fracture of an anterior tooth in an otherwise intact dentition
is a traumatic event for any person. In addition to acute pain and
the possibility of infection, there are always concerns about cos- A
metic replacement and problems in the future. Immediate re-
placement with a provisional restoration and the fabrication of a
final restoration that has an excellent long-term prognosis should
be the goals of the dentist.

HPI
The maxillary left central incisor was fractured during an automo-
bile accident. The patient was a passenger in the vehicle. She was
drinking from a travel mug when the impact with the inflated
airbag occurred. The tooth had endodontic treatment 3 years be-
fore the accident and was restored with a ceramic crown. A fiber-
reinforced resin endodontic post had been placed.

PMHX/PDHX/Medications/Allergies/SH/FH
The patient has an unremarkable medical history. She has no
known allergies and takes no medications that would have an
impact on her dental treatment. She has had regular dental care
and has several restorations in the area of the injury, including full
crowns and porcelain veneers.
It is imperative to obtain a complete medical history when
evaluating alternative treatment options for the replacement of a B
tooth. Systemic medications, including bisphosphonates and an-
tineoplastic agents, and medical conditions such as uncontrolled • Fig. 39.1 A, Intraoral, retracted view of the fractured incisor. B, Fractured
incisor, out of the mouth.
diabetes are known to have deleterious effects on wound healing
and bone metabolism, and may be contraindications to implant
placement. was upset about her injury and the prospects for replacement of the
fractured tooth. There was no radiographic evidence of injury to ad-
Examination jacent teeth or bone. Intraoral and extraoral examination revealed no
other injuries in either arch. There was no injury to the lips or other
The left maxillary central incisor was fractured slightly above the level soft tissue. The anterior teeth were normal in appearance and showed
of the alveolar crest of bone and was out of the mouth (Fig. 39.1). The neither discomfort on percussion nor abnormal mobility. Periodontal
patient had no pain and had not taken any analgesic medications. She pocket depths were 3 mm or less, and there was no bleeding on

192
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 CHAPTER 39 Implants in the Esthetic Zone 193

probing. Oral health care was excellent. When making a full smile, Treatment
the patient displayed the cervical lines of the maxillary incisors.
When a patient sustains trauma to an anterior tooth, there is Irreversible hydrocolloid (alginate) impressions were made of the
often injury to adjacent tissues or in the opposite arch. A com- upper and lower arches, and a shade was selected for a provisional
plete examination is necessary to determine whether there is dam- prosthetic replacement. The patient was referred to an oral and
age to the teeth, bone, or soft tissue. Follow-up evaluations should maxillofacial surgeon for removal of the remainder of the frac-
be conducted to detect undisclosed damage to other teeth or tured tooth and evaluation of the buccal plate of the alveolar
bone. Fractures that are not displaced may not be evident on bone, with a request that an endosseous dental implant be placed
clinical or radiographic examination. The patient should be ad- at the time of extraction. The surgical appointment was the next
vised that additional problems might become evident in the fu- day. At that visit, the surgeon used minimally invasive techniques
ture and that more treatment may be needed. to remove the root fragment. It was determined that the alveolar
bone was intact and that there was sufficient bone volume for im-
Imaging mediate placement of the implant. A tapered titanium implant
(4 mm in diameter, 13 mm long) was placed in the osteotomy
Panoramic and periapical (intraoral) radiographs (Fig. 39.2) were site. Insertion torque was 50 N-cm, and no bone graft was neces-
made and evaluated. There was no evidence of injury to the adja- sary. A healing abutment was selected and placed. It had an emer-
cent teeth or bone. gence profile of 5 mm and was 2 mm high. The superior surface
Consideration should be given to the use of cone-beam com- of the healing abutment was just below the level of the crest of
puted tomography (CBCT) to assess for damage to bony structures the ridge. Before placement of the healing abutment, an index
in the area of an injury. If there is evidence of soft tissue damage, of the implant position was made with poly-vinyl siloxane mate-
the field of interest should be adequate to include all areas of con- rial and an open-tray impression transfer assembly. A periapical
cern. If this patient had sustained injury to the maxillary incisor as radiograph was made to verify the seating of the healing abutment
a result of impact to the mandible, it would have been appropriate (Fig. 39.3). The provisional restoration made for the patient was
to use additional imaging to evaluate the mandible, including the an Essix-type retainer. There was no load on the implant at the
body, ramus, and condyle on both sides of the mouth. time of surgery. The surgical index was placed on a modified study
model, and a screw-retained provisional restoration was made but
Labs was not placed on the implant at the time of surgery (Fig. 39.4).
The patient was monitored for 4 months after surgery. No ad-
No laboratory tests were indicated in the treatment of the current ditional injuries were detected, and the implant was deemed ready
patient. If the patient had been on injectable or long-term oral for restoration. A small amount of gingival tissue was removed
bisphosphonate therapy, a serum C-terminal telopeptide test may with a tissue punch, and the healing abutment was removed
have been appropriate. If the patient had diabetes, the appropriate (Fig. 39.5A). The provisional restoration, which had been made
test to measure blood glucose levels would be in order. during the healing phase, was tried in and adjusted. The contours
of the provisional were modified until the emergence profile gave
the correct tissue support and the interproximal contact areas had

• Fig. 39.2 Periapical radiograph of fractured incisor. • Fig. 39.3 Radiograph of implant and healing abutment at time of placement.

t.me/Dr_Mouayyad_AlbtousH
194 S E C TI O N Dental Implant Surgery

The patient returned periodically over the next 3 months. It

was noted that the papilla on the mesial aspect filled the space
below the contact area. A custom impression coping was fabri-
cated (Fig. 39.6A and B) and an impression made of the maxillary
arch. The color was selected for the final restoration. Using
CAD-CAM (-Computer-Aided Design–Computer -Aided Man-
ufacturing) technology, the laboratory made a custom screw-
retained zirconia abutment (Fig. 39.6C). The margins of the crown
preparation were located 0.5 mm below the free gingival margin.
A prosthetic crown was made of lithium silicate in the color
specified. The abutment and crown were tried in the mouth; seat-
ing and adaptation were verified with a radiograph (Fig. 39.6D).
Occlusal and interproximal contacts were evaluated and adjusted.
A Impressions were made for a bruxism splint, which was delivered
the next day. Follow-up examinations were conducted, and pho-
tographs were taken 4 months after placement of the crown and
abutment (Fig. 39.7). The patient was satisfied with the outcome.
Consideration of another case will demonstrate management
of adjacent implant restorations in the esthetic zone (eFigs. 39.8
to 39.11).

CASE 2

CC
B
This patient, a 22-year-old female, presents to the dental office for
• Fig. 39.4 Facial view (A) and incisal view (B) of the provisional restoration replacement of her maxillary central incisors. She was very con-
on the model.
cerned about her appearance both in the short and long terms.

HPI
The patient states that the teeth were lost in a motor vehicle ac-
cident 1 month before this visit and that she had been seen in the
emergency department of a community hospital for urgent care.
She had no provisional restoration for function or cosmesis. She
is in excellent health and has no medical conditions that would
compromise healing or implant osseointegration.

Examination
A
The right and left central incisors were missing. The patient expe-
rienced pain in the maxillary left lateral incisor upon application
of cold and when percussed. There was no radiographic evidence
of root or crown fracture. The maxillary right lateral incisor was
asymptomatic. The maxillary frenum was attached near the crest
of the alveolar ridge, and the contour and buccopalatal width of
the alveolar ridge was inadequate for implant placement.

Treatment
The oral and maxillofacial surgeon performed two procedures.
B The first was to develop the implant sites. The muscle attachment
was repositioned in an apical direction, and the alveolar ridge was
• Fig. 39.5 A, Implant platform exposed. B, Provisional restoration at augmented. Care was taken to maintain a wide band of attached
placement. gingiva. Two weeks after surgery, the patient received a removable
provisional restoration. It was an Essix-type retainer, supported on
correct pressure and were located less than 5 mm from the levels of the maxillary teeth, with pontics simulating the missing central
bone on the adjacent teeth (Fig. 39.5B). The height of the papilla incisors. It placed no pressure on the alveolar ridge. Endodontic
on the mesial side of the provisional restoration was noted to be therapy was performed on the maxillary left lateral incisor.
inadequate at the time of placement. The access cavity of the pro- At the second surgery, two tapered titanium implants, 4.1 mm
visional restoration was closed, and a bruxism splint was delivered. in diameter, were placed in the locations of the maxillary central

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194.e1 SE C TI O N Dental Implant Surgery

• eFig. 39.10 Intraoral, retracted view of definitive implant abutments and

prepared natural teeth before placement of restorative crowns.

• eFig. 39.8 Intraoral view of alveolar ridge.

• eFig. 39.11 Intraoral, retracted view of definitive restorations.

• eFig. 39.9 Incisal view of gingival contours achieved by screw-retained

provisional restorations.

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 CHAPTER 39 Implants in the Esthetic Zone 195

C D
• Fig. 39.6 A, Custom impression coping. B, Custom impression coping in place. C, Zirconia abutment
in place. D, Periapical radiograph of seated abutment and crown.

incisors. The patient was able to continue wearing the provisional excess cement in all the sulci. Occlusal and interproximal contact
restoration during the next phase of healing. locations and strengths were evaluated and adjusted as necessary.
After 5 months of healing, the patient returned for additional
restorative procedures. The treatment of the implant restorations Discussion
was the same as described in the preceding case.
The definitive restorations were individual full crowns. Screw- The gold hue of the implant abutments, achieved using a coating
retained, custom-made titanium abutments, which were coated with of titanium nitride, contributed to the esthetic outcome. With an
titanium nitride, were attached to the implants with the appropriate adequate thickness of the ceramic crown material, no shadow or
torque force. The maxillary lateral incisors were prepared and discoloration was observable. The luting resin material had the
restored with full crown restorations. All crown restorations were same shade as the crown restorations. It is important that the
medium translucency lithium disilicate with labial veneers of low- abutment be designed to give the same thickness of porcelain as
temperature fused porcelain. They were luted to the supporting struc- the restorations on the adjacent natural teeth. This allows the in-
tures with dual-cured resin adhesive cement. Care was taken to avoid ternal reflection of light in all four restorations to be similar. If this

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196 S E C TI O N Dental Implant Surgery

is not done, it is possible that there will be an esthetic discrepancy,

which may not be apparent until after cementation.
The papilla between the adjacent implant restorations appears
slightly shorter than the papillae between implant and adjacent
teeth. This is consistent with reports in the literature and is not
clinically noticeable if, as in this case, it is in the midline. This can
be a challenge in the restoration of adjacent implants that are not
in the midline. Patients should be advised of this possibility if it
may apply to their clinical conditions.

A Complications
Many complications can be associated with implants in the es-
thetic zone. They include implant location and angulation, soft
tissue defects, and the consequences of not removing excess ce-
ment. Improper placement of the implant or poorly designed
abutments or crowns may lead to results that are not esthetically
acceptable. Proper surgical and restorative techniques and good
communication between the surgeon and restorative dentist are
essential to a good outcome.

Discussion
Several alternatives were possible for the treatment of this patient’s
B problem. These included options for the type of restoration and the
timing of the steps in the implant reconstruction. Instead of an im-
plant-supported individual crown, the missing tooth could have been
replaced with a fixed partial denture (FPD) or an individual restora-
tion after crown-lengthening surgery. However, crown-lengthening
surgery would have resulted in an unfavorable crown-to-tooth ratio,
unacceptable esthetics, and a poor prognosis. Considering the age of
the patient and the predicted lifetime of an FPD, it was thought that
an implant restoration offered the better choice. If the alveolar plate
had been fractured or deficient, implant placement would have been
delayed. If there had been a gap between the implant and the sur-
rounding bone, graft material would have been placed. Because cir-
cumstances were favorable, the implant was placed immediately after
extraction of the root. This procedure is associated with retention of
the buccal plate of bone, which leads to good esthetic results.
The patient had a class I occlusion, with approximately 50%
overbite and no overjet. This precluded placement of a provisional
restoration at the time of surgery because it would have been impos-
sible to avoid contacts in centric occlusion or protrusive movement,
which are mandatory conditions for immediate provisionalization of
individual teeth. The provisional restoration is essential for develop-
ing tissue contours. It is more efficient to make the provisional res-
C
toration during the healing period than at a patient appointment.
Using a custom impression post allows capture of the properly
developed soft tissue profile, which is essential for the fabrication
of the custom abutment. The zirconia abutment does not darken
the appearance of the gingiva below the crown margins. The mar-
gins of the crown were located just below the free gingival margin
to facilitate removal of cement. The interproximal contacts were
located in accordance with well-established guidelines, and the
tissue responded as expected. The restorative material was selected
for its translucency and strength.
For clinicians, following well-established clinical procedures
leads to predictable results. Also, a thorough understanding of the
biologic and technical aspects of implant dentistry can lead to
D patient satisfaction and long-term success.
• Fig. 39.7 Final restoration. A, View of the high smile. B, Incisal view. ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
C, Lateral view. D, Retracted view.
complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 196.e1

Bibliography Saadoun AAP, LeGall M, Touati B: Selection and ideal tridimensional

implant position for soft tissue aesthetics, Pract Periodontics Aesth Dent
11(9):103-172, 1999.
Al-Sabbagh M: Implants in the esthetic zone, Dent Clin North Am 50(3): Tarnow D, Elian N, Fletcher P, et al: Vertical distance from the crest of
391-407, 2006. bone to the height of the interproximal papilla between adjacent im-
Elian N, Jalbout Z, Cho S, et al: Realities and limitations in the manage- plants, J Periodontol 74(12):1785-1788, 2003.
ment of the interdental papilla between implants: three case reports, Tarnow DP, Magner AW, Fletcher P: The effect of the distance from the
Pract Proced Aesthet Dent 15(10):737-744, 2003. contact point to the crest of bone on the presence or absence of the
Potashnick SR: Soft tissue modeling for the esthetic single-tooth implant interproximal dental papilla, J Periodontol 63:995-996, 1992.
restoration, J Esthet Dent 10(3):121-131, 1998.

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40
Pleomorphic Adenoma
DE EPAK K A D E M A N I , J AM E S C. M E LV ILL E , SIM O N YO U NG , C H I T. VI E T,
M ICH AE L R . M A R K I E W I C Z , A S H IS H PAT EL , A UD R A AL E X AN DR A B O EH M ,
and J O - L AW RE N C E M A R T I NE Z BIG C A S

Introduction sialadenitis with painful swelling with eating. Local invasion of the
mandibular, zygomatic, or maxillary periosteum or cortex can im-
A 45-year-old female who works as a hair stylist presents with a mobilize the tumor to the bone. Minor salivary gland tumors may
right-sided subcutaneous mass of the lower third of the face. The present as an ulcerative or locally invasive mass in the lip, oral cav-
mass is anterior and inferior to the tragus, overlying the angle of ity, palate, nasal cavity, or paranasal sinuses.
the mandible. Metastatic cervical lymphadenopathy is a hallmark of malig-
nancy. Pleomorphic adenoma, being a benign process, does not
HPI present with associated cervical nodal metastases. Pain, local inva-
sion, and facial nerve paralysis are not typical of a pleomorphic
The mass has been present for more than 20 years with slow pro- adenoma and should shift suspicion toward malignancy. Pleomor-
gressive enlargement over the past 15 years. The mass is firm but phic adenomas are usually painless, mobile, and the chief com-
mobile. There is a contour abnormality because the mass measures plaints tend to be more cosmetic or seeking reassurance of a benign
about 4 cm 3 4 cm underneath the skin. Because of her job as a process.
hair stylist, she often wears her hair down to avoid drawing atten-
tion to the mass. She has no complaints of pain, numbness, tris- PMHX/PDHX/Medications/Allergies/SH/FH
mus, facial paralysis, or cycles of parotid swelling. She denies any
constitutional symptoms, such as weight loss, fevers, chills, or The patient has no significant medical history. She takes no
night sweats. She denies the presence of any other masses in the medications. She smokes occasionally. She consumes alcohol in
head and neck. social settings only. She has no history of head and neck cancer,
Pleomorphic adenomas, or benign mixed tumors, of the head head and neck radiation, or other head and neck pathology.
and neck generally arise from the salivary and lacrimal glands. The There are no known risk factors for the development of pleo-
major salivary glands include the parotid gland, submandibular morphic adenomas. Evidence of tobacco use and alcohol abuse
gland, and sublingual glands. Minor salivary glands can be found being linked to pleomorphic adenomas is not strong. Pleomor-
throughout the mucosa of the head and neck. The overwhelming phic adenoma is not associated with any familial or genetic syn-
majority of pleomorphic adenomas are found in the parotid dromes. A prior history of head and neck tumors, particularly
gland. Submandibular gland pleomorphic adenomas are uncom- pleomorphic adenomas themselves, are of utmost interest in the
mon, and those in the sublingual gland are extremely rare. Minor past medical history. Pleomorphic adenoma is unique in that it is
salivary gland pleomorphic adenomas are also very uncommon the only benign salivary gland tumor with the potential to convert
and account for such tumors in unusual locations, such as the lip, into a malignant process, known as carcinoma ex-pleomorphic
palate, nasal cavity, and the paranasal sinuses. adenoma (CXPA). Thus, a drawn-out course of disease in con-
The clinical history of pleomorphic adenoma is usually benign. junction with more severe examination and diagnostic workup
It tends to present as a solitary mass. It may have been present for findings may clue a seasoned diagnostician into suspicion for
long periods of time with very slow growth. They may be stable transformation of a benign tumor into CXPA.
in size for years, which may reassure some patients that the tumor Conversely, in patients with a surgical history of a previous
is benign. This may result in a delay in care or diagnosis. pleomorphic adenoma, a new mass (or masses) in the operative
Conversely, salivary gland malignancy presents with signs and field may suggest a spillage of pleomorphic adenoma cells into
symptoms of invasion and metastasis. Parotid malignancy may adjacent healthy tissues, a devastating complication that will be
present with a firm, fixed mass; pain; trismus; and sometimes facial discussed later. If the capsule of the pleomorphic adenoma is rup-
nerve paralysis, which is suggestive of locoregional invasion. Ma- tured during surgery, daughter cells spilled into the operative field
lignancies in the sublingual and submandibular glands may pres- can give rise to multifocal disease. Treatment of this phenomenon
ent as a firm mass. They may have signs of cranial neuropathy is complicated because these tumors are best treated with surgery.
caused by local invasion of the distal lingual and hypoglossal Radiation and chemotherapeutic agents play little role in the
nerves, such as tongue numbness, tongue fasciculations, or tongue management of pleomorphic adenomas. Returning to a scarred
paralysis. Salivary ductal invasion may present like a sialolith and operative field increases the risk of complications, including facial

198
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 40 Pleomorphic Adenoma 199

nerve paralysis, secondary tumor spillage, and possibly missing

microscopic disease, necessitating future visits to the operating
room. To complicate matters further, each new focus of pleomor-
phic adenoma that resulted from spillage also carries a risk of de-
generating into CXPA.

Exam
General. The patient is in no distress. She is well developed and
well nourished.
Vital Signs. The patient is afebrile. Blood pressure is 118/78,
heart rate is 74 bpm, and respirations are 16 breaths per minute.
Face. There is a noticeable right-sided facial mass posterior to
the mandible. It measures about 4 cm 3 4 cm and mobile. It is soft
but firm. There is no fixation to the surrounding tissues. Sensation
is grossly intact. She has a House-Brackmann score of 1 of 6. The
mass is nontender. There is no associated erythema or warmth.
Neck. There is no palpable lymphadenopathy on either side of
the neck.
Intraoral. There is no trismus. The patient has healthy denti-
tion. The parotid duct and the submandibular duct are patent
without any signs of inflammation or induration. Tongue move-
ment and sensation are unremarkable. There are no floor or
mouth, buccal, palatal, or pharyngeal lesions of concern.
Neurologic. The patient is alert and oriented. Her cranial
nerve examination is unremarkable. There is no facial nerve
weakness. Sensation is intact throughout the trigeminal nerve • Fig. 40.1 Noncontrast computed tomography (CT) scan ordered by the
distribution. patient’s primary care provider showing a right parotid tail mass with
A pleomorphic adenoma typically presents as a painless mass similar density to the parotid gland. Contrast enhancement is recom-
in the superficial lobe of the parotid or submandibular gland. The mended for CT imaging of soft tissue tumors.
examination findings are usually benign. There is no associated
pain or tenderness. The mass is generally mobile without evidence
of spread or invasion. There is no evidence of perineural invasion
resulting in cranial nerve palsy, such as a facial nerve paralysis. masses. They may be homogenous when they are small. Larger
Cranial nerve palsies, pain, trismus, tumor fixation, and cervical tumors may be more complex with a more heterogeneous compo-
adenopathy are signs of a malignant process, and they are not sition. On T1-weighted imaging, they present as a hypointense
typical of a treatment-naïve pleomorphic adenoma. Deep lobe solid mass (Fig. 40.2). On T2-weighted imaging, they may be
parotid tumors may not be present on clinical examination. If hyperintense with decreased signal intensity along the capsule of
sizeable, they may be visible or palpable on the neck examination the tumor (Fig. 40.3). Contrasted T2-weighted images of smaller
or may create a mass effect on the pharynx on transoral examina- tumors may show homogeneous enhancement. However, as the
tion. Typically, deep lobe and parapharyngeal space masses are tumors get larger, inhomogenous enhancement may be more pro-
found incidentally on imaging. nounced (Fig. 40.4).
Ultrasonography, CT, and MRI are the most common mo-
Imaging dalities used in evaluating salivary gland pathology. CT and MRI
are frequently used as complementary studies. CT scans are an
A noncontrast computed tomography (CT) scan was ordered by excellent objective modality that are accurately used by seasoned
the patient’s primary care physician along with a referral to a head clinicians for both creating a clinical impression and for surgery
and neck surgeon. The patient’s CT scan showed a right-sided planning. MRI is a powerful complementary study because of its
parotid mass. Without contrast, it had a similar appearance to the superiority in evaluating salivary gland soft tissue.
parotid parenchyma (Fig. 40.1). Subsequent magnetic resonance Ultrasonography is an excellent, low-cost imaging study that is
imaging (MRI) was ordered by the head and neck surgeon. The useful as an initial first study. However, its objectivity can be lack-
MRI showed a 3.2-cm 3 2.3-cm 3 3.3-cm well-circumscribed, ing when performed by a third party. Ultrasonography is most
heterogeneously enhancing, partially cystic superficial right pa- useful as a guided study for fine-needle aspiration (FNA) biopsy.
rotid mass. An incidental left deep lobe parotid mass was identi- FNA biopsy under ultrasound guidance is best performed by an
fied as well, measuring 1.6 cm 3 1.2 cm 3 1.3 cm. There was no experienced clinician. For tumors in the superficial parotid lobe,
associated pathologic lymph node enlargement. There was sym- the tail of parotid, and the submandibular gland, ultrasound-
metric enhancement of the facial nerves on MRI. guided FNA is usually feasible. However, for tumors in difficult-
On imaging, pleomorphic adenomas appear as well-circum- to-reach spaces in the neck, such as the deep lobe of the parotid,
scribed masses, often with bosselated borders. On ultrasonography, parapharyngeal space, or masticator space, CT-guided FNA is
pleomorphic adenomas are hypoechoic solid masses with internal generally preferred. Analysis of the biopsy is best performed by an
cystic foci. On CT scan, they typically enhance with contrast. On experienced pathologist who can provide diagnostic information
MRI, pleomorphic adenomas present as well-circumscribed to help guide treatment.

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200 S E C TI O N Head and Neck Pathology

• Fig. 40.2 T1-weighted magnetic resonance image showing a hypoin-

tense solid mass in the right parotid measuring 3.2 cm 3 2.3 cm 3 3.3 cm. • Fig. 40.4 Contrasted T1-weighted imaging shows the same hyperin-
It is well circumscribed. tense mass. Heterogeneity and pleomorphism of the larger right-sided
mass is more appreciable compared with the left deep lobe parotid mass,
which has more homogenous enhancement.

Labs
No routine laboratory tests are specific for the diagnosis of a pleo-
morphic adenoma or any other salivary gland tumor. However,
laboratory tests may be used to evaluate for other causes of facial
masses or swelling. A complete blood cell count may be obtained
to evaluate for leukocytosis caused by an infectious process. Viral
markers may be helpful in evaluating for viral causes of parotid
swelling, such as mumps. An HIV test may slant the differential
diagnosis toward a lymphoepithelial cyst.
Rheumatologic testing such as antinuclear antibody, erythro-
cyte sedimentation rate (ESR), and C-reactive protein (CRP) may
be suggestive of an autoimmune process. ESR and CRP are mark-
ers that may also be elevated in infectious processes. In Sjögren’s
syndrome, there may be elevation of markers SS-Ro and SS-La.
The diagnosis of Sjögren’s syndrome is left to the clinical judg-
ment of a rheumatologist. Parotid swelling can occur in sarcoid-
osis, in which angiotensin-converting enzyme and vitamin D
levels may be elevated. In cases of systemic autoimmune disease,
bilateral or symmetric involvement portends a more benign pro-
cess. In the case of our patient, a unilateral salivary gland process
is less likely to favor a rheumatologic condition.
In the workup of any solitary or unilateral mass, the clinical
suspicion should be for a neoplastic process until proven other-
wise. Biopsy and histopathologic analysis are imperative in the
• Fig. 40.3 T2-weighted imaging showing a hyperintense solid right-sided diagnostic workup. For easy-to-access tumors in the lip, oral cav-
mass. An incidental finding of a left parotid deep lobe mass is visualized ity, or nasal cavity, biopsy under direct or indirect visualization is
in the T2-weighted image, measuring 1.6 cm 3 1.2 cm 3 1.3 cm. feasible. For tumors in the parotid gland, submandibular gland,

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 CHAPTER 40 Pleomorphic Adenoma 201

or other deep neck space, image-guided (ultrasound or CT) FNA has variable appearance. In fact, the diverse morphology of the
of the solid portion of the mass is often diagnostic. Aspirate of the tumor is where the “pleomorphism” or benign “mixed” tumor
cystic portion of a salivary tumor may yield fluid that may be sug- moniker is derived. Aspirate smears show a mix of bland ductal
gestive of a disease process but is generally insufficient for diagno- polygonal epithelial cells, spindle-shaped myoepithelial cells, and
sis of a neoplastic process. For example, aspirate demonstrating a a fibrillary myxochondroid stroma. The stromal component com-
brownish fluid may be suggestive of a Warthin tumor. Yellow- prises at least 25% of lesion material. Stroma is metachromatic on
green mucopurulent material may be suggestive of a first bran- Romanowsky stains. Myoepithelioma and basal cell adenoma
chial cleft cyst. Saliva aspirated from a cystic mass may suggest a cytologically represent pleomorphic adenoma but are rarer. None-
sialocele. theless, they are on the cytologic differential diagnosis for pleo-
Our patient declined a biopsy, electing to move forward with morphic adenoma.
excision of the mass. Grossly, pleomorphic adenomas appear as solitary, well-
circumscribed masses. There is usually an avascular areolar plane
Differential between the mass and the surrounding parenchyma. When pos-
sible, it is best to keep a margin around the tumor. The color of
The differential diagnosis for pleomorphic adenoma of the parotid the tumor varies from white-tan to blue-gray. On core biopsy or
gland includes other benign lesions, primarily a Warthin tumor excisional biopsy, they demonstrate pleomorphism and variable
or, less commonly, an oncocytoma. Lymphoepithelial cysts are a proportions of ductal to myoepithelial cells in a background of
consideration in patients who are immunocompromised. Less stromal elements (eFigs. 40.5 to 40.8). There are epithelial and
common tumors include solitary fibrous tumor, which is a tumor mesenchymal elements. Epithelial elements may include ducts,
of mesenchymal origin. Other benign considerations include si- tubules, solid sheets, and ribbons. The mesenchymal component
alocele and first branchial cleft cyst. A sialocele is usually consid- may appear myxoid, hyalinized, or cartilaginous. Myoepithelial
ered in the setting of trauma or recent surgery. A branchial cleft cells may appear as spindle cells. When present, plasmacytoid
cyst is a congenital epithelial cyst, and first branchial cleft cysts are cells are characteristic of mixed tumors because they are never
exclusively found between the ear and the submandibular gland. found in any other salivary gland tumors. Encapsulation under
Regarding salivary gland malignancies, slow-growing pro- a microscope is seen as a pseudocapsule, which may appear
cesses, such as an adenoid cystic carcinoma, mucoepidermoid smooth or as fingerlike projections, or pseudopodia. These pro-
carcinoma, and acinic cell carcinoma, are on the differential. jections are thought to contribute to the pathophysiology of
More rapidly progressing tumors include poorly differentiated recurrence.
mucoepidermoid carcinoma, CXPA, squamous cell carcinoma Diagnostic biopsy is invaluable in counseling patients about
metastasis from a separate primary cutaneous or mucosal site, and their treatment plan. Pleomorphic adenoma is assurance of a be-
primary squamous cell carcinoma of the salivary gland. Less com- nign process. No neck dissection is required. At least for the im-
monly, a hematologic malignancy such as a lymphoma may pres- mediate future in most patients with asymptomatic disease, there
ent as a solid tumor of the major salivary glands. is no urgency to remove it. However, pleomorphic adenoma has
Salivary gland abscess is an infectious consideration in the the potential for malignant transformation, so surgical excision is
presence of an acute onset and rapidly progressing sepsis, includ- generally recommended, particularly in younger patients. For
ing fever, erythema, and pain. For unvaccinated measles, mumps, older adult patients with reduced life expectancy because of exten-
rubella patients with exposure in endemic areas, mumps is a con- sive medical comorbidities, observation may be recommended
sideration. An autoimmune process may be more chronic and because the risk of removing a benign tumor should be weighed
systemic manifestations. Patients with Sjögren’s syndrome may against the perceived benefits.
have dry eyes. Pediatric patients may have swelling of their parotid There are a few downsides to preoperative biopsy. Needle bi-
glands in recurrent parotitis in children. opsy implies violation of the tumor capsule to extract cells for
For tumors in the parapharyngeal space, prestyloid tumors fa- cytology or tissue diagnosis. Spillage of pleomorphic adenoma is
vor salivary gland origin, most commonly pleomorphic adenoma. a well-known complication that can be difficult to manage. The
Poststyloid parapharyngeal space tumors tend to favor paragan- reported incidence of tumor spillage along the tract of FNA or
gliomas and nerve sheath tumors. For tumors of the palate, a core needle biopsy is quite low. During surgery, a ruptured cap-
polymorphous low-grade adenocarcinoma and necrotizing sali- sule, theoretically, may be weakened to the point that daughter
vary metaplasia are other considerations. cells can spill through during the surgery. Because the tumor
capsule is ruptured during the biopsy, this can be interpreted as
Assessment such when the pathologist analyzes the final specimen. It can re-
sult in a stressful, drawn-out surveillance process.
A unilateral salivary gland mass is considered malignancy until Another risk of preoperative biopsy is a nondiagnostic sample,
proven otherwise. Imaging is useful in assessment and surgery resulting in repeated biopsies and further manipulation of the
planning of salivary gland masses but is generally nondiagnostic. tumor capsule. In cases of nondiagnostic preoperative biopsy,
The presence of bilateral tumors, deep lobe tumors, or prestyloid open biopsy by complete excision of the pleomorphic adenoma
parapharyngeal space tumors may favor a benign process. Imaging may be warranted. In cases when there is uncertainty about ma-
suggesting extracapsular spread, increased facial or lingual nerve lignancy, robust scarring or inflammatory response from a needle
enhancement, asymmetric widening of skull base foramina, and biopsy can create the appearance that the surgeon is dealing with
cervical nodal metastases favor a malignant process. Nonetheless, a malignant process. Scarring can make separation of the mass
the diagnosis requires tissue. The diagnosis is established with bi- from the facial nerve or other surrounding structures difficult.
opsy via FNA, core needle, or excisional surgical biopsy. There may be unnecessary sacrifice of these tissues to confirm that
For pleomorphic adenoma, FNA can provide high diagnostic the tumor is, in fact, benign. Of note, incisional biopsy may result
accuracy (89.5%–96.2%). Microscopically, pleomorphic adenoma in spillage of the tumor and is not recommended.

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 CHAPTER 40 Pleomorphic Adenoma 201.e1

• eFig. 40.7 Histology demonstrating pleomorphism. (Photo credit: Al-

fredo Aguirre, DDS, MS.)

• eFig. 40.5 Histology demonstrating pleomorphism. Note the variable

proportions of ductal to myoepithelial cells in a background of fibrillary
stromal elements. (Photo credit: Alfredo Aguirre, DDS, MS.)

• eFig. 40.8 Histology demonstrating pleomorphism. (Photo credit: Al-

fredo Aguirre, DDS, MS.)

• eFig. 40.6 Histology demonstrating pleomorphism. (Photo credit: Al-

fredo Aguirre, DDS, MS.)

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202 S E C TI O N Head and Neck Pathology

For the patient being discussed, the overall impression based on the oral cavity can be resected via extracapsular dissection, but
clinical history and imaging favors a benign process, most likely a again, the management of the margin is up to the experience of
pleomorphic adenoma or Warthin tumor. In discussing the op- the surgeon.
tions with this patient, she was intent on moving forward with For our patient, a superficial parotidectomy with facial nerve
surgery because of the disfigurement of her face, regardless of the dissection of the lower facial nerve branches was performed. A
biopsy results. She declined a preoperative biopsy. The plan for her modified Blair incision was designed from the tragus to the base
was excisional biopsy in the operating room via superficial paroti- of the lobule, where a sharp 90-degree turn is made posteriorly
dectomy with facial nerve dissection and intraoperative frozen and turned back inferiorly into a resting skin crease in the neck.
section with the option to move forward with supraomohyoid The incision was made with a #15 blade. The dissection was car-
dissection of levels II and III if malignancy was demonstrated. ried through the skin and subcutaneous fat down to the parotid
fascia and the platysma. Skin flaps were elevated over the tumor.
Treatment The great auricular nerve was identified; when possible, it is best
to save it, especially in patients who have earrings. The parotid tail
The surgical goal of any salivary gland pleomorphic adenoma is is elevated off the sternocleidomastoid fascia and posterior belly of
complete en bloc excision with a surgical margin surrounding the the digastric muscle. The preauricular parotid gland is elevated off
capsule when possible. Maintenance of the tumor capsule is the key the tragal and conchal cartilage. This portion of the parotid can
factor in minimizing recurrence. Enucleation of parotid pleomor- be safely and quickly elevated off the perichondrium of the carti-
phic adenoma is classically associated with higher rates of recurrence. laginous ear canal up to the bony ear canal. The facial nerve can
For tumors in the superficial parotid lobe or tail of the parotid, be identified between the tragal pointer and the digastric, anterior
superficial parotidectomy with facial nerve preservation, dissec- and inferior to the tympanomastoid suture line. The nerve was
tion, or both is recommended (eFig. 40.9). For tumors in the followed out to the pes anserinus. For our patient, the superior
submandibular gland, complete excision of the gland can be per- aspect of the tumor was lateral to the lower facial nerve branches.
formed with low morbidity. Limited dissection of the upper branch was needed to confirm
Tumors in the deep lobe of the parotid gland can be more chal- that only lower facial nerve branch dissection was required. The
lenging (Fig. 40.10). Access can be difficult through the transcer- marginal mandibular and midface branches of the facial nerve
vical, transparotid route. Visualization of the deep aspect of a were identified, and extracapsular dissection of the tumor along
deep lobe parotid pleomorphic adenoma might be incomplete or these nerves was carried out to the masseter muscle to clear the
blind. Mandibulotomy or a combined transoral–transcervical ap- anterior-to-posterior dimension of the tumor (Fig. 40.11). A cuff
proach may be needed to completely excise these tumors. Deep of parotid tissue was included on the anterior, inferior deep, and
lobe parotidectomy can place the facial nerve under more duress superior aspects of the specimen. Laterally, the margin was the
and traction, resulting in higher rates of facial nerve weakness— parotid fascia. As is usually the case with many of these tumors, a
transient or permanent. Transoral robotic surgery for deep lobe true deep (medial) margin at the level of the facial nerve dissec-
parotid pleomorphic adenomas has also been described. tion is impossible without taking the facial nerve. Frozen section
For pleomorphic adenoma of the minor salivary glands of the of the tumor confirmed the diagnosis of a pleomorphic adenoma.
palate, there may be some debate about how best to treat the Electromyography and four-channel facial nerve monitoring were
margins of the hard palate. Extracapsular dissection in the sub- used during the case. The nerve stimulator confirmed that all
periosteal plane might be sufficient. One may consider shave os- four branches being monitored were functioning before closure
tectomy or even an infrastructure maxillectomy in managing the (Fig. 40.12). Although the extracapsular dissection had no
hard palate margin. Pleomorphic adenomas of other subsites of concerns for tumor spillage, the neck was copiously irrigated.

• Fig. 40.11 Operative photo from the case being discussed. The pleo-
morphic adenoma occupies almost the entire inferior parotid. The tumor
• Fig. 40.10 Operative photo of a pleomorphic adenoma deep to the up- extends to the lateral border of the superficial parotid. The facial nerve was
per branches of the facial nerve. The superficial lobe is preserved and identified to protect it and to maximize inclusion of a soft tissue cuff of
anteriorly and inferiorly retracted to gain access to the deep lobe mass. superficial parotid around the pleomorphic adenoma.

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202.e1S EC T I O N Head and Neck Pathology

• eFig. 40.9 The operative field after superficial parotidectomy with facial
nerve dissection.

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 CHAPTER 40 Pleomorphic Adenoma 203

significant amount of parotid tissue is removed. For tumors in the

deep lobe or parapharyngeal space, first bite syndrome is a poten-
tial complication. The underlying mechanism is poorly under-
stood. Patients experience pain during the first few bites of their
meals. Patients are advised to start meals with bland foods.
For pleomorphic adenomas in the submandibular gland, com-
plications including hemorrhage, hematoma, infection, reduced
saliva, marginal mandibular nerve weakness, and tongue tip par-
esthesia caused by lingual nerve injury are unique to the surgery
in this area. Salivary fistula is a potential risk if the surgical site is
made in communication with the oral cavity. For tumors of the
palate, oronasal fistula is a potential risk if the bony margin is
treated with infrastructural maxillectomy.
Pleomorphic adenoma recurrence is a complication that is dif-
ficult to manage. Recurrence of pleomorphic adenoma tends to be
multiple. The reasons for recurrence have been extensively debated.
• Fig. 40.12 The operative bed after superficial parotidectomy and tail of Recurrence can be caused by poor surgical technique in which the
parotid resection. The upper branch is minimally dissected because the tumor is incompletely resected, the capsule is violated, or the tumor
pleomorphic adenoma is mostly overlying the lower facial nerve branches.
spills. Enucleation of parotid pleomorphic adenoma is described to
The lower facial nerve branches are completely followed out and pre-
served. Intraoperative electromyography confirms function of the dissected
have a high rate of recurrence. The rate of recurrence has decreased
nerve branches. as the surgical experience in removing these tumors has improved.
Techniques of extracapsular dissection with uninvolved margins,
when possible, have the lowest rates of recurrence. Positive margins
have been found to be associated with tumor recurrence. Pseudopo-
Acellular dermal matrix was placed on the exposed parotid gland dia is another theory attributed to recurrence.
and inset to the sternocleidomastoid and parotid fascia to assist The most devasting complication of pleomorphic adenoma sur-
with contouring and reducing the risk of Frey’s syndrome. A gery is multifocal recurrence caused by spillage. There is a significantly
small, round Jackson-Pratt drain, exiting behind the hairline, higher rate of recurrence if the tumor capsule is ruptured during sur-
was placed to reduce the risk of postoperative sialocele and se- gery. The tumor seeds daughter cells into the operative field. As time
roma. The wound was closed in layers with absorbable suture. passes, multiple pleomorphic adenomas grow (Fig. 40.13). Revision
Final analysis of the specimen confirmed complete excision of
the tumor without any signs of rupture. The patient had no
recurrence of her tumor.

Complications
Surgical complications of salivary gland surgery include hemor-
rhage, hematoma, surgical site infection, salivary leak, sialocele,
and seroma formation. Most pleomorphic adenomas are in the
parotid gland. Facial nerve injury is a potential risk for treating
tumors in this area. Most facial nerve injury is caused by traction
or trauma (i.e., the nerve is rarely severed), and the prognosis for
recovery of nerve function is good. If the nerve is severed, it
should be recognized by the surgeon immediately. Nerve repair
may be performed intraoperatively. Motor nerve damage to the
upper branches of the facial nerve is more severe because incom-
plete eye closure opens the possibility of exposure keratitis and
other ophthalmologic complications. Damage to midface
branches is more forgiving because of redundancy of input. Dam-
age to the marginal mandibular branch can result in a crooked
smile, oral insufficiency, and drooling.
Great auricular nerve damage is quite common with parotidec-
tomy, either through traction injury or sacrifice of the nerve for
access early in the surgery. Great auricular nerve palsy results in
hypoesthesia of the ear lobule. Frey’s syndrome, or gustatory
sweating, is a rare complication believed to be caused by crossing
of parasympathetic fibers of the parotid gland to the sweat glands
in the skin. Interposition grafts (superficial musculoaponeurotic • Fig. 40.13 Magnetic resonance imaging from a case of recurrent spilled
system flaps, sternocleidomastoid muscle flaps, dermal substi- pleomorphic adenoma. This patient underwent superficial parotidectomy.
tutes, abdominal fat grafting) between exposed parotid paren- They presented 8 years after their surgery with the development of multi-
chyma and the skin reduces the risk of Frey’s syndrome. In some ple masses in the operative field. The patient underwent revision surgery
cases, contouring deformities can be quite pronounced when a and adjuvant radiation therapy.

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204 S E C TI O N Head and Neck Pathology

surgery is the only option because pleomorphic adenomas tend to be for the posterior palatal mucosa and again present as a painless,
radiation resistant. The success rate of reoperation varies. However, firm mass. CT or MRI are the preferred imaging modalities in
when recurrences occur, the time between reoperation tends to further characterization of these lesions, which typically appear as
shorten. The revision pleomorphic adenoma surgery is a lifelong mor- well-circumscribed masses often with a bosselated border.
bidity when tumor spillage occurs. To complicate things further, each On gross examination, pleomorphic adenomas appear as a
repeated surgery becomes more difficult because of operating in a white to grey-blue myxoid mass with a surrounding fibrous capsule.
scarred or radiated field. The risk of permanent facial nerve damage is Of note, this capsule is more appropriately deemed a pseudocapsule
significantly higher. because it is frequently disrupted by intervening pseudopodic
Conversely, not operating on a pleomorphic adenoma carries projections of tumor tissue. As the name implies, pleomorphic
the risk of malignant transformation into CXPA. This is a poten- adenomas take on a variable appearance at the histologic level. In
tially rapidly metastatic process. The possibility of death from a general, these neoplasms are characterized by the presence of duc-
benign tumor is one of the justifications for operating on these tal cells, myoepithelial cells, and a stromal component. Cells may
tumors, particularly in patients who have been deferring from appear in different configurations, including islands, sheets, or
surgery for a long time. All pleomorphic adenoma, including the ductal arrangements, and adjacent stromal material is usually myx-
multiply recurrent ones from tumor spillage, carry this malignant oid or chondroid (or both) in quality. Malignant histopathologic
potential. features of pleomorphic adenomas include findings such as cellular
atypia, calcification, hyalinization, and necrosis.
Discussion Management of pleomorphic adenomas is with surgical exci-
sion. In the case of parotid tumors that are isolated to the superfi-
The most frequently occurring tumor of both the major and mi- cial lobe of the gland, a partial parotidectomy may be pursued to
nor salivary glands is the pleomorphic adenoma. Pleomorphic preserve facial nerve function. Those extending or arising within
adenomas are estimated to make up 45% to 75% of all salivary the deep lobe necessitate a total parotidectomy. No matter the lo-
gland tumors. They demonstrate a possibly slight female predilec- cation, enucleation of pleomorphic adenomas is not recommended
tion and can present in any age group but tend to occur in the because recurrence rates are as high as 25% and are attributed to
third to sixth decades of life. incomplete excision. The nature of the incomplete pseudocapsule
Pleomorphic adenomas are benign and slow growing. Al- seen with this neoplasm leaves a high likelihood of leaving behind
though these neoplasms may present in any salivary gland, they tumor cell nests during enucleation procedures. Complete excision
show an overwhelming predilection for the parotid gland. The of a pleomorphic adenoma is considered curative with success rates
parotid gland is affected in approximately 85% of cases followed greater than 95%. Monitoring of these neoplasms is not recom-
by the submandibular gland and the minor salivary glands at mended because of a considerable risk of malignant transforma-
significantly lower rates. A pleomorphic adenoma most frequently tion into CXPA, which occurs at rates of approximately 5%. Ma-
presents as a slow-growing, painless, firm mass that is freely move- lignant transformation is associated with recurrent disease, larger
able, although there are reported instances of fluctuation in size tumor size, long-standing lesions, previous radiation exposure, and
and presence of pain. When found in the parotid gland, pleomor- older age. CXPAs generally carry a poor prognosis and typically
phic adenomas are isolated within the superficial lobe more than require larger resections and radiation therapy.
80% of the time. They do not cause facial nerve palsy; therefore,
any evidence of facial nerve disturbance should raise suspicion for ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
a malignant process. Intraoral tumors demonstrate a propensity complete set of bibliography.

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 204.e1

Bibliography Henriksson G, Westrin KM, Carlsöö B, et al: Recurrent primary pleomorphic

adenomas of salivary gland origin: intrasurgical rupture, histopathologic
features, and pseudopodia, Cancer 82(4):617-620, 1998. doi:10.1002/
Ahn S, Kim Y, Oh YL: Fine needle aspiration cytology of benign salivary (sici)1097-0142(19980215)82:4,617::aid-cncr1.3.0.co;2-i.
gland tumors with myoepithelial cell participation: an institutional Kanatas A, Ho MWS, Mücke T: Current thinking about the manage-
experience of 575 cases, Acta Cytol 57(6):567-574, 2013. doi:10. ment of recurrent pleomorphic adenoma of the parotid: a structured
1159/000354958. review, Br J Oral Maxillofac Surg 56(4):243-248, 2018. doi:10.1016/j.
Almeslet AS: Pleomorphic adenoma: a systematic review, Int J Clin Pedi- bjoms.2018.01.021.
atr Dent 13(3):284-287, 2020. doi:10.5005/jp-journals-10005-1776. Lim DWJ, Tan TSH, Tan JL, et al: Solitary fibrous tumour of the parotid
Alzumaili B, Xu B, Saliba M, et al: Clinicopathologic characteristics and gland: a case report and a 15-year literature review, AME Case Rep
prognostic factors of primary and recurrent pleomorphic adenoma: a 3:14, 2019. doi:10.21037/acr.2019.04.05.
single institution retrospective study of 705 cases, Am J Surg Pathol Loke WL, Rahimi S, Brennan PA: An update on extracapsular dissection
46(6):854-862, 2022. doi:10.1097/PAS.0000000000001837. for the management of parotid gland pleomorphic adenoma, J Oral
Aro K, Valle J, Tarkkanen J, et al: Repeatedly recurring pleomorphic Pathol Med 51(3):219-222, 2022. doi:10.1111/jop.13251.
adenoma: a therapeutic challenge, Acta Otorhinolaryngol Ital Mc Loughlin L, Gillanders SL, Smith S, et al: The role of adjuvant radio-
39(3):156-161, 2019. doi:10.14639/0392-100X-2307. therapy in management of recurrent pleomorphic adenoma of the
Chan JY, Tsang RK, Eisele DW, et al: Transoral robotic surgery of the parotid gland: a systematic review, Eur Arch Otorhinolaryngol
parapharyngeal space: a case series and systematic review, Head Neck 276(2):283-295, 2019. doi:10.1007/s00405-018-5205-z.
37(2):293-298, 2015. doi:10.1002/hed.23557. Panda S, Sikka K, Thakar A, et al: Transoral robotic surgery for the para-
Dulguerov P, Todic J, Pusztaszeri M, et al: Why do parotid pleomorphic pharyngeal space: expanding the transoral corridor, J Robot Surg
adenomas recur? A systematic review of pathological and surgical 14(1):61-67, 2020. doi:10.1007/s11701-019-00932-3.
variables, Front Surg 4:26, 2017. doi:10.3389/fsurg.2017.00026. Shah KS, Ethunandan M: Tumour seeding after fine-needle aspiration and
Grasso M, Fusconi M, Cialente F, et al: Rupture of the pleomorphic core biopsy of the head and neck—a systematic review, Br J Oral Maxillofac
adenoma of the parotid gland: what to know before, during and after Surg 54(3):260-265, 2016. doi:10.1016/j.bjoms.2016.01.004.
surgery, J Clin Med 10(22):5368, 2021. doi:10.3390/jcm10225368. Storck K, Brandstetter M, Keller U, et al: Clinical presentation and char-
Griffith CC, Pai RK, Schneider F, et al: Salivary gland tumor fine-needle acteristics of lymphoma in the head and neck region, Head Face Med
aspiration cytology: a proposal for a risk stratification classification, 15(1):1, 2019. doi:10.1186/s13005-018-0186-0.
Am J Clin Pathol 143(6):839-853, 2015. doi:10.1309/AJCPMII6O-
SD2HSJA.

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41
Acute Herpetic Gingivostomatitis
S C O T T S T E WA R D -T HAR P, K EL LY M AGL I O C CA, K E TA N PAT E L , a n d D E E PAK K A D E M A N I

CC when she brushes her teeth. She does not have any known drug
allergies and is not currently taking any medications. She is pre-
An 11-year-old female is accompanied to the pediatric dentist by menarche. A friend at school who occasionally borrows her lip
her mother. The child was home from school the past 3 days with balm recently had cold sores.
“flu-like” symptoms; she complains of oral soreness that is accen- Herpes simplex virus is transmitted via direct contact with in-
tuated by eating or drinking. fected secretions from the saliva and other bodily fluids. The main
Herpes simplex virus (HSV) infections of the oral and perioral risk factor is a known exposure to the virus. HSV type 1 (HSV-1)
tissues are very common with more than 50% of individuals being is the most common virus responsible for oral herpes but also can
affected before adulthood. The vast majority of primary childhood infect other mucosal sites and skin. Young individuals may become
HSV infections are asymptomatic. Symptomatic cases are labeled exposed from a caretaker who is shedding reactivated virus. Latent
acute herpetic gingivostomatitis and are most commonly diagnosed HSV-1 frequently resides in the trigeminal ganglion, and reacti-
between 6 months and 5 years of age. Infection before 6 months vated virus involves the distribution of this nerve. Several studies
of age is uncommon because of passive immunity (transplacental have demonstrated viral DNA in the saliva of asymptomatic
transfer of protective maternal antibodies). Primary HSV infection HSV-1 seropositive individuals, with estimates of asymptomatic
ultimately leads to latent neurotropic virus in nerve ganglia, with shedding being present in 2% to 9% of a randomly sampled
a continual risk for viral reactivation and secondary symptomatic population. The incubation time from viral exposure to first symp-
infection (herpetic stomatitis or herpes labialis). toms ranges from a few days to just more than 1 week.

HPI Examination
The patient reports acute onset of malaise, neck soreness, head- General. The patient is moderately anxious but cooperative and
ache, and low-grade fever 3.5 days ago. Diffuse oral soreness be- is in otherwise good health.
came more pronounced 1 day later with painful gingiva and Vital signs. Blood pressure is 110/70 mm Hg, heart rate is
multiple small ulcers on her tongue, lips, and cheeks. The patient 100 bpm, respirations are 18 per minute, and temperature is
has not brushed her teeth in 2 days because of a severe burning 38.2°C. (The patient reports it has been 10 hours since the last
sensation that accompanied an earlier attempt. The fever has been acetaminophen dosage.)
manageable with acetaminophen. Irritability and decreased oral Maxillofacial. She has palpable cervical lymph nodes (this is
intake because of discomfort are frequently the initial presenting commonly seen with acute herpetic gingivostomatitis). The face is
symptoms in younger patients. symmetrical, with no other obvious signs of infection or edema.
It is important to distinguish between primary and recurrent Intraoral. Multiple small shallow ulcerations are noted to bi-
HSV infection. The symptoms of primary infection are generally laterally involve the lips, tongue, and vestibule (Fig. 41.1). The
more severe and can be associated with malaise, lymphadenopa- maxillary and mandibular gingiva appear erythematous and en-
thy, and fever. Primary infection can involve the entire oral cavity, larged with focal erosions noted near the free gingival margin (see
both keratinized mucosa that is attached to bone and unattached Fig. 41.1). Ulcerations of unattached or movable mucosa are well
or movable mucosa. Recurrent infection is distinctly limited in defined and typically measure less than 3 mm in greatest dimen-
distribution in immunocompetent individuals. Most commonly, sion. They are centrally surfaced with a yellow fibrin coating and
it is limited to the site of primary inoculation (e.g., lip) or adja- are surrounded by a thin erythematous halo. The irregular borders
cent mucosal sites supplied by the same nerve branch. When re- of individual ulcers occasionally run into one another or coalesce.
current infection is limited to the intraoral mucosa alone, it is The lip lesions are centered on the mucosa but spill over across the
generally confined to attached palatal mucosa or gingiva. vermillion border.
Lesions first appear as pinpoint white fluid-filled vesicles; these
PMHX/PSHX/Medications/Allergies/SH/FH have frequently burst, ulcerated by the time of clinical examina-
tion. The number of lesions is highly variable, but both the
The patient has not been to the dentist in several years. She re- gingiva and unattached or movable mucosa should generally be
ports intermittent mild discomfort of her gums over the past affected. Primary infection in teens and young adults can present
several months and occasionally sees small amounts of blood as pharyngotonsillitis.

205
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206 S E C TI O N Head and Neck Pathology

or recurrent infection at these sites presents as ulcerating

vesicles with an erythematous base and is known as herpetic
whitlow.

Imaging
No imaging modalities are necessary for the diagnosis and man-
agement of acute herpetic gingivostomatitis.

A Labs
Acute herpetic gingivostomatitis is primarily a diagnosis made
based on history and physical examination. With characteristic
findings in a young individual, no laboratory-based diagnostic
measures are required. However, accurate diagnosis of herpes in-
fection in immunosuppressed and at-risk individuals is sometimes
necessary, and laboratory tests are available. Vesicles may be sam-
pled with a fine-gauge needle and the fluid aspirate tested for virus
by a number of means. Viral culture is not generally necessary.
Instead, viral DNA amplification-based methods, such as real-
time polymerase chain reaction, can provide faster results. If pres-
ent, testing of skin lesions is preferred over oral lesions because of
a higher likelihood for finding intact vesicles and a lower risk for
sample contamination.
B Cytologic smears and tissue biopsies can show characteristic
cytomorphologic changes in infected epithelial cells. HSV-in-
fected cells demonstrate acantholysis (Tzanck cell) and distinct
nuclear changes, including enlargement, margination of chroma-
tin to the edges of the nuclear membrane with central clearing,
and multinucleation (eFig. 41.2). Immunohistochemical stains
and direct immunofluorescence can further support the diagnosis
but are most useful in identifying recurrent herpetic lesions in
biopsy samples of clinically nonspecific ulcers. Serologic testing is
available but is not of clinical utility in the diagnosis of acute
herpetic gingivostomatitis.

C
Assessment
Acute (primary) herpetic gingivostomatitis.

Treatment
Acute herpetic gingivostomatitis is a self-limiting condition, usu-
ally resolving within 1 to 3 weeks from the onset of symptoms.
Treatment predominantly involves observation and palliative care.
This may involve topical anesthetics and over-the-counter pain
relief, such as acetaminophen or ibuprofen. Fluids and electrolyte
status should be monitored as needed to avoid dehydration.
Pharmacologic treatment is often minimal because of the self-
limiting course of the infection. In more severe cases, pharmaco-
D therapy can be of use if administered appropriately. Conventional
antiviral therapy that inhibits virus-specific DNA polymerases
• Fig. 41.1 Herpetic ulcers involving the ventral tongue (A) and lip (B). Diffusely (e.g., acyclovir, valacyclovir, and penciclovir) has proven effective
enlarged and erythematous gingiva with focal erosion and sloughing (C and D).
and can shorten the overall healing time by several days when
initiated early.
Extremities. This patient had no skin lesions other than Primary acute herpetic gingivostomatitis can be managed on
some crusting where mucosal lip lesions crossed the vermillion an outpatient basis with aggressive oral hydration, analgesia, and
border. Perioral skin vesicles are common in those with acute her- topical and systemic antiviral therapy. The main criteria for hos-
petic gingivostomatitis. Distant sites can also be self-inoculated. pital admission include severe dehydration and pain. Severe dis-
Abraded skin, such as the back of a thumb or finger on a thumb ease refractory to treatment may indicate an underlying cause of
sucker or cuticle biter, is at particular risk for infection. Primary immunosuppression.

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 CHAPTER 41 Acute Herpetic Gingivostomatitis 206.e1

• eFig. 41.2 Herpes simplex virus–infected epithelial cells showing acan-

tholysis, multinucleation, nuclear enlargement, and margination of chromatin.

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 CHAPTER 41 Acute Herpetic Gingivostomatitis 207

Complications likely causative agent. Before the routine use of gloves, herpetic
whitlow was common among dentists, being transmitted by the
The primary complications include potential nutritional deficien- infected oral secretions of patients. Transmission is easily pre-
cies and inadequate fluid intake, leading to dehydration. Noncon- vented by the use of gloves and by observation of universal fluid
tiguous spread as herpetic whitlow has already been discussed and precautions.
is expounded upon further later. Additionally, more serious ocular
and central nervous system (CNS) involvement may occur. Discussion
Herpes simplex virus involvement of the eye more commonly
occurs in secondary infection but can lead to corneal scarring and, Acute herpetic gingivostomatitis is the symptomatic oral presenta-
rarely, blindness. Typical symptoms to look out for include red, tion of primary HSV infection, mostly HSV-1. Primary HSV infec-
watery eyes; swelling; pain; blurred vision; and sensitivity to tion typically presents in children between the ages of 6 months and
bright light. Topical and systemic antivirals and occasionally ste- 5 years, with a peak incidence at 2 to 3 years of age. Primary infec-
roids are used for treatment. tion in teens and young adults can present as pharyngotonsillitis.
Herpes simplex virus involvement of the CNS as encephalitis The initial clinical presentation includes fever and cervical
may occur via the trigeminal nerve or alternate route after pri- lymphadenopathy. Patients develop a variable number of small
mary or recurrent HSV infection. HSV-1 accounts for more than white fluid-filled vesicles of the oral mucosa that rapidly degener-
2000 encephalitis cases in the United States per year and is fatal ate into 1- to 3-mm ulcers. Painful erythematous enlargement of
in more than 70% of cases if left untreated. Typical symptoms the gingiva with focal surface erosion accompanies the vesicles,
include acute onset of altered mental status, fever, seizures, and often leading to constitutional symptoms such as dehydration
focal cranial nerve and other neurologic deficits. Recognition of from lack of adequate oral intake.
these symptoms is crucial to allow for rapid referral for imaging The diagnosis is primarily based on relevant patient history
studies and empiric intravenous (IV) antiviral therapy. Rapid and clinical presentation. The disease process is generally self-
treatment with IV acyclovir significantly improves survival rate limiting and resolves within 1 to 3 weeks. Palliative management
(# 80%) and reduces long-term complications that may be re- of oral discomfort to allow for adequate nutritional intake and
lated to immune overactivation. outpatient observation for rare but potentially serious complica-
Herpetic whitlow may involve one or more fingers, typically tions is standard of care. Early administration of topical or orally
the skin over the terminal phalanx. Most often the initial symp- administered systemic antiviral drugs can shorten the disease
toms are pain, burning, or tingling of the infected digit. This course. Education of caretakers should include signs of dehydra-
usually is followed by erythema, edema, and the development of tion, risk of self-inoculation of different sites, typical disease time
small, grouped vesicles on an erythematous base over 7 to 10 days. course, and the need to quickly follow up on any signs of poten-
Vesicles may ulcerate or rupture. After 10 to 14 days, symptoms tial CNS involvement.
improve, and lesions crust over and heal. HSV-1 is the cause in
approximately 60% of cases of herpetic whitlow, and HSV-2 is ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
the cause in the remaining 40%. In children, HSV-1 is the most complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 207.e1

Bibliography McDonald RE, Avery DR, Weddell JA, et al: Gingivitis and periodontal
disease. In Dean JA, Avery DR, McDonald RE (eds): Dentistry for the
Child and Adolescent, ed 9, St. Louis, 2011, Mosby, pp 366-402.
Ajar AH, Chauvin PJ: Acute herpetic gingivostomatitis in adults: a re- Miller CS, Danaher RJ: Asymptomatic shedding of herpes simplex virus
view of 13 cases, including diagnosis and management, J Can Dental (HSV) in the oral cavity, Oral Surg Oral Med Oral Pathol Oral Radiol
Assoc 68(4):247-251, 2002. Endod 105:43-50, 2008.
Blevins JY: Primary herpetic gingivostomatitis in young children, Derma- Smith TT, Whitley RJ: Herpesviruses. In Cohen J, Powderly WG, Opal SM
tol Nurs 29(3):199-202, 2003. (eds): Infectious Diseases, ed 4, 2017, New York: Elsevier, pp 1426-1438.
Fatahzadeh M: Primary oral herpes: diagnosis and management, J N J Steiner I, Kennedy PG, Pachner AR: The neurotropic herpes viruses:
Dent Assoc 83(2):12-13, 2012. herpes simplex and varicella-zoster, Lancet Neurol 6(11):1015-1028,
Levitz RE: Herpes simplex encephalitis: a review, Heart Lung 27(3):209- 2007.
212, 1998.

t.me/Dr_Mouayyad_AlbtousH
42
Aphthous Ulcers
KEL LY M AGL I O C CA , S C O T T S T E WA R D -T HAR P, a n d D E E PA K K A D E M A N I

CC • BOX 42.1 Categorization of Aphthous Ulcers

A 19-year-old female is referred for evaluation of recurrent painful • Minor aphthous ulcer (Mikulicz aphthae). Less than 10 mm in size, re-
ulcerations inside her mouth. (Recurrent aphthous ulcerations, or quiring no treatment and resolving within 7–10 days without scarring. If the
synonymously, recurrent aphthous stomatitis [RAS], affects 20% ulcer remains after 2 weeks, topical corticosteroid therapy is indicated. Pal-
of the population, with a slight female predilection.) liative therapy in the form of a topical local anesthetic, such as 2% viscous
lidocaine, diphenhydramine elixir (12.5 mg/mL), or topical benzocaine, may
be indicated in cases of severe pain associated with minor aphthous ulcers.
HPI • Major ulcers (periadenitis, mucosa necrotica recurrens, Sutton
disease). Major aphthous ulcers, by definition, are .10 mm in diameter
The patient reports that for the past 2 years (ulcerations often with deeper penetration than minor ulcers and therefore heal with scarring.
begin in adolescence and early adulthood), she has had episodes Resolution of major aphthous ulcers may take longer than several weeks.
of one or more painful oral ulcers that develop spontaneously and Treatment of more severe forms of major aphthous ulcers includes the use
last for up to 2 weeks, with ulcer-free intervals ranging from 1 to of topical or systemic corticosteroid therapy. A protocol has been estab-
3 months. She does not have any history of trauma or known lished by Kerr and Ship in the management of aphthous ulcers, especially
infectious diseases. The ulcers occasionally occur at multiple sites with reference to those seen in HIV-infected patients.
simultaneously. The patient denies ocular irritation, hoarseness, • Herpetiform ulcers. Herpetiform ulcers occur as many (10–100) small ul-
and dysphagia. She further denies a history of lip swelling, cutane- cerations coalescing within a large area of nonkeratinized mucosa that can
ous ulcerations, and anogenital ulcerations (extraoral mucosal extend to keratinized mucosa. In name and clinical characteristics, these
ulcers resemble ulcerations resulting from primary herpes simplex infec-
ulcerations are atypical for simple RAS).
tion. Herpetiform ulcers are distinct from herpetic ulcers in that they lack
viral particles and are not preceded by the formation of vesicles. Healing
PMHX/PDHX/Medications/Allergies/SH/FH occurs within 7–10 days.

The patient is a nonsmoker; takes no medications; and has no

known history of immunosuppression, HIV, malnutrition, can-
cer, or previous infections of the head and neck region (potential
risk factors for oral ulceration). She reports that her mother had Examination
“canker sores” as a teenager (family history often reported in
RAS). Careful documentation of the patient’s HPI in conjunc- General. The patient is a well-developed and well-nourished fe-
tion with past medical history, medications, and family history is male in no apparent distress.
paramount in triaging RAS. Aphthous ulceration can be catego- Vital signs. Her blood pressure is 115/70 mm Hg, heart rate is
rized on the basis of ulcer morphology into minor, major, and 92 bpm, respirations are 18 breaths per minute, and temperature is
herpetiform (Box 42.1). RAS can also be classified as simple or 36.1°C (afebrile; fever is unexpected with simple aphthous ulcers).
complex. Simple RAS is the most common form of disease and Maxillofacial. There is no extraoral or asymmetric lip or facial
is characterized by one or more ulcers (of any morphology) oc- swelling (lip swelling and RAS may occur in underlying gastroin-
curring several times each year, limited to the oral mucosa and testinal disorders) and no cervical lymphadenopathy or cutaneous
resolving within 2 weeks. Patients with complex aphthosis tend lip or facial skin ulceration. There is no evidence of conjunctivitis.
to experience larger and numerous ulcerations involving oral or Intraoral. There are several superficial ulcerations at various
orogenital locations. Lesions may take up to 4 weeks to resolve. stages of development in the oral mucosa, measuring 3 to 7 mm.
Patients with unusual clinical findings or extraoral findings A 7-mm ulcer is located on the left buccal mucosa, with a 3-mm
and those suspected to have complex aphthosis may warrant erythematous focus (developing ulceration) anterior to it. A 5-mm
additional or multidisciplinary evaluation to exclude Behçet ulceration is present on the right ventral tongue (Fig. 42.1). The
syndrome, MAGIC (mouth and genital ulcers with inflamed well-developed ulcerations appear round to oval with a central yel-
cartilage) syndrome, underlying gastrointestinal disease (gluten- low ulceration surrounded by an erythematous margin of mucosa
sensitive enteropathy, ulcerative colitis, Crohn disease), cyclic (characteristic clinical appearance for RAS). There does not appear
neutropenia, and PFAPA (periodic fever with aphthous stomati- to be any source of trauma in association with the ulcers, such
tis, pharyngitis, adenitis) syndrome. as sharp dental restorations or fractured dental cusps. Gentle

208
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 42 Aphthous Ulcers 209

A B
• Fig. 42.1 A and B, A 5-mm ulceration on the right ventral tongue.

Labs
Routine laboratory tests are not indicated unless dictated by other
underlying medical conditions. For patients developing new-
onset RAS or RAS-like ulcerations after the age of 40 years, evalu-
ation of an erythrocyte sedimentation rate, complete blood count,
iron studies, and survey for nutritional deficiencies (vitamin B12,
folate, other) may be warranted.

Assessment
Multiple minor aphthous ulcers in an otherwise healthy 19-year-old
female.
The diagnosis of recurrent aphthous ulcers or RAS is usually a
clinical diagnosis. In the case of nonhealing ulceration, an unusu-
ally severe or an atypical clinical presentation, a biopsy may be
indicated to evaluate for granulomatous inflammation, vesicu-
lobullous disease, bacterial (syphilis), and viral or neoplastic causes.
Therefore, all lesions should be followed for observation for ade-
quate healing. The diagnosis of RAS is established by clinical his-
tory without the need for routine histopathology. If a biopsy is
performed, it would likely show surface mucosal ulceration with
an intense inflammatory infiltrate, depending on age of the sam-
• Fig. 42.2 An example of vestibular fissuring (arrowheads) in a pediatric pled lesion. Biopsy material of RAS cannot assist in distinguishing
patient with recurrent aphthous stomatitis later shown to have underlying simple versus complex RAS and is unlikely to be helpful in exclud-
inflammatory bowel disease. ing an underlying RAS-associated medical condition.

Treatment
palpation of the ulcerations reveals they are superficial in nature,
without induration or fixation to deeper structures. There is no There is no definitive cure for aphthous ulcerations. Treatment
evidence of vestibular mucosal fissuring, mucosal “tags” or mucosal goals include symptom relief; hastening ulcer healing if possible;
redundancy, or diffuse gingival erythema (nonspecific yet suggestive and ideally, decreasing the episodes’ frequency and severity.
extraintestinal clinical findings that may occur in the oral cavity in
the setting of underlying inflammatory bowel disease). Fig. 42.2 is General Recommendations
example of vestibular fissuring in a pediatric patient with RAS later
shown to have underlying inflammatory bowel disease. General recommendations revolve around good hygiene, avoid-
ance of oral trauma, and local pain control. A subset of patients
Imaging with RAS have ulceration preceded by local trauma (positive
pathergy). Conducting oral hygiene measures with a soft tooth-
No imaging studies are indicated for the evaluation of simple brush and avoidance of oral products known for mucosal irrita-
RAS. tion, such as sodium lauryl sulfate preservatives in toothpastes and

t.me/Dr_Mouayyad_AlbtousH
210 S E C TI O N Head and Neck Pathology

alcohol-containing mouth rinses, should be avoided. Pain control with thalidomide 200 mg/day for 1 month resulted in a significantly
with a topical anesthetic (2% viscous lidocaine, available by pre- greater number of individuals with complete or partial resolution of
scription) can provide temporary relief when applied to the ulcer ulcers and decreased pain compared with control participants. Tha-
surface or for use as a swish and spit product. Spot treatment with lidomide is a known teratogen, and prescription requires registration
laser therapy may provide pain relief for some patients. and monitoring via the Risk Evaluation and Mitigation Strategy
program (REMS; www.thalomidrems.com). Thalidomide is limited
Topical Agents by adverse effects, including constipation, drowsiness, and a poten-
tially irreversible form of peripheral neuropathy.
For patients with simple RAS, topical corticosteroid therapy is the
first-line treatment and may be more effective when initiated early in Complications
ulcer development. In one randomized trial, patients with RAS were
treated with dexamethasone ointment versus placebo TID for 5 days, The most common complication of RAS is pain leading to diffi-
with a higher proportion of ulcer healing in patients in the dexa- culty eating. Scar formation can be seen with major aphthous
methasone group (88% vs 55% placebo). Topical therapy should be ulcers. Complications related to treatment depend on the profile
discontinued within 2 weeks if no improvement is observed. Clini- of the medication.
cians should be cautious with prolonged use of topical steroids because
pseudomembranous candidiasis or mucosal atrophy may develop. Discussion
Suggested Topical Corticosteroid Regimens Recurrent aphthous stomatitis remains one of the most common
oral mucosal disorders, often developing in adolescents and young
• Fluocinonide 0.05% ointment or gel over ulcer four times daily adults. In the oral cavity, ulceration tends to involve the labial and
• Clobetasol propionate 0.05% ointment over ulcer three times daily buccal mucosa, though the vestibular mucosa, soft palate, and ven-
• Dexamethasone elixir 0.5-mg/5-mL swish for 3 minutes and trolateral tongue may also show involvement. Despite the preva-
expectorate three times daily lence of RAS, the etiology is largely unknown but is thought to be
multifactorial. Although a hereditary or familial component exists
Other Topical Agents for RAS, it is suspected that an oral mucosal immune dysregulation
(exaggerated proinflammatory response vs weak antiinflammatory
These should be used in combination with corticosteroids or as an response) likely has an etiologic role. Deficiencies of iron, vitamin B12,
alternative. and folate have been implicated in the pathogenesis of a subset of
• Topical tetracycline: mouth rinse, gels, or pastes. They may patients with RAS. According to a study by Scully and colleagues,
reduce pain associated with RAS. 18% to 28% of cases of recurrent aphthous ulcers occurred in pa-
• Sucralfate suspension: This may reduce pain associated with RAS. tients with these deficiencies compared with 8% in healthy cohorts.
In some cases, replacement of the deficiencies results in clinical
improvement. Diet may exacerbate RAS, but currently, specific
Refractory Simple Aphthosis and Patients foods or food allergies are not implicated in the cause of RAS.
With Complex Aphthosis Similarly, stress can exacerbate this condition. HIV infection has
been shown to increase the propensity for developing recurrent
First-Line Systemic Therapy aphthous ulcers, especially the major aphthous variant. The rela-
If topical corticosteroid therapy fails to resolve the pathology, intra- tionship between HIV infection and ulcer formation may be related
lesional or systemic corticosteroid therapy is indicated, possibly af- to the decrease in circulating CD4 T lymphocytes (,100 cells/mm3)
ter consideration of biopsy sampling if the diagnosis remains in and resultant immunosuppression related to this disease.
question. An intralesional injection of 20 mg of triamcinolone has Although multiple regimens have been advocated for the treat-
been shown to be efficacious in reducing pain and resolving recur- ment of these lesions, a relatively recent Cochrane review suggests
rent and major aphthous ulcers in a subset of HIV-positive patients. that there is no difference in the outcome between patients treated
Additionally, short-course, high-dose (“short-burst”) prednisone with any regimen, whether antiinflammatory, immunomodula-
(40–80 mg) therapy for 3 to 7 days without taper has been tory, or another form of treatment. Overall, simple aphthosis is
described with excellent clinical results. Clinicians should be cau- associated with periodic moderate discomfort; however, the prog-
tioned about the use of systemic corticosteroid therapy during ac- nosis is excellent, and ulcerations tend to wane as the patient ages.
tive infections, such as tuberculosis, which is prevalent in the For a subset of patients with complex aphthosis, the frequency,
HIV-positive population. Where queries arise regarding dosing of extent, and pain of oral ulcerations is likely to impact quality of
steroids, concurrent medication, or potential adverse reactions, care life. For patients with such recalcitrant disease, interdisciplinary
coordination with the patient’s primary physician is recommended. or multidisciplinary management, including evaluation for un-
derlying disease, may be appropriate.
Second-Line Systemic Therapy for Complex Aphthosis
or Patients Unable to Use Systemic Corticosteroids Acknowledgments
Colchicine alone or in combination with dapsone has been used in
the management of complex aphthosis, including patients The authors and publisher wish to acknowledge Dr. Anthony A.
with Behçet syndrome. One study showed montelukast, a leukot- Indovina, Jr., Ketan Patel, and Ma’Ann C. Sabino for their con-
riene inhibitor, improved healing or oral ulcerations of patients tributions on this topic in previous editions.
unresponsive to corticosteroids. Thalidomide has been shown to be
a potent immunomodulator that is efficacious in the treatment of ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
severe refractory or complex RAS. Treatment of eligible patients complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 210.e1

Bibliography Lau CB, Smith GP: Recurrent aphthous stomatitis: a comprehensive re-
view and recommendations on therapeutic options, Dermatol Ther
35:e15500, 2022.
Brocklehurst P, Tickle M, Glenny AM, et al: Systemic interventions for Letsinger JA, McCarty MA, Jorizzo JL: Complex aphthosis: a large case
recurrent aphthous stomatitis (mouth ulcers), Cochrane Database Syst series with evaluation algorithm and therapeutic ladder from topicals
Rev (9):CD005411, 2012. to thalidomide, J Am Acad Dermatol 52:500-508, 2005.
Chen H, Sui Q, Chen Y, et al: Impact of haematologic deficiencies on re- Liu C, Zhou Z, Liu G, et al: Efficacy and safety of dexamethasone oint-
current aphthous ulceration: a meta-analysis, Br Dent J 218:E8, 2015. ment on recurrent aphthous ulceration, Am J Med 125:292-301, 2012.
Cheng LL: Limited evidence suggests that patients with recurrent aph- Scully C, Grosky M, Lozada-Nur F: The diagnosis and management of
thous stomatitis may benefit from using sodium lauryl sulfate-free recurrent aphthous stomatitis: a consensus approach, J Am Dent Assoc
dentifrices, J Evid Based Dent Pract 19:101349, 2019. 134:200-207, 2003.
Chugh A, Patnana AK, Kumar P, et al: The clinical efficacy of minocy- Seyyedi SA, Olyaee P, Fekrazad R, et al: The effect of carbon dioxide laser
cline mouth rinse on recurrent aphthous stomatitis—a randomized on aphthous stomatitis treatment: a double-blind randomized clinical
controlled trial, Indian J Dent Res 33:24-29, 2022. trial, J Lasers Med Sci 11(suppl 1):S67-S72, 2020.
Cui RZ, Bruce AJ, Rogers RS: Recurrent aphthous stomatitis, Clin Staines K, Greenwood M: Aphthous ulcers (recurrent), BMJ Clin Evid
Dermatol 34:475-481, 2016. 2:1303, 2015.
Galbraith SS, Drolet BA, Kugathasan S, et al: Asymptomatic inflamma- Wray D, Graykowski EA, Notkins AL: Role of mucosal injury in initiat-
tory bowel disease presenting with mucocutaneous findings, Pediatrics ing recurrent aphthous stomatitis, Br Med J (Clin Res Ed) 283:1569-
116:e439-e444, 2005. 1570, 1981.
Kerr AR, Ship JA: Management strategies for HIV-associated aphthous
stomatitis, Am J Clin Dermatol 4:669-680, 2003.

t.me/Dr_Mouayyad_AlbtousH
43
Sialolithiasis
J EFF R EY W. C H A DW I C K , M ICH AE L R. M A R K I E W I C Z , J AM ES C. M E LV ILL E, J O N AT H A N
W. SH UM , and K AR L K. CU D DY

CC is appreciated, which is soft and tender to palpation. There are no

cutaneous abnormalities within the left submandibular region. No
A 41-year-old male reports to your office with pain and swelling intraoral mucosal abnormalities are identified. The patient is fully
within the left submandibular region. dentated with no gross evidence of odontogenic infection. Tem-
poromandibular joint range of motion is within functional limits.
HPI Mucous membranes appear well lubricated. The oropharynx is pat-
ent and symmetric with no evidence of oropharyngeal effacement
The patient reports eight episodes of periprandial pain reaching a or displacement of the uvula from the midline. Bimanual palpation
maximum severity of 4 out of 10 and visible extraoral swelling between the left floor of mouth and left submandibular region re-
within the left submandibular region over the past 12 months. veals a firm and tender mass measuring approximately 3 cm in its
The patient’s pain is controlled with the use of acetaminophen greatest dimension. Salivary flow from the left submandibular
and ibuprofen. The submandibular swelling resolves spontane- gland duct is decreased relative to the contralateral side. The quality
ously within hours to days after the initiation of each episode of the saliva is relatively viscous with no expression of purulent
without intervention and is occasionally associated with either a material. The parotid ducts expressed saliva in both normal quanti-
foul or salty taste. The patient denies fever, chills, dysphagia, ody- ties and quality.
nophagia, dysphonia, and dysarthria during the aforementioned
episodes. The current episode, which has nearly resolved, began Imaging
three days before their presentation and they have not previously
sought investigation or treatment for these symptoms. In view of the aforementioned physical examination findings, a
computed tomography (CT) study with contrast was ordered as
PMHX/PSHX/Medications/Allergies/SH/FH the initial radiographic investigation (Fig. 43.1). CT imaging
demonstrated a 1.4 cm 3 1.6 cm 3 2.4 cm (transverse 3 antero-
The patient’s past medical history is significant for well-controlled posterior 3 craniocaudal) calcified mass within the hilum of the
hypertension, hypercholesterolemia, type 2 diabetes mellitus, and left submandibular gland consistent with a sialolith resulting in
major depressive disorder. Previous surgical procedures include a postobstructive parenchymal hyperenhancement and sialectasis
tonsillectomy and adenoidectomy as well as laparoscopic chole- suggestive of sialadenitis. No abscesses or reactive lymph nodes
cystectomy. Current medications include amlodipine, metformin, were appreciated.
atorvastatin, and amitriptyline. The patient has no known aller-
gies. The patient’s social history is significant for a past smoking Labs
history of 15 pack-years, social alcohol consumption of approxi-
mately one to two drinks per week, and smoking of approxi- Recent complete blood count, serum electrolytes, liver function
mately 1 g of cannabis per month. His family history is significant tests, lipid profile, creatinine, glomerular filtration rate, and gly-
for paternal coronary artery disease. cosylated hemoglobin values were within the range of normal.
Laboratory studies were not ordered at the time of examination
Examination and are generally not indicated in the setting of suspected sialoli-
thiasis unless required for pertinent conditions discovered during
General. The patient is a well-developed and well-nourished male the review of the patient’s medical history or on the discovery of
who appears younger than his stated age. He is alert and oriented, concerning findings during the physical examination such as evi-
overweight, and in no acute distress. dence of infection or sepsis.
Vital signs. Blood pressure is 125/84 mm Hg, heart rate is
94 bpm, and respiratory rate is 16 breaths per minute. The pa- Assessment
tient is afebrile with a temperature of 99.3°F.
Head and neck. There is no palpable cervical lymphadenopa- Sialolithiasis involving the left proximal Wharton’s duct and sub-
thy. Minimal residual swelling within the left submandibular region mandibular gland hilum with associated chronic sialadenitis.

211
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212 S E C TI O N Head and Neck Pathology

• Fig. 43.2 Profile view of the left neck demonstrating the position of the
planned transcervical incision and the absence of submandibular swelling
and overlying cutaneous involvement.

• Fig. 43.1 Selected coronal contrast-enhanced computed tomography

image (soft tissue window) demonstrating the presence of an irregularly
shaped and homogenous radiopaque mass (long arrow) within the body
of the left submandibular gland that demonstrates slight parenchymal
hyperenhancement (short arrow) and sialectasis (arrowhead) relative to
the right submandibular gland.

Treatment
In the present case of chronic sialadenitis and the presence of
a large sialolith, informed consent was rendered for the transcu-
taneous excision of the left submandibular gland with the accom-
panying sialolith. After the induction of general anesthesia via
intravenous access, oral endotracheal intubation was facilitated
with the use of succinylcholine to allow for accurate nerve testing
during the following approach. A cutaneous incision was made
approximately 3 cm below the inferior border of the mandible • Fig. 43.3 Intraoperative photograph demonstrating the initial exposure
with a #10 scalpel blade centered over the submandibular gland of the submandibular gland.
parallel to the cervical rhytids (Fig. 43.2). Subcutaneous tissue
and the platysma muscle were divided with monopolar electro-
cautery, and subplatysmal flaps were developed to facilitate
wound closure. The investing layer of deep cervical fascia was el-
evated superiorly from an incision originating at the most inferior
extent of the submandibular gland to protect the marginal man-
dibular branch of the facial nerve, which lies within this layer,
from inadvertent trauma (Fig. 43.3). The marginal mandibular
nerve, in this case, was visualized following the elevation of the
superior subplatysmal flap, and its identity was confirmed with a
nerve stimulator. The superior dissection was aided by the inferior
retraction of the submandibular gland with Allis forceps. The fa-
cial artery and vein were identified, ligated, and divided. The
mylohyoid muscle was then exposed and retracted superiorly and
anteriorly to facilitate visualization of the lingual nerve. The
submandibular ganglion and its associated vein were identified,
ligated, and divided. The submandibular duct was identified infe-
rior to the lingual nerve and was ligated and divided as far distally
as was achievable. The left submandibular gland was subsequently
delivered from the neck and submitted in 10% formalin for • Fig. 43.4 Photograph of extirpated left submandibular gland (arrow) and
histopathologic analysis (Fig. 43.4). The wound was closed in a associated sialoliths (arrowheads).

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 CHAPTER 43 Sialolithiasis 213

layered fashion. The placement of a drain can be considered when its genu at the posterior border of the mylohyoid muscle and
there is a concern for a large dead space from the extirpated gland. within the terminal segment of the duct upon entry to the oral
Histopathology revealed the presence of a large submandibular cavity, where the dimension of its punctum is reduced compared
sialolith within the hilum and gland parenchyma as well as find- with the overall caliber of the duct.
ings consistent with sialadenitis, including the presence of a Unfortunately, the etiopathogenesis of sialolithiasis remains
patchy lymphocytic and plasma cell infiltrate, acinar atrophy, unclear. Opposing mechanisms suggest that sialoliths arise from
ductal dilatation, and fibrosis of glandular parenchyma. either the excretion of microcalculi originating from within the
acinar and ductal cells or via retrograde migration of organic debris
Complications and bacteria from the oral cavity. Both mechanisms ultimately re-
sult in the formation of a nidus upon which organic substances,
Complications associated with submandibular gland excision including glycoproteins and mucopolysaccharides, and inorganic
include injury to the marginal mandibular branch of the facial substances, including hydroxyapatite, magnesium whitlockite, and
nerve, lingual nerve, hypoglossal nerve, and greater auricular brushite, accumulate. Regardless of the mechanism, multiple non-
nerve; minor and major hemorrhage; hematoma and sialocele anatomic risk factors for sialolithiasis have been suggested in the
formation; infection; and cutaneous scarring. Submandibular literature, including conditions and medications that reduce sali-
gland excision may be delayed in the setting of acute infection vary flow; dehydration; smoking; and systemic diseases, including
as preexisting inflammation may complicate surgical dissection Sjögren’s syndrome and gout. Unfortunately, the association of si-
and increase the risk of several of the aforementioned complica- alolithiasis with entities such as nephrolithiasis, cholelithiasis, or
tions, including nerve injury and infection. It should be noted Sjögren’s syndrome, as well as the administration of diuretics, an-
that the submandibular glands are responsible for 69% of un- tihistamines, antihypertensives, antipsychotics, or antidepressants,
stimulated salivary production. Reduced salivary flow secondary is mired in controversy within the literature. There is, however, an
to the loss of a single submandibular gland is of concern regard- association between an increased salivary pH and concentrations
ing patient quality of life because xerostomia may precipitate of several ions, including calcium, magnesium, and phosphorus, as
dysphagia, dysgeusia, and dental caries. Several studies have well as smoking and gout with the development of sialoliths.
characterized a reduction in unstimulated saliva production Various imaging modalities may be used to image the salivary
with no deficits during stimulated flow. With respect to the exci- glands, which may include plain film radiography in the form of
sion of the parotid gland, complications include facial nerve panoramic or occlusal images, computed tomography (CT),
injury, sialocele and hematoma formation, cutaneous scarring, cone-beam computed tomography (CBCT), ultrasonography,
and Frey’s syndrome. magnetic resonance imaging (MRI), and sialography. Sialography
can be accomplished by conventional means or paired with several
Discussion advanced imaging modalities, including CT, CBCT, or MRI, and
is especially useful in the presence of radiolucent sialoliths. Unfor-
Obstructive sialadenitis is the most common nonneoplastic condi- tunately, each of these imaging modalities is associated with its
tion associated with the salivary glands. Ductal obstruction may own set of disadvantages, including exposure to ionizing radiation
manifest in the setting of sialolithiasis, fibromucinous plugs, ductal in the case of plain film and CT modalities; allergies to contrast
strictures, foreign bodies, trauma, idiopathic insults during surgi- agents with the use of CT, sialography, or MRI; significant imag-
cal procedures, external-beam radiation or brachytherapy, and ing artifact during CT and MRI acquisition; and technique
ductal compression secondary to locoregional space-occupying le- sensitivity with the application of sialography and ultrasound
sions. Although sialolithiasis is the most common nonneoplastic techniques. Furthermore, all techniques possess variable sensitivi-
cause of salivary gland obstruction with a suggested incidence of ties and specificities for sialolith identification.
approximately 1% based on postmortem analyses, the prevalence There is a large body of literature guiding the treatment of pa-
of symptomatic disease remains markedly lower with estimates tients with sialolithiasis. Despite the advent and modification of
ranging between 0.01% and 0.03%. Sialolithiasis is encountered several treatment algorithms and the contemporary shift away
across a board range of ages with the majority of those affected from gland excision to the application of minimally invasive tech-
within their third to sixth decades of life with no significant sexth niques that aim to preserve gland function, the selection of the
predilection. optimal treatment approach will ultimately be based on myriad
There is an overwhelming prevalence of sialoliths involving the patient characteristics, clinical presentation, physical examination,
submandibular gland over the parotid gland ranging between radiographic and laboratory investigations, surgeon experience and
80% to 90% versus 5% to 10%, respectively. Sialolithiasis affect- preference, and the availability of the surgical armamentarium.
ing the sublingual and minor salivary glands remains relatively The absence of clinical symptoms associated with sialolithiasis may
rare. The increased incidence of submandibular gland versus pa- afford clinicians with the ability to monitor the patient on an as-
rotid gland sialolithiasis may be attributed to several physiologic needed basis. Patient education in these cases should aim to high-
and anatomic factors. Saliva produced within the submandibular light symptoms of salivary gland obstruction that mandate a return
gland is comparatively more mucoid in nature, demonstrating an to clinic for evaluation, including pain, swelling, and the presence
increased viscosity and alkaline pH, with an elevated concentra- of purulent discharge within the oral cavity. In the presence of
tion of inorganic components that contribute to sialolith forma- these symptoms, conservative management that aims to reestablish
tion. Compared with the parotid gland duct, also known anterograde salivary flow may include self-massage and application
as Stenson’s duct, the course of the submandibular gland duct, of warm compresses to the affected gland, maintenance of ade-
otherwise known as Wharton’s duct, is longer and possesses a quate hydration, and administration of antiinflammatory agents
cranially directed course, which necessitates salivary flow against and sialagogues. In some cases, systemic antibiotics may be re-
gravity. Furthermore, the course of Wharton’s duct is convoluted quired that provide staphylococcal coverage, which may be further
and characterized by two significant changes in direction, including tailored by culture and sensitivity results. Failing conservative

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214 S E C TI O N Head and Neck Pathology

management may mandate the use of one or more surgical ap- ment. Sialoliths located within the distal and middle segments of the
proaches, including ductal dilation; conventional or endoscopically salivary ducts may be approached with interventional sialendoscopy,
assisted transoral duct surgery (TDS); and sialolithectomy with or TDS, and ISWL. Sialoliths located within the proximal duct, hilum,
without sialodochoplasty, extracorporeal shock-wave lithotripsy and parenchyma may require interventional sialendoscopy; ISWL;
(ESWL), diagnostic and interventional sialendoscopy, intraductal and in the cases of impacted and inaccessible sialoliths, ESWL. In
shock-wave lithotripsy (ISWL) techniques incorporating intraductal the same way that minimally invasive techniques have reduced the
pneumatic lithotripsy (IPL) or intraductal laser lithotripsy, com- frequency of gland excision from 50% to less than 5%, the advent
bined endoscopic and transcutaneous approaches, and salivary gland and refinement of ISWL techniques has reduced the utility of both
excision. Transoral robotic surgery and CT-guided techniques have ESWL and TDS. Furthermore, success of sialoendoscopic tech-
also been described but are not without a significant consumption niques has been reported to provide durable long-term symptom-
of health care resources with comparatively elevated costs and are free rates in excess of 90% of cases. Finally, in cases that are resistant
generally not considered for first-line surgical management. A criti- to minimally invasive techniques with persistent symptoms, gland
cal aspect of management is predicated on early surgical treatment excision may be considered. In settings where patients are deemed
after the failure of conservative therapy, which has been associated inoperable, symptomatic relief from obstructive symptoms may be
with improved symptomatic outcomes. In general, the position, size, achived by chemodenervation via the administration of botulinum
mobility, and number of sialoliths will assist in guiding treatment. toxin to the affected gland.
After conservative techniques, dilation of the terminal segment and
papilla of the salivary gland ducts may allow for the spontaneous ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
expulsion of smaller sialoliths and preclude the escalation of treat- complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 214.e1

Bibliography Luers JC, Grosheva M, Reifferscheid V, et al: Sialendoscopy for sialoli-

thiasis: early treatment, better outcome, Head Neck 34:499, 2012.
Lustmann J, Regev E, Melamed Y: Sialolithiasis. A survey on 245 patients
Burghartz M, Hackenberg S, Sittel C, et al: Surgery of the major salivary and a review of the literature, Int J Oral Maxillofac Surg 19:135, 1990.
glands and its impact on salivary flow—a review, Laryngoscope Marchal F, Dulguerov P: Sialolithiasis management: the state of the art,
129:2053, 2019. Arch Otolaryngol Head Neck Surg 129:951, 2003.
Capaccio P, Torretta S, Ottavian F, et al: Modern management of ob- McCain JP, Montero J: Surgical retrieval of submandibular stones, Atlas
structive salivary diseases, Acta Otorhinolaryngol Ital 27:161, 2007. Oral Maxillofac Surg Clin North Am 26:111, 2018.
Foletti JM, Graillon N, Avignon S, et al: Salivary calculi removal by McGurk M, Brown J: Alternatives for the treatment of salivary duct ob-
minimally invasive techniques: a decision tree based on the diameter struction, Otolaryngol Clin North Am 42:1073, 2009.
of the calculi and their position in the excretory duct, J Oral Maxil- McGurk M, Escudier MP, Brown JE: Modern management of salivary
lofac Surg 76:112, 2018. calculi, Br J Surg 92:107, 2005.
Fritsch MH: Sialendoscopy and lithotripsy: literature review, Otolaryngol Nahlieli O, Shacham R, Yoffe B, et al: Diagnosis and treatment of strictures
Clin North Am 42:915, 2009. and kinks in salivary gland ducts, J Oral Maxillofac Surg 59:484, 2001.
Guastaldi FPS, da Silva JSP, Troulis MJ, et al: Surgical retrieval of parotid Nahlieli O: Complications of sialendoscopy: personal experience, litera-
stones, Atlas Oral Maxillofac Surg Clin North Am 26:105, 2018. ture analysis, and suggestions, J Oral Maxillofac Surg 73:75, 2015.
Huoh KC, Eisele DW: Etiologic factors in sialolithiasis, Otolaryngol Head Nahlieli O: Extracorporeal lithotripsy, Atlas Oral Maxillofac Surg Clin
Neck Surg 145:935, 2011. North Am 26:159, 2018.
Koch M, Mantsopoulos K, Müller S, et al: Treatment of sialolithiasis: Ngu RK, Brown JE, Whaites EJ, et al: Salivary duct strictures: nature and
what has changed? An update of the treatment algorithms and a re- incidence in benign salivary obstruction, Dentomaxillofac Radiol 36:
view of the literature, J Clin Med 11(1):231, 2021. 63, 2007.
Koch M, Zenk J, Iro H: Algorithms for treatment of salivary gland ob- Schroder SA, Homoe P, Wagner N, et al: Does saliva composition affect
structions, Otolaryngol Clin North Am 42:1173, 2009. the formation of sialolithiasis? J Laryngol Otol 131:162, 2017.
Kolenda J: Intracorporeal lithotripsy, Atlas Oral Maxillofac Surg Clin Sigismund PE, Zenk J, Koch M, et al: Nearly 3,000 salivary stones: some
North Am 26:169, 2018. clinical and epidemiologic aspects, Laryngoscope 125:1879, 2015.
Kraaij S, Karagozoglu KH, Forouzanfar T, et al: Salivary stones: symp- Williams MF: Sialolithiasis, Otolaryngol Clin North Am 32:819, 1999.
toms, aetiology, biochemical composition and treatment, Br Dent J Zenk J, Koch M, Klintworth N, et al: Sialendoscopy in the diagnosis and
217: E23, 2014. treatment of sialolithiasis: a study on more than 1000 patients, Oto-
Kraaij S, Karagozoglu KH, Kenter YAG, et al: Systemic diseases and the laryngol Head Neck Surg 147:858, 2012.
risk of developing salivary stones: a case control study, Oral Surg Oral
Med Oral Pathol Oral Radiol 119:539, 2015.

t.me/Dr_Mouayyad_AlbtousH
44
Acute Suppurative Parotitis
DAN I EL P. C AR U SO, VI NC E N T M . AQ U I N O, T U AN G . B UI, R UI P. F E R N A N D E S ,
DA N IE L J . M E A R A , a n d MI C H A E L R. M A R K IE W IC Z

CC Examination
A 69-year-old female presents to the emergency department (ED) General. The patient is an older adult female who appears older
complaining of left-sided facial pain and swelling. You are con- than her stated age. She is shaking and appears to be in substantial
sulted for further management. pain with subtle facial movements. She has a nasal cannula in
place for her baseline oxygen requirement.
HPI Vital signs. Her blood pressure is 160/73 mm Hg, heart rate is 79
bpm, and respiratory rate is 18 breaths per minute. She has an oxygen
The patient reports that 1 week ago, she experienced left-sided saturation of 97% with a nasal cannula at 3 L/min. Her temperature
facial swelling after a meal, which gradually self-resolved. Two is 39.6°C, and she is endorsing 8 of 10 on the pain scale.
days before presentation, she experienced another episode of left- Maxillofacial. She has obvious facial asymmetry with swelling
sided facial swelling after a meal, which continued to worsen. of the soft tissues overlying the left preauricular area and angle of
Because of the progressive nature of the swelling and onset of the mandible (Fig. 44.1). The tissue is indurated and exquisitely
pain, she presented to the ED for further care. She reports a foul tender to palpation. She has palpable, mobile, tender lymph
taste in her mouth, limited mouth opening, and decreased appe- nodes in her left precervical chain. The inferior border of the
tite. She also endorses the onset of fever and chills with tempera- mandible is easily palpable. Her maximal incisal opening is 18
tures ranging between 38.3° and 38.9°C starting 1 day earlier. mm (Fig. 44.2).
A thorough clinical history refines the differential diagnosis Intraoral. Oral hygiene is poor with generalized build-up of
and guides the work-up and treatment. In a case in which paroti- plaque and calculus throughout the dentition. The oral mucous
tis is at the top of the differential diagnosis, it is important to as- membranes are dry (dehydration). Extraoral palpation of the left
sess the following: (1) duration of symptoms; (2) presence of pain; parotid gland elicits intraoral purulent drainage from Stenson’s
(3) continuous, episodic, or recurrent symptoms; (4) presence of duct (Fig. 44.3). The contralateral parotid gland and both sub-
viral prodrome; and (5) associated joint pains or dry eyes. mandibular glands express clear saliva. There is no fluctuance or
swelling within the buccal vestibules. The floor of mouth is soft
PMHX/PDHX/Medications/Allergies/SH/FH and nonelevated. The uvula is midline. The oropharynx and ton-
sillar pillars are benign.
The patient’s medical history includes chronic obstructive pulmo-
nary disease requiring oxygen at home, atrial flutter, prior pulmo- Imaging
nary embolus on warfarin, hypertension, hyperlipidemia, congestive
heart failure, rheumatoid arthritis, and hypothyroidism. She has Facial swelling, pain, and fever are the common presenting symp-
previously undergone tonsillectomy. Her medications include gaba- toms for ASP, but other infections, such as those of odontogenic
pentin, omeprazole, torsemide, tramadol, multiple inhalers, meto- origin, may present in a similar manner and cause swelling of the
prolol, levothyroxine, and warfarin. She denies any alcohol, tobacco, periparotid region. In patients with a poor dentition and unclear
or recreational drug use. source of infection, a panoramic radiograph is a useful screening
The patient’s age and extensive list of medical comorbidities is study to help rule out possible odontogenic sources of infection.
consistent with the bimodal distribution of patients most com- The current patient’s panoramic radiograph shows a heavily re-
monly affected by acute suppurative parotitis (ASP). A majority stored posterior dentition with periapical radiolucencies associated
of cases occur in older adult patients and infants younger than 1 with the roots of the left mandibular second molar but no obvious
year of age. Risk factors for ASP demonstrated by this patient identifiable source for her current presentation (Fig. 44.4).
include dehydration, hypothyroidism (immunosuppressed state), Further imaging may be warranted if there are concerns for
mechanical obstruction of salivary flow (sialolithiasis), poor oral abscess with extraglandular extension and deep space involvement
hygiene, and decreased salivary flow secondary to medications. or obstructive pathology (sialolith or neoplasm). Of note, a creati-
Other potential comorbidities such as bulimia and autoimmune nine level or estimated glomerular filtration rate is typically re-
diseases must be assessed on the review of systems. quired for all patients before intravenous (IV) contrast-enhanced

215
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216 S E C TI O N Head and Neck Pathology

A B
• Fig. 44.1 A, Frontal clinical photograph demonstrating facial asymmetry with swelling of the soft tissues
over the left preauricular area and angle of the mandible. There is distortion of the left nasolabial fold. B,
Submental vertex clinical photograph.

• Fig. 44.3 Clinical photograph demonstrating purulent drainage from the

left Stenson’s duct on extraoral manipulation of the parotid gland.

• Fig. 44.2 Clinical photograph demonstrating the patient’s maximal

mouth opening with an interincisal distance of 18 mm.

computed tomography (CT). The patient underwent contrast CT,

which showed swelling of the left parotid gland and edema of the
surrounding soft tissues (Fig. 44.5). There is no evidence of a
• Fig. 44.4 Panoramic radiograph demonstrating a heavily restored pos-
drainable fluid collection or abscess formation. A 6-mm-diameter terior dentition. The left mandibular second molar is broken down and has
stone is seen at the end of Stensen’s duct with proximal dilatation a periapical radiolucency on each of its roots. There is a radiopacity over-
(Fig. 44.6). If a mass, fluid collection, or lesion had been noted, a lying the left mandibular body.

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 CHAPTER 44 Acute Suppurative Parotitis 217

A B
• Fig. 44.5 A, Contrast computed tomography (CT), soft tissue window, axial cut demonstrating diffuse
swelling of the left parotid gland with fat stranding of the overlying soft tissue. There is no obvious abscess.
B, Contrast CT, soft tissue window, coronal cut demonstrating similar findings.

A B
• Fig. 44.6 A, Contrast computed tomography (CT), bony window, axial cut demonstrating a 6-mm sialo-
lith (red arrow) within Stensen’s duct. B, Contrast CT, bony window, coronal cut demonstrating a 6-mm
sialolith (red arrow) within Stensen’s duct.

fine-needle aspiration (FNA) may be warranted as part of the (WBC) count. A basic metabolic panel (BMP) is also important
workup. Also, a sialogram is likely contraindicated in this acute to evaluate and rule out any metabolic or electrolyte derange-
setting because it is extremely painful in the patient with acute ments. A ratio of blood urea nitrogen to creatinine greater than
parotitis and could lead to glandular damage. Of note, a sialogram 20 to 1 suggests prerenal azotemia and is consistent with dehydra-
is performed to diagnose blockage of the salivary flow caused by tion. Blood cultures should be obtained in patients presenting
stones or strictures. This examination is done by introducing a with sepsis or if the patient is immunocompromised. Of note,
small tube into Stenson’s duct intraorally and injecting a small signs of sepsis include fever, mental status changes, tachycardia,
amount of radiopaque dye to delineate the duct anatomy. tachypnea, and hypotension. The patient had a leukocytosis with
a WBC count of 14,320/mL and a neutrophil predominance
Labs (86.7%). The absolute neutrophil count was elevated at 12,430/
mL. Her BMP was unremarkable.
A complete blood count with differential is part of the workup for Purulent fluid should be sampled when present and sent
any infectious patient, particularly to assess the white blood cell for Gram stain and culture. Cultures should be sent for aerobes,

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218 S E C TI O N Head and Neck Pathology

anaerobes, fungi, and mycobacteria. The patient was swabbed in

the ED because she was already draining purulent fluid. It is
important to note that cultures obtained from Stensen’s duct may
be contaminated with oral flora and unreliable for identifying
the causative organism. The Gram stain showed gram-positive
cocci in clusters and gram-negative bacilli. The potassium
hydroxide (KOH) was unremarkable. The cultures ultimately
grew Staphylococcus aureus.
Serum amylase and C-reactive protein (CRP) tests can also be
performed and usually show marked elevation. A CRP value
obtained weekly postoperatively can be used as a marker for reso-
lution of infection. Of note, CRP is a protein produced by the
liver, and elevated levels are a nonspecific indication of systemic • Fig. 44.7 Clinical photograph demonstrating a 6-mm salivary stone ex-
tracted from the left Stensen’s duct.
inflammation.

Differential Diagnosis Complications

The differential diagnosis should include sialadenitis, odontogenic The most severe complications are related to the spread of infec-
abscess, lymphadenopathy, brachial cleft cyst, temporomandibular tion to the deep spaces of the neck. The parotid space is immedi-
joint septic arthritis, otitis externa, masseter hypertrophy, and Lemierre ately adjacent to the parapharyngeal space with infectious spread
syndrome (septic thrombophlebitis of the internal jugular vein). taking the path of least resistance. Involvement of the lateral
parapharyngeal space can lead to respiratory compromise, septic
Assessment jugular thrombophlebitis, and bacteremia. Rare complications
that can occur with severe infections include osteomyelitis of sur-
Acute suppurative parotitis in the setting of dehydration and sialolith. rounding facial bones, facial nerve palsy, and fistulas to the skin.
The prognosis is generally good in healthy patients who receive
Treatment: early treatment. However, there is a high mortality rate in those
with significant risk factors and comorbidities. Surgical interven-
The initial management of patients with ASP is mostly medical. tion is only warranted when there is a frank abscess fluid collec-
There should be a low threshold for admission (especially in vul- tion or if there is failure to respond to medical therapy and can
nerable populations) because there is the potential for spread to also potentially be considered in cases of multiple recurrences.
the deep fascial spaces. Management includes administration of
IV antibiotics, aggressive hydration (IV fluids), warm compresses, Discussion
nutritional support, and sialogogues. If there is a lack of response
over a 48-hour period, cultures should be redrawn, antibiotics Parotitis is a general term that denotes inflammatory swelling of
broadened, and further imaging considered. the parotid gland. The goal of diagnosis should be to categorize
The initial antibiotic regimen is selected based on the expected the patient with parotitis into the correct etiologic subset, which
microbiology known to cause ASP because there is no systematic will help to dictate the appropriate treatment (Box 44.1).
data to inform the selection. S. aureus has been the most com- Antibiotics and improved postsurgical care have made this
monly isolated pathogen, but infections are usually polymicro- condition relatively uncommon, and thus the precise incidence is
bial. Empiric regimens for immunocompetent individuals should unknown. Older data estimate the incidence to be 0.01% and
be directed against methicillin-susceptible S. aureus, Haemophilus 0.02% of all hospital admissions. Culture data are important for
influenzae, viridans streptococci, and oral anaerobes, with strict directing antimicrobial therapy, and because of the potential for
anaerobes as the causative agent in almost half of the cases of ASP. contamination by oropharyngeal flora, FNA is thought to be the
A large portion of bacteria causing sialadenitis produce beta-lacta- superior means for obtaining appropriate culture data.
mase, which should be taken into account when deciding initial Ultrasonography is an easy, well-tolerated, inexpensive, and
empiric therapy. Beta-lactamase–resistant penicillins (e.g., ampi- readily available imaging modality as an initial means to evaluate
cillin–sulbactam) are a first-line choice. In patients with a true the parotid gland, although it is operator dependent. Ultrasonogra-
penicillin allergy, cefuroxime, ceftriaxone, or levofloxacin com- phy is capable of detecting abscess formation, nodules within the
bined with metronidazole or clindamycin provides appropriate parenchyma, duct dilatation, and sialoliths. Contrast-enhanced CT
coverage. Methicillin-resistant S. aureus should only be considered is used to assess the extent and depth of an abscess and is the most
in susceptible populations and should not be covered empirically. sensitive tool for differentiating suppurative parotitis from a discrete
When the patient starts to clinically improve, typically within 3 abscess. Noncontrast CT is helpful for identifying calculi. Magnetic
to 5 days, IV antibiotics can be converted to an oral regimen. resonance imaging (MRI) may be indicated for patients with recur-
There are no data to guide the duration of therapy, but for rent parotitis or atypical findings on examination. MR sialography
uncomplicated cases, 10 to 14 days of therapy is considered is contraindicated in the setting of acute infection.
reasonable. The aim of diagnosis should be to categorize the patient with
The patient in this case was admitted to the hospital, started parotitis into one of three possible subcategories to guide manage-
on the appropriate IV antibiotics, and aggressively hydrated. She ment (Box 44.2).
improved, was discharged, and completed a course of oral antibi-
otics for a total 2-week course. She underwent duct dilation and ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
sialolith extraction several weeks after resolution (Fig. 44.7). complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 44 Acute Suppurative Parotitis 219

• BOX 44.1 Categorization of Parotitis to Guide Management

Acute suppurative (bacterial) parotitis (ASP) is a result of decreased salivary • Granulomatous inflammation: Most commonly Mycobacterium tuberculosis.
flow leading to retrograde infection of the parotid gland. Risk factors affect- Further considerations include other Mycobacterium spp., Actinomycosis
ing salivary flow and thus predisposing patients to ASP include dehydration, spp., and Bartonella henselae (cat-scratch disease).
recent surgery, sepsis, immunosuppressed states (diabetes, hypothyroidism, • Autoimmune conditions: Common conditions include Sjögren’s disease, systemic
alcoholism, malnutrition), autoimmune conditions (Sjögren’s disease), me- lupus erythematosus, diabetes, cystic fibrosis, and collagen vascular disease.
chanical obstruction of salivary flow (sialolithiasis, ductal strictures, neo- Chronic recurrent (bacterial) parotitis (CRP) is a nonspecific parotid sialade-
plasms), poor oral hygiene, prior radiation, and decreased salivary flow sec- nitis that may be unilateral or bilateral and can present as either episodes
ondary to medications (antidepressants, antihistamines, anticholinergics, of swelling and remission or persistent swelling with recurrent infection. It
diuretics, beta-blockers). Appropriate history, clinical examination, and radio- is a primary disease process often confused with ASP and NSP because of
graphic findings are imperative to obtain the correct diagnosis. Clinical the overlap of risk factors. The inciting factor for CRP is decreased salivary
symptoms of ASP include sudden swelling of the parotid region with frank flow, which leads to episodic swelling of the parotid region that lasts for
suppuration from Stensen’s duct. If systemic symptoms are present, hospital days to months. Unlike in ASP, there is usually no purulence on examina-
admission should be considered. A panoramic radiograph can be used to help tion, and swelling is unrelated to meals. Inflammation within the gland in-
rule out obstructive ASP secondary to sialolith, and computed tomogra- cites characteristic changes to the ductal and parenchymal architecture,
phy (CT) with contrast is indicated when there is concern for abscess forma- which ultimately leads to peripheral dilation and stricture formation. These
tion. Further imaging studies, such as sialography, and exploration of Sten- changes can be seen with sialography, CT, magnetic resonance imaging, or
son’s duct should be delayed until resolution of acute symptoms. Treatment of scintigraphy. Continued destruction of the parenchyma leads to extravasa-
ASP includes aggressive hydration and antibiotic therapy targeting Staph- tion of contrast material in late stages. Treatment of patients with CRP tar-
ylococcus aureus or gram-negative bacterium. gets reduction of the inflammatory state and is best accomplished with oral
Nonsuppurative parotitis (NSP) is inflammatory swelling of the parotid gland dexamethasone. Other adjunct treatments include sialogogues, warm com-
without purulent discharge. NSP has numerous causes, including viruses, presses, and antibiotics when indicated. Antibiotic therapy should target S.
granulomatous inflammation, and autoimmune disorders. When the underly- aureus adults and Streptococcus viridans in the pediatric population. Sialo-
ing condition is appropriately treated, the accompanying parotitis will resolve. endoscopy can be used as both a means of diagnosis and treatment by
Additionally, it is crucial to avoid low-flow salivary states when possible. providing direct visualization of the ductal system and allowing for inter-
• Viruses: Most commonly paramyxovirus (mumps), although there has been a ventions (e.g., sialolith retrieval, ballooning and stenting of strictures). Pa-
decreased incidence with vaccinations. Other causative viruses include Ep- rotidectomy is indicated if conservative and minimally invasive treatment
stein-Barr virus, coxsackievirus, herpes simplex, cytomegalovirus, and HIV modalities are unsuccessful.
(bilateral parotid enlargement secondary to intraglandular lymphadenopathy).

• BOX 44.2 Subcategories of Parotitis

Definitions Nonsuppurative or Sialadenosis
• Sialadenitis: inflammation of a salivary gland • Gland involvement is often bilateral
• Sialadenosis: a recurrent, noninflammatory, nonneoplastic enlargement of • Multiple potential causes, including viral, autoimmune, or metabolic
salivary glands usually associated with an underlying systemic disorder • Mumps virus is most common and includes younger age, prodromal period
(fever, headache, and malaise), and leukopenia instead of leukocytosis
Acute Parotitis • Other common viral organisms include enteroviruses, influenza, parainflu-
Suppurative enza, coxsackie, EBV, HIV, and in the COVID-19 era, one must also consider
• Bacterial SARS-CoV-2
• Duration .1 month
• Characterized by sudden enlargement of the gland Chronic Recurrent Parotitis
• Often associated with pain • Duration .1 month
• Cause is typically infectious, obstructive, or inflammatory • The size of the gland can range from normal to enlarged or even atrophic
• Patient may complain of a foul taste in the mouth • Less likely to be painful
• Purulence may be expressed from Stenson’s duct • Causes include primary salivary gland tumors, autoimmune disease,
• Common bacterial organisms include: granulomatous disease, vasculitides, HIV, and infiltrative diseases
• Community acquired: staphylococci, Haemophilus influenzae, oral aer- • Autoimmune diseases such as Sjögren’s syndrome can evolve from a
obes or anaerobes sialadenosis to a an acute parotitis and ultimately to a chronic condition
• Hospital acquired: MRSA, enterobacterials, Pseudomonas aeruginosa • Other causes are broad and include alcoholism, antihistamines, cystic
• Obstruction is most common, and cases are the result of salivary stones, fibrosis, gout, sarcoidosis, diabetes mellitus, bulimia nervosa, IgG4-related
strictures, or both disease, and Melkersson-Rosenthal syndrome
• Juvenile recurrent parotitis is an acute parotitis of unknown cause, typically EBV, Epstein-Barr virus; MRSA, methicillin-resistant Staphylococcus aureus; SARS-CoV-2, severe
in males between 4 months and 15 years of age that is self-limited and acute respiratory syndrome–related coronavirus.
resolves at puberty, with treatment focused on symptom management

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 219.e1

Bibliography Jibidar H, Souchon S, Miric D, et al: Occurrence of suppurative parotitis

in elderly people remains a bad omen, J Am Geriatr Soc 2008;56(4):760-
761. doi:10.1111/j.1532-5415.2008.01614.x.
Abdel Razek AAK, Mukherji S: Imaging of sialadenitis, Neuroradiol J Katz J, Fisher D, Levine S: Bacterial colonization of the parotid duct in
30(3):205-215, 2017. doi:10.1177/1971400916682752. xerostomia, Int J Oral Maxillofac Surg 19:7-9, 1990.
Abu-Taleb NSM, Abdel-Wahed N, Amer ME: The role of magnetic reso- Komagamine J, Osawa H: Acute suppurative parotitis following acute
nance imaging and magnetic resonance sialography in the diagnosis of ischemic stroke: a case report, Cureus 14(1):e21497, 2022. doi:10.7759/
various salivary gland disorders: an interobserver agreement, J Med cureus.21497.
Imaging Radiat Sci 45(3):299-306, 2014. doi:10.1016/j.jmir.2014. Krippaehne WW, Hunt TK, Dunphy JE: Acute suppurative parotitis: a
03.092. study of 161 cases, Ann Surg 156:251-257, 1962. doi:10.1097/00000658-
Alabraba E, Manu N, Fairclough G, et al: Acute parotitis due to MRSA 196208000-00010.
causing Lemierre’s syndrome, Oxf Med Case Reports 2018(5):omx056, Lampropoulos P, Rizos S, Marinis A: Acute suppurative parotitis: a
2018. doi:10.1093/omcr/omx056. dreadful complication in elderly surgical patients, Surg Infect (Larchmt)
Chow AW: Suppurative parotitis in adults. In UpToDate, Post TW. 13(4):266-269, 2012. doi:10.1089/sur.2011.015.
Baurmash HD: Chronic recurrent parotitis: a closer look at its origin, McQuone SJ: Acute viral and bacterial infections of the salivary glands,
diagnosis, and management, J Oral Maxillofac Surg 62:1010-1018, Otolaryngol Clin North Am 32(5):793-811, 1999. doi:10.1016/s0030-
2004. 6665(05)70173-0.
Brook I: Microbiology and antimicrobial management of sinusitis, J Lar- Nahlieli O, Bar T, Shacham R, et al: Management of chronic recurrent
yngol Otol 119(4):251-258, 2005. doi:10.1258/0022215054020304. parotitis: current therapy, J Oral Maxillofac Surg 62:1150-1155, 2004.
Cohen MA, Docktor JW: Acute suppurative parotitis with spread to the Naragund AI, Halli VB, Mudhol RS, et al: Parotid fistula secondary to
deep neck spaces, Am J Emerg Med 17(1):46-49, 1999. doi:10.1016/ suppurative parotitis in a 13-year-old girl: a case report, J Med Case
s0735-6757(99)90015-3. Rep 4:249, 2010. doi:10.1186/1752-1947-4-249.
Fattahi TT, Lyu PE, Van Sickels JE: Management of acute suppurative Scoggins L, Vakkas TG, Godlewski B: Rapidly progressing bilateral sub-
parotitis, J Oral Maxillofac Surg 60(4):446-448, 2002. doi:10.1053/ mandibular sialadenitis and suppurative parotitis with concomitant
joms.2002.31234. group C streptococcal pharyngitis, J Oral Maxillofac Surg 68(10):2585-
Fisher J, Monette DL, Patel KR, et al: COVID-19 Associated parotitis, 2590, 2010. doi:10.1016/j.joms.2009.09.102.
Am J Emerg Med 39:254.e1-254.e3, 2021. Tan VES, Goh BS: Parotid abscess: a five-year review—clinical presenta-
Hernandez S, Busso C, Walvekar RR: Parotitis and sialendoscopy of the tion, diagnosis and management, J Laryngol Otol 121(9):872-879,
parotid gland, Otolaryngol Clin North Am 49(2):381-393, 2016. 2007. doi:10.1017/S0022215106004166.
doi:10.1016/j.otc.2015.12.003. Ugga L, Ravanelli M, Pallottino AA, et al: Diagnostic work-up in ob-
Hoffman HT: Salivary gland swelling: evaluation and diagn approach. In structive and inflammatory salivary gland disorders, Acta Otorhinolar-
UpToDate, 2022, Wolters and Kluwer. yngol Ital 37(2):83-93, 2017. doi:10.14639/0392-100X-1597.

t.me/Dr_Mouayyad_AlbtousH
45
Differential Diagnosis of a Neck Mass
J AI K. ME DI R AT TA a n d K E V I N L. R I E C K

CC freely movable subcutaneously with no clear attachment to the

overlying skin. No fluctuance or frank fluid component is appre-
A 63-year-old male is referred for evaluation of a mass in his neck. ciated within the mass on bimanual examination. It is not warm
to palpation as would be seen with inflammation. The overlying
HPI skin appears normal (Fig. 45.1). No palpable cervical adenopathy
is noted. Palpable cervical lymphadenopathy may be a harbinger
The patient reports a several-month history of a midline subman- of metastasis or acute or chronic inflammation.
dibular neck swelling that he associated with an abscessed tooth. A Intraoral. The patient is partially edentulous with no grossly
mandibular tooth was subsequently removed by his dentist, but the carious dentition noted. There are no soft tissue lesions in the oral
patient indicates no improvement with his submandibular swelling. cavity. Salivary flow appears normal and without evidence of ob-
The patient reports that the area is slightly tender. Of note, struction or erythema at the orifices of the submandibular and
swellings of neoplastic origin are unlikely to be painful or tender.
He further indicates the swelling under his jaw had been present
for many months, suggesting a chronic process, but had become
especially bothersome over the past several weeks. There are no
associated symptoms of hoarseness or dysphagia as would be seen
with impingement of a mass on the vocal cords or posterior oro-
pharynx. There is no history of recent weight loss, a nonspecific
constitutional symptom suggestive of a malignant process. He does
not have any complaints of airway obstruction or difficulty breath-
ing. Airway compromise, either caused by an expanding mass or
infectious processes (e.g., cellulitis), requires acute intervention.

PMH/PDH/Medications/Allergies/SH/FH
The patient has an unremarkable past medical and surgical his-
tory. There is no family history of similar presentations. He does
not have any social risk factors for neoplastic causes of his neck A
mass such as smoking or alcohol abuse. His abscessed tooth could
cause submandibular swelling, but this would be unlikely because
of the persistence of symptoms after removal of the infectious
source. Patients should be questioned regarding a history of ma-
lignancies that may present with a metastatic lesion in the neck.

Examination
General. The patient is a well-developed and well-nourished male
in no apparent distress.
Vital signs. Vital signs are stable, and the patient is afebrile,
further ruling out an infectious cause. Fever and tachycardia may
be suggestive of an infectious process. Tumors can also cause fever
either secondary to associated inflammation or infection or be
caused by the release of inflammatory mediators, such as tumor B
necrosis factor.
Maxillofacial. There is a soft, doughy midline swelling of the • Fig. 45.1 Frontal view (A) and profile (B) swelling of the submandibular
submandibular area measuring 6 cm in diameter. The mass is area measuring 6 cm in diameter. The overlying skin appears normal.

220
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 45 Differential Diagnosis of a Neck Mass 221

parotid ducts, an important finding that makes sialadenitis un-

likely. The muscles of mastication and temporomandibular joints
function normally and appear unremarkable on examination. Bi-
manual intraoral examination also reveals a palpable mass in the
midline floor of the mouth that appears to be contiguous with the
anterior neck mass. The mass does not elevate with tongue protru-
sion or swallowing. Elevation of the mass would be consistent
with a thyroglossal duct cyst.

Imaging
Imaging plays an important role in the diagnosis of neck lesions.
It offers details on the anatomic location of a mass, consistency of
the mass, and possible involvement of adjoining anatomic struc-
tures. Imaging modalities include Panorex imaging, computed
tomography (CT), magnetic resonance imaging, combined posi-
tron emission tomography (PET/CT) scans, and ultrasonography.
For the pediatric population, ultrasonography is the first-line
imaging modality for the evaluation of superficial pediatric masses
because of reduced radiation exposure and need for iodinated
contrast material. A vast majority of these lesions found in this
population ultimately prove to be benign.
Panoramic, lateral cephalometric or lateral neck films are rarely
used in evaluating soft tissue neck masses. However, panoramic • Fig. 45.2 Contrast-enhanced computed tomography scan showing a
5-cm, cystic-appearing mass in the anterior midline neck between the
radiography should be used as a screening tool for evaluation of the
mandible and the hyoid bone.
dentition if there is suspicion of an odontogenic source of infec-
tion. Contrast-enhanced CT scanning is the first line and best
imaging for evaluating a neck mass. Contrast-induced acute kid-
ney injury is a feared adverse event when obtaining contrast-en- Differential Diagnosis
hanced CT imaging. Risks and benefits of this imaging modality
should be considered in patients with a compromised kidney func- The differential diagnosis of a neck mass can be quite extensive and
tion (i.e., estimated glomerular filtration rate ,30 mL/min). can include any or all of the intricate structures in the neck. There
Magnetic resonance imaging is indicated for masses requiring are several considerations in distinguishing between inflammatory
further definition of soft tissue such as infiltrative soft tissue and infectious causes, anatomic variants, congenital lesions, and
masses or suspicion of malignant perineural spread. PET/CT benign or malignant processes. One of the most important aspects
scans play a very limited role in the initial evaluation of a neck in assessing a neck mass is a thorough patient history. The age of the
mass and are instead more useful in the later evaluation when patient is an important initial consideration. An adult patient older
considering malignancy as well as possible distant metastasis. than 40 years of age has an 80% chance that a nonthyroidal neck
For the current patient, the panoramic radiograph demon- mass will be neoplastic; of these, 80% of cases are metastatic squa-
strated no source of odontogenic or osseous pathology. The con- mous cell carcinoma (SCC) from the aerodigestive tract. Fig. 45.3
trast-enhanced CT scan showed a 5-cm, cystic-appearing mass in presents a flowchart for the diagnosis of a neck mass that incorpo-
the anterior midline neck between the mandible and the hyoid rates age and location as distinguishing factors.
bone (Fig. 45.2). Several spherical densities were noted within the In general, for differential diagnosis of a neck mass, it is useful
lesion. There was no evidence of adenopathy. The mass appeared to consider four broad categories: neoplastic, inflammatory and/
discrete and not attached to the overlying skin. or infectious, congenital, and anatomic (Box 45.1).
The clinician must maintain a high index of suspicion for
Labs metastatic disease processes. These commonly include SCCs of the
head and neck, in addition to lung, thyroid, and salivary gland
No specific laboratory tests are indicated in the absence of a malignancies. Melanoma may also present in this area. Primary
pertinent medical history. However, in patients in whom the neck tumors presenting as a neck mass typically result from sali-
provided history or the physical examination findings are am- vary gland lesions, lymphoma, or thyroid masses. Benign masses
biguous, it is suggested that laboratory studies be performed in result from several of the tissues in the neck. These can include
concurrence with a malignancy work-up in select patients. Most lipomas, neural tumors, vascular lesions, sebaceous cysts, and
patients should have a complete blood count with differential. fibromas, to name a few.
For some patients, you may consider an erythrocyte sedimenta-
tion rate or C-reactive protein to evaluate for systemic inflam- Assessment
mation. A blood culture is helpful for patients who are febrile.
Infectious causes such as Epstein-Barr virus, cytomegalovirus, A well-circumscribed soft tissue mass of the anterior midline neck.
HIV, Toxoplasma gondii infection, brucellosis, and Bartonella Fine-needle aspiration (FNA) was performed and revealed
infection may be investigated based on an increased index of scant cellular material. The diagnosis would require surgical ex-
suspicion. ploration with an excisional biopsy.

t.me/Dr_Mouayyad_AlbtousH
222 S E C TI O N Head and Neck Pathology

Age younger than

Age 40 y or older
40 y

1. Inflammatory 1. Neoplastic
malignant .benign

2. Congenital or
developmental 2. Inflammatory

3. Neoplastic 3. Congenital/
benign .malignant developmental

Location

Midline or Lateral
anterior neck neck

Inflammatory: Inflammatory:
Bacterial, viral Bacterial, viral
Congenital: Congenital:
Dermoid cyst, thyroglossal Branchial cleft cysts,
duct cyst lymphangioma
Neoplastic: Neoplastic:
Thyroid, lymphoma Lymphoma, metastatic
carcinoma, salivary gland
tumors, carotid body tumor

• Fig. 45.3 Evaluation of a neck mass using age and location as distinguishing factors.

• BOX 45.1 Four Major Categories for Differential Diagnosis of a Neck Mass
• Anatomic. Several anatomic structures are palpable in certain patients. • Dermoid cysts are midline masses that lie deep to the cervical fascia and
These include the transverse process of C1, the hyoid bone, the thyroid and tend to be slow growing. They are above the hyoid bone and do not move
cricoid cartilages, and prominent or atherosclerotic carotid bulbs. with protrusion of the tongue.
• Inflammatory or infectious. This category encompasses several causes of a • Branchial cleft cysts are remnants of the branchial arch apparatus pres-
neck mass, which is generally a reactive process. Cervical adenitis can arise ent during embryogenesis.
from bacterial, viral, parasitic, and fungal sources. Staphylococcus aureus, • First branchial cleft cysts (two types are possible):
cutaneous skin infections, Epstein-Barr virus, and herpes simplex viruses are (a) Type I cysts tend to occur in the preauricular or postauricular region
frequent culprits. Other inflammatory causes include infectious or obstructive and connect the skin to the external auditory canal.
lesions of the salivary glands. Sialadenitis and associated sialolithiasis of the (b) Type II cysts are near the mandibular angle and closely associated
major salivary glands can cause significant swelling in the neck. with the parotid gland.
• Congenital lesions or masses. These are frequently recognized at an early • Second branchial cleft cysts are the most common of the branchial cleft
age but may also present later in life with the onset of new symp- toms. cysts. The cyst or opening to the cyst is usually found at the anterior edge
Several common disorders are encountered: thyroglossal duct cyst, of the sternocleidomastoid muscle.
branchial cleft cyst or fistula, cystic hygroma, dermoid cyst, lymphangioma, • Third branchial cleft cysts are very rare. These are also found along the
and ranula. Other rare conditions, such as thymic mass, laryngoceles, and anterior border of the sternocleidomastoid muscle but ultimately empty into
teratomas, also can occur. the piriform sinus.
• Thyroglossal duct cysts are midline or anterior neck masses. These fre- • Fourth branchial cleft cysts can occur and have an extensive course
quently appear after upper respiratory tract infections. The mass itself through the neck, looping around the hypoglossal nerve and aortic arch.
moves with swallowing or tongue protrusion. The cyst, thyroglossal tract, • Neoplastic. Neoplastic lesions in the neck are common and have certain
and midportion of the hyoid bone are removed in the Sistrunk procedure to characteristics that set them apart from other conditions. Masses fixed to the
treat this condition. underlying structures and matted nodes are ominous findings for malignancy.

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 45 Differential Diagnosis of a Neck Mass 223

Treatment progression, and any associated symptoms must be elicited from

the patient when possible. Similarly, the association of SCC with
The patient underwent a cervical exploration under general anes- alcohol and tobacco abuse has been well documented, and the
thesia in the hospital. Before any incision, the lesion was aspirated patient’s present and past use of these products should be noted.
and returned several milliliters of a viscous, yellowish fluid. A Any recent exposure to infectious diseases, trauma, animals such as
transverse incision was made in the anterior neck well below the cats, dental work, or surgical intervention should be determined.
mass. Subcutaneous skin flaps were raised, and the platysma mus- The adult patient presenting with a neck mass should have a
cle was identified. Blunt dissection was performed around the thorough history taken to assist in the diagnosis. Our approach to
mass. The mylohyoid muscle was identified and divided in the evaluating a neck mass, after consideration of age as outlined in
midline. No communication with the oral cavity was encountered. Fig. 41.2, is to first exclude or treat a bacterial infection. Although
The mass was removed and submitted for permanent histopatho- infectious masses are uncommon, they must be promptly treated
logic examination (Fig. 45.4). A drain was placed in the neck de- or ruled out. Treatments for infectious causes include broad-
fect, and the wound was closed in standard layered fashion. spectrum antibiotics, incision and drainage, or both followed by
The pathologic diagnosis revealed the lesion to be a dermoid serial reevaluation.
cyst. These cysts can have tremendous histologic variability. There If an infectious cause is ruled out, further work-up should be
is a connective tissue wall that may have a thin lining of epithelial performed to rule out malignancy, especially in an adult in the
cells. This can exhibit keratinization, and the lumen may be filled fourth decade of life or beyond. Most neck masses in this popula-
with keratin and a sebaceous fluid. Glandular components from tion are in fact neoplastic rather than infectious. The presence of
apocrine or sebaceous tissue may also be present. a nonpainful, chronic mass (.2 weeks) without an infectious
cause and a size larger than 1.5 cm with fixed or reduced mobil-
Complications ity are all signs suggestive of malignancy. Supplemental evalua-
tion with contrast-enhanced CT can further characterize the
Several complications can occur in performing neck surgery. He- lesion beyond physical examination; however, FNA of the mass
matomas; seromas; wound infections; injury to branches of the is ultimately diagnostic. If a neoplastic lesion is determined to be
facial, trigeminal, or hypoglossal nerves; and atypical scar forma- resectable, management will typically be surgical excision as well
tion are all possible sequelae. Surgeons must have a thorough as reconstruction when indicated. Patients with advanced locore-
understanding of anatomy to effectively recognize and manage gional disease are considered high risk for reoccurrence, and a
lesions and complications in this complex area. multidisciplinary approach to treatment is typically considered.
In addition to resection and reconstruction, high-risk patients
Discussion may undergo chemotherapy, radiation, or both. Although a mul-
tidisciplinary approach is considered the standard of care for
The diagnostic challenge in assessing a neck mass can be over- patients with advanced locoregional disease, the 5-year survival
whelming. It is important to have a consistent system in both rate in for these patients remains suboptimal.
history taking and examination aspects in the approach to this Immunotherapy is an emerging class of treatments that has
complex anatomic region. Onset, duration, size fluctuations or revolutionized the management of multiple cancers, including
head and neck cancers. Currently, there are four approved immu-
notherapies for the treatment of patients with head and neck
cancers. Cetuximab, the first immunotherapy approved in pa-
tients with head and neck SCC, is a monoclonal antibody that
targets the epidermal growth factor receptor pathway and is often
considered first-line therapy. Dostarlimab, nivolumab, and pem-
brolizumab are checkpoint inhibitors that target the programmed
cell death-1 (PD-1)–programmed cell death-ligand 1 (PD-L1)
pathway, an important pathway in both cellular apoptosis and
cancer immune escape. Advantages of immunotherapy include
favorable toxicity; however, the efficacy of this treatment remains
to be further studied. Early studies indicate response to current
immunotherapies to be moderate with about 15% to 20% of
patients responding.
The current patient tolerated the surgical procedure well and
had an uneventful postoperative course. Histopathologic evalua-
tion confirmed the diagnosis of a dermoid cyst. This is thought to
result from entrapment of midline epithelial tissue during the
closure of the mandibular and hyoid branchial arches. In this lo-
cation, they are rarely present at birth and typically present in
young adulthood. As in this case, these cysts typically feel dough-
like, but this can vary with the actual contents of the cyst. They
can be either above or below the mylohyoid.

,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for

• Fig. 45.4 The surgical specimen, later diagnosed as a dermoid cyst. complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 223.e1

Bibliography Lee J, Fernandes R: Neck masses: evaluation and diagnostic approach, Oral
Maxillofac Surg Clin North Am 20(3):321-337, 2008. doi:10.1016/j.
coms.2008.04.001.
Bansal AG, Oudsema R, Masseaux JA, et al: US of pediatric superficial Navarro OM: Soft tissue masses in children, Radiol Clin North Am
masses of the head and neck, Radiographics 38(4):1239-1263, 2018. 49(6):1235-1259, vi-vii, 2011. doi:10.1016/j.rcl.2011.07.008.
doi:10.1148/rg.2018170165. Pignon JP, le Maître A, Maillard E, et al: Meta-analysis of chemotherapy
Blanchard P, Baujat B, Holostenco V, et al: Meta-analysis of chemother- in head and neck cancer (MACH-NC): an update on 93 randomised
apy in head and neck cancer (MACH-NC): a comprehensive analysis trials and 17,346 patients, Radiother Oncol 92(1):4-14, 2009.
by tumour site, Radiother Oncol 100(1):33-40, 2011. doi:10.1016/j. doi:10.1016/j.radonc.2009.04.014.
radonc.2011.05.036. Pulte D, Brenner H: Changes in survival in head and neck cancers in the
Brown RE, Harave S: Diagnostic imaging of benign and malignant neck late 20th and early 21st century: a period analysis, Oncologist 15(9):
masses in children-a pictorial review, Quant Imaging Med Surg 994-1001, 2010. doi:10.1634/theoncologist.2009-0289.
6(5):591-604, 2016. doi:10.21037/qims.2016.10.10. Pynnonen MA, Gillespie MB, Roman B, et al: Clinical practice guide-
Burtness B, Harrington KJ, Greil R, et al: Pembrolizumab alone or with line: evaluation of the neck mass in adults, Otolaryngol Head Neck
chemotherapy versus cetuximab with chemotherapy for recurrent or Surg 157(suppl 2):S1-S30, 2017. doi:10.1177/0194599817722550.
metastatic squamous cell carcinoma of the head and neck (KEY- Rosenberg TL, Brown JJ, Jefferson GD: Evaluating the adult patient with
NOTE-048): a randomised, open-label, phase 3 study, Lancet a neck mass, Med Clin North Am 94(5):1017-1029, 2010. doi:
394(10212):1915-1928, 2019. doi:10.1016/S0140-6736(19)32591-7. 10.1016/j.mcna.2010.05.007.
Erratum in: Lancet. 395(10220):272, 2020. Erratum in: Lancet. Shareef S, Ettefagh L: Dermoid cyst. [Updated 2022 Aug 29]. In Stat-
395(10224):564, 2020. Erratum in: Lancet. 397(10291):2252, 2021. Pearls [Internet], Treasure Island, FL, 2022, StatPearls Publishing.
Chaturvedi AK: Epidemiology and clinical aspects of HPV in head and Available at: https://www.ncbi.nlm.nih.gov/books/NBK560573/.
neck cancers, Head Neck Pathol 6 suppl 1(suppl 1):S16-S24, 2012. Vermorken JB, Herbst RS, Leon X, et al: Overview of the efficacy of ce-
doi:10.1007/s12105-012-0377-0. tuximab in recurrent and/or metastatic squamous cell carcinoma of
Davenport MS, Perazella MA, Yee J, et al: Use of intravenous iodinated the head and neck in patients who previously failed platinum-based
contrast media in patients with kidney disease: consensus statements therapies, Cancer 112:2710-2719, 2008.
from the American College of Radiology and the National Kidney Foun-
dation, Kidney Med 2(1):85-93, 2020. doi:10.1016/j.xkme.2020.01.001.

t.me/Dr_Mouayyad_AlbtousH
46
Oral Leukoplakia
LIO R A L J AD E F F, A N T H O N Y B . P. M O R L AN DT, and D E EPAK K AD EM AN I

CC Labs
A 53-year-old male is referred to your office by his general dentist No routine laboratory studies are necessary for workup of or be-
for evaluation of an intraoral lesion that was found during a rou- fore biopsy of a white lesion in an otherwise healthy patient.
tine dental examination.
Differential Diagnosis
HPI
The differential diagnosis of a white lesion of the buccal mucosa
The patient presents with an asymptomatic, corrugated white that cannot be scraped off should include hyperkeratosis, fric-
patch of the left buccal mucosa; he was not aware of the lesion tional keratosis, morsicatio buccarum (chronic cheek biting),
until his general dentist detected it during a routine oral exami- lichen planus, nicotine stomatitis, leukoedema, white sponge ne-
nation. The lesion has been present for an unknown duration. vus, oral epithelial dysplasia, and squamous cell carcinoma (SCC).
He denies any history of trauma, cheek biting (morsicatio Leukoplakia is a clinical term that simply describes a lesion as
buccarum), or chewing tobacco use. He denies any history a white plaque; it is not a histologic diagnosis, and like various
of weight loss, fatigue, neck masses, or other constitutional grades of mucosal dysplasia, is not predictive of malignant trans-
symptoms. formation to invasive carcinoma. Leukoplakia, applied as a provi-
sional diagnosis at initial detection, is appropriate if no other
PMHX/PSHX/Medications/Allergies/SH/FH differential diagnoses emerge as likely candidates. An incisional or
excisional biopsy can rule out the many other well-established
The patient’s history is significant for a 44 pack year history of diagnoses that present as white plaques of the oral cavity. If histo-
smoking. He drinks three or four beers per week. pathologic examination does not establish any of the other diag-
noses listed, then leukoplakia transitions from being the clinical
Examination description to the diagnosis of exclusion. It is important to under-
stand that leukoplakia cannot be considered the diagnosis of
General. The patient is an male who appears his stated age. He is exclusion without a biopsy.
well nourished with no signs of cachexia.
HEENT. There is a 2.3-cm 3 2.8-cm irregular, multifocal, Biopsy
superficial, soft, slightly elevated, heterogenous white plaque of
the left buccal mucosa. The lesion is nonindurated, nonulcerated, To rule out traumatic causes, it is reasonable to begin by identify-
and nonadherent to the underlying tissues. The lesion does not ing and eliminating possible etiologic factors and then waiting 2 to
rub off with gauze and does not form bullae with firm pressure 3 weeks to reassess for resolution. Biopsy of a persistent white
(negative Nikolsky sign). No Wickham striae (seen in lichen pla- patch or plaque in the oral cavity is recommended to establish a
nus) are present, and the lesion does not diminish or disappear formal diagnosis. Whether the biopsy is incisional or excisional
when stretched (seen in leukoedema). No other lesions or masses depends on the size and character of the lesion. Typically, lesions
are noted in the oral cavity. He is partially edentulous with poor smaller than 1 cm in size can be easily excised with primary closure
oral hygiene but no grossly carious teeth. of the surrounding mucosa. To avoid confounding future attempts
Neck. No submandibular or cervical lymphadenopathy is at excision, an incisional biopsy, without violating the margin, is
noted. indicated for larger lesions or when malignancy is suspected.
In this patient, an incisional biopsy demonstrated moderate
Imaging dysplasia, which has a 3% to 36% rate of malignant transforma-
tion. Definitive treatment included wide local excision with
Imaging for soft tissue lesions is based on the clinical presentation 5-mm margins followed by CO2 laser ablation of the surrounding
and differential diagnosis. This lesion is a superficial mucosal le- at-risk mucosa, and cadaveric dermal allograft of the defect fol-
sion that does not appear to invade underlying structures; there- lowed by aggressive physiotherapy to preserve mandibular range
fore, no imaging studies are required. of motion. Final histology revealed architectural and cytologic

224
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 CHAPTER 46 Oral Leukoplakia 225

changes involving the full thickness of squamous epithelium, in- Discussion

cluding the basal layer. Some of these include cellular polymor-
phism, enlarged nucleoli, nuclear hyperchromatism, increased A clinical term, leukoplakia describes a lesion as a white patch or
nuclear-to-cytoplasmic ratio, mitotic figures, loss of polarity of plaque. Meanwhile, erythroleukoplakia describes a lesion as a pre-
basal cells, basaloid appearance of several cell layers, and irregular dominantly white patch or plaque with red areas. However, ac-
epithelial stratification. Despite full-thickness epithelial involve- cording to the World Health Organization (WHO), these terms
ment, the integrity of the basement membrane was maintained in are also used as diagnoses of exclusion when “a white patch or
this specimen, and there was no evidence of epithelial invasion plaque cannot be characterized clinically or pathologically as any
into the underlying submucosal connective tissue. Thus, a final other disease.” When reading about or discussing this condition
diagnosis of severe dysplasia was made. with patients and colleagues, it is important to distinguish
whether the term is being used as a clinical descriptor or diagnosis
Assessment of exclusion. Leukoplakia is the most common oral potentially
malignant disorder (OPMD) encountered in the oral cavity with
The provisional clinical diagnosis was oral leukoplakia. The final a prevalence of 1% to 4%, varying primarily because of ethnicity.
histopathologic diagnosis was biopsy-proven severe dysplasia of It is most commonly found on the vermillion of the lip, buccal
the left buccal mucosa. mucosa, and gingiva; however, lesions of the floor of the mouth
and tongue are most likely to exhibit dysplasia and are associated
Treatment with a higher rate of malignant transformation. Proliferative ver-
rucous leukoplakia is an aggressive and problematic subtype of
The patient’s leukoplakia was amenable to excision (Fig. 46.1) leukoplakia that is most common in older adult females with a
with CO2 laser ablation of the surrounding at-risk buccal mu- malignant transformation rate of approximately 50% and an an-
cosa. The benefit of cold knife excision is that it is both diagnos- nual malignant transformation rate of 9.3%.
tic and therapeutic. (If carcinoma would have been detected in Management of oral leukoplakia remains controversial, princi-
the specimen, the patient would have undergone a complete oral pally because the literature tends to blend clinical descriptors—
SCC workup.) Thermodestructive modalities such as laser treat- leukoplakia and erythroplakia—with histologic terms such as
ment do not allow for histologic assessment, which may lead to dysplasia, oral potentially malignant disorders, and others. In gen-
missing a carcinoma within a leukoplakic lesion. In our case, an eral, microscopic dysplasia in a white mucosal patch elevates the
elliptical incision was made around the entire lesion, and the risk of malignant transformation. The absence of dysplasia in a
depth was taken down to the submucosa. Microscopic examina- leukoplakic lesion, however, does not ensure that invasive carci-
tion of the junction between the basement membrane and noma will not develop in the future. In a retrospective study of
submucosa is necessary to rule out invasive carcinoma. Five mil- 4886 patients, Chaturvedi et al. noted that 39.6% of SCCs arose
limeters of normal-appearing tissue surrounding the area was also from leukoplakias without dysplasia seen on biopsy. Known risk
included in the specimen. Histopathologic assessment of the factors for malignant transformation of oral leukoplakia include
leukoplakia revealed severe dysplasia, not extending to the speci- (1) female patients, (2) nonsmokers, (3) longstanding lesions, (4)
men margins; this is a departure from the initial biopsy grade of lesions larger than 200 mm2, (5) floor-of-mouth and tongue sub-
“moderate.” The defect was covered with thin cadaveric dermal sites, (6) nonhomogeneous leukoplakia, and (7) presence of Can-
allograft, and jaw stretching physiotherapy was initiated on post- dida albicans within the lesion.
operative day 21. The patient demonstrated complete healing The most widely used grading system for oral dysplasia was
after surgery and was followed for surveillance with his surgeon published by the WHO and was most recently revised in 2017. It
and local dentist (Fig. 46.1C). defines 12 characteristics of epithelial dysplasia and establishes

A B C
• Fig. 46.1 A, Heterogenous leukoplakia of the buccal mucosa. B, Excision with CO2 laser of surrounding
at-risk mucosa was followed by cadaveric dermal allograft repair. C, Six-month follow-up.

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226 S E C TI O N Head and Neck Pathology

dysplasia categories as mild, moderate, or severe grade based on Nonsurgical treatment options such as b-carotene, vitamin A, or
location: whether the dysplastic features are restricted to the lower retinoids have been shown to reverse leukoplakias in select cases;
third of epithelium, involve the middle third, or extend up to the however, no randomized controlled trials have proven the efficacy
upper third, respectively. Unfortunately, data have shown that the of these drugs. Additionally, therapy must be maintained indefi-
inter- and even intraobserver reproducibility of this classification nitely and thus requires significant patient compliance and cost.
system is poor, which confounds the data on the prognostic im- Several algorithms, such as the Liverpool, Awadallah, and Spei-
plications of dysplasia and makes management highly controver- ght algorithms, exist for managing dysplasia. These algorithms
sial. In blinded studies, pathologists often disagree with other attempt to stratify patients into general risk categories, which
pathologists’—and even their own—grading, leading to a lack of then dictate treatment and surveillance. However, risk stratifying
reproducibility when using the WHO grading scheme. patients must always be balanced against the probability that le-
Lacking foreknowledge of which lesions will ultimately prog- sions without any evidence of epithelial dysplasia can still undergo
ress to cancer, clinicians must combine clinical appearance, histo- malignant transformation.
pathology, and patient risk factors to formulate a subjective risk This conundrum highlights the urgent need for a data-driven
assessment for each patient. Established treatment options range method to distinguish dysplastic lesions that will progress to can-
from observation to surgical excision. Patients believed to carry a cer from those that will not. As the molecular underpinnings of
low risk of malignant transformation, who are averse to invasive cancer have become better understood, molecular biomarkers of
treatment and willing to accept the risk of developing cancer, are these critical processes have received a lot of attention as potential
reasonable candidates for close observation. Meanwhile, patients predictors of malignant transformation. Interestingly, artificial
who have a high risk of malignant transformation and are willing intelligence (AI) has also shown some promise as a tool for inte-
to accept the morbidity of treatment to minimize the risk of de- grating large amounts of data to estimate the risk of malignant
veloping cancer might consider myriad treatment options ranging transformation. The ability to digitize stained tissue specimens
from laser ablation to surgical excision. If a lesion is small, surgical and develop machine learning tools in digital pathology have
excision is a suitable option. However, if a lesion is large or in- paved the way for several widely used AI-based tests in oncology,
volves critical structures such as teeth or salivary duct orifices, including Oncotype DX (Genomic Health) and Mammaprint
excision carries additional morbidity. (Agendia) for breast cancer, DecisionDx (Castle Diagnostics) for
Thermodestructive techniques such as electrodessication, laser skin cancers, and Afirma (Veracyte) for thyroid nodules and pap-
therapy, and cryotherapy are widely used for the treatment of illary thyroid carcinoma. One such test designed specifically for
premalignant cutaneous and gynecologic lesions. In the oral cav- oral dysplasia is Straticyte (Proteocyte AI). This prognostic test
ity, CO2 lasers are often preferred, offering minimal damage to uses digitized immunohistochemical stains for inflammatory bio-
adjacent tissues and reduced wound contracture and scarring. The markers to calculate a quantitative, 0 to 100 risk score of a white
laser-treated wound bed may also be left exposed to granulate or red patch progressing to malignancy within 5 years. This tech-
without the need for skin grafting. As a single modality, CO2 laser nology may allow clinicians to achieve new levels of sophistication
therapy may be effective. Hamadah and Thompson reported on in the management of dysplasia based on objective assessments of
78 patients, 86% of whom had moderate or severe dysplasia with patient specific histopathologic data and molecular signatures.
two years of follow-up. Only 4% developed SCC after treatment,
and 64% demonstrated normal mucosa after 2 years. However, Acknowledgments
the most significant disadvantage of laser ablation is that it does
not provide a specimen for histopathological analysis that may The authors acknowledge Drs. Derek H. Lamb, Ketan Patel, and
affect further treatment (e.g., if a focus of carcinoma exists in the Shahrokh Bagheri for their contributions on this topic in previous
lesion). Thus, CO2 laser ablation should not be used on lesions editions.
that are clinically suspicious for malignancy even if there was no
malignancy identified in the specimen sampled during incisional ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
biopsy. complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 226.e1

Bibliography epithelial lesions: current knowledge and future implications, Oral Surg
Oral Med Oral Pathol Oral Radiol 125(6):650-669, 2018.
Porter S, Gueiros LA, Leão JC, et al: Risk factors and etiopathogenesis of
Braakhuis BJ, Leemans CR, Brakenhoff RH: A genetic progression potentially premalignant oral epithelial lesions, Oral Surg Oral Med
model of oral cancer: current evidence and clinical implications, Oral Pathol Oral Radiol 125(6):603-611, 2018.
J Oral Pathol Med 33(6):317-322, 2004. precancer: a patient cohort study, Lasers Surg Med 41(1):17-25, 2009.
Chandu A, Smith AC: The use of CO2 laser in the treatment of oral Rhodus NL: Oral cancer: leukoplakia and squamous cell carcinoma,
white patches: outcomes and factors affecting recurrence, Int J Oral Dent Clin North Am 49:143-165, 2005.
Maxillofac Surg 34(4):396-400, 2009. Saito T, Suguira C, Hirai A, et al: Development of squamous cell carci-
Chaturvedi AK, Udaltsova N, Engels EA, et al: Oral leukoplakia and risk noma from preexisting oral leucoplakia with respect to treatment
of progression to oral cancer: a population based cohort study, J Natl modality, Int J Oral Maxillofac Surg 30:49-53, 2001.
Cancer Inst 112(10):1047-1054, 2020. Silverman S Jr: Leukoplakia, dysplasia, and malignant transformation
Hamadah O, Thompson P: Factors affecting carbon dioxide laser treat- [editorial], Oral Surg Oral Med Oral Pathol 82:117-125, 1996.
ment for oral precancer: A patient cohort study. Lasers Surg Med Slaughter DP, Southwick HW, Smejkal W: Field cancerization in oral
41(1):17–25, 2009. stratified squamous epithelium: clinical implications of multicentric
Jerjes W, Hamdoon Z, Hopper C, et al: CO2 lasers in the management origin, Cancer 6(5):963-968, 1953.
of potentially malignant and malignant oral disorders, Head Neck Speight PM, Khurram SA, Kujan O: Oral potentially malignant disor-
Oncol 4:17, 2012. ders: risk of progression to malignancy, Oral Surg Oral Med Oral
Jerjes W, Upile T, Hamdoon Z, et al: CO2 lasers for oral dysplasias: Pathol Oral Radiol 125(6):612-627, 2018.
clinicopathological features or recurrence and malignant transforma- Van der Hem PS, Nauta JM, van der Wal JE, et al: The results of CO2
tion, Lasers Med Sci 27(1):169-179, 2012. laser surgery in patients with oral leukoplakia: a 25 year follow up,
Lee JJ, Hung HC, Cheng SJ, et al: Factors associated with underdiagno- Oral Oncol 41(1):31-37, 2005.
sis from incisional biopsy of oral leukoplakic lesions, Oral Surg Oral Vigliante CE, Quinn PD, Alwai F: Proliferative verrucous leukoplakia: a
Med Oral Pathol Oral Radiol Endod 104(2):217-225, 2007. case report with characteristic long term progression, J Oral Maxillofac
Lodi G, Porter S: Management of potentially malignant disorders: evi- Surg 61:626-631, 2003.
dence and critique, J Oral Pathol Med 37(2):63-69, 2008.
Nikitakis NG, Pentenero M, Georgaki M, et al: Molecular markers associ-
ated with development and progression of potentially premalignant oral

t.me/Dr_Mouayyad_AlbtousH
47
Osteoradionecrosis
AM B E R L. WAT T E R S , A S H I S H A . PAT E L , a n d H E ID I J . H ANS E N

CC Examination
A 67-year-old male is referred for evaluation of left perimandibu- General. The patient is a thin male in no apparent distress. He
lar swelling, pain, and exposed intraoral bone. has mild dysarthria.
Maxillofacial. There is left lower facial edema with overlying
cutaneous erythema. The skin is thin and atrophic with superficial
HPI telangiectasias. The left upper neck is fibrotic, firm, and indu-
The patient is a 67-year-old male with a history of cT2N1M0 rated, making lymph node examination difficult.
Intraoral. There is severe trismus with maximal incisal open-
SCC p161 left base of tongue status after definitive concurrent
chemoradiotherapy with weekly cisplatin 70 Gy to gross disease. ing of 15 mm. Postradiation changes are noted. There is a 2-cm
He completed therapy with complete response. Unfortunately, 3 1-cm area of exposed bone on the lingual mandibular alveolus
adjacent to the roots of teeth #18 and #19. This is painful to
he developed an area of osteoradionecrosis in his left mandible 1
year later and was treated with multiple rounds of superficial palpation with mild purulent discharge.
debridement by his dentist. Shortly thereafter, he developed a Nasal fiberoptic endoscopy. No obvious mass or lesion is
identified. Postradiation changes are noted with lack of tonsillar
superinfection along the osteonecrotic left mandible with severe
trismus requiring antibiotic therapy. Since then, he reports pro- and tongue base lymphoid tissue. He has smooth, desiccated mu-
gressive inferior alveolar nerve numbness, including the left cosa with mild lymphedema. The vocal cords abduct and adduct
symmetrically.
lower lip and chin distribution, left-sided persistent facial swell-
ing, and severe trismus; he is unable to open his mouth more Extremities. Warm and atraumatic. No signs of edema, ve-
than 1 to 2 finger breadths. nous stasis, or arterial insufficiency. Normal male hair growth.
Capillary refill is less than 2 seconds with 21 palpable popliteal,
Has been taking pentoxifylline and vitamin E for more than 1
month. He is also had 40 of 50 dives of hyperbaric oxygen ther- dorsalis pedis, and posterior tibial pulses bilaterally.
apy (HBOT). Unfortunately, his symptoms have worsened in the
past several months. His main goals are to be able to eat, improve Imaging
his facial function, be able to open his mouth, and improve his
Orthopantomogram or cone-beam computed tomography
lower lip numbness.
(CBCT) of the maxillofacial skeleton is an excellent imaging mo-
dality to assess the osseous and dentoalveolar structures. When
PMHX/PDHX/Medications/Allergies/SH/FH osteoradionecrosis is suspected, in-office CBCT is sufficient.
When there is concern for deep abscess formation or neoplasia, a
The patient has a history of hypertension and previous cutaneous medical-grade CT scan with intravenous contrast is preferred.
squamous cell carcinoma (SCC) treated with Mohs surgery. As CBCT in this patient demonstrated a large area of “moth-eaten”
per his HPI, he was diagnosed with a stage I human papillomavi- bone in the left mandibular body and ramus. There is full-thick-
rus–associated oropharynx SCC 2 years before this presentation ness involvement of the mandible from the buccal to the lingual
and treated with definitive concurrent chemoradiation. He devel- cortex and the superior to inferior border. Although there does
oped radiation-induced hypothyroidism and has been taking not appear to be fracture or displacement of the segments, there
therapeutic levothyroxine for this. is almost certainly a pathologic fracture of the mandible, which is
In addition, he has been taking pentoxifylline and vitamin E held in place by fibrosis and soft tissue (Fig. 47.1).
for the past month. He is a never smoker and is a social alcohol There have been many proposed staging systems to help clas-
drinker. He has no previous history of bleeding or clotting disor- sify the severity of mandibular osteoradionecrosis, but one major
ders, myocardial infarction, or cerebrovascular accidents. common theme is the extent of bone destruction. Notani et al.
He takes all his nutrition by mouth but requires liquids and described a commonly used staging system in 2003:
purees since his cancer radiotherapy. In addition, his oral intake Stage: 1: necrotic and exposed bone limited to the alveolus
has reduced in the setting of new trismus, swelling, and pain with Stage 2: necrotic bone limited to the alveolus and mandible above
a 3- to 4-lb weight loss. the inferior alveolar canal

227
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228 S E C TI O N Head and Neck Pathology

alveolar and mental nerves when this process encroaches on the

canal. In most patients with stage III disease, the only treatment
effective in eradication of this disease is surgical resection and
vascularized flap reconstruction.

Labs
Routine preoperative laboratory examination includes a complete
A blood count, comprehensive metabolic panel, and coagulation
studies. In patients with acute or chronic infection, inflammatory
markers, including C-reactive protein or procalcitonin, can be
used to trend and track response to therapy. In addition, patients
who have received neck radiation or have documented hypothy-
roidism should have thyroid function tests to optimize levothyrox-
ine dosage. Untreated hypothyroidism may lead to perioperative
wound and cardiac complications. All laboratory study results in
this patient were within normal ranges. Patients who have previ-
ously undergone chemotherapy may be less likely to develop leu-
kocytosis in the setting of acute inflammation because of ongoing
bone marrow suppression, making the white blood cell count a less
useful marker.

Assessment
Stage III osteoradionecrosis of the left mandible with superimposed
infection and worsening malnutrition.

Treatment
B There has always been controversy in the optimal management of
osteoradionecrosis. In the 1980s, HBOT was considered a back-
• Fig. 47.1 A, Reconstructed orthopantomogram from cone-beam com-
bone of therapy, though many clinical trials since then have failed
puted tomography (CBCT) demonstrating osteolysis of the left mandible
from the first molar region into the ramus. Note full-thickness involvement
to demonstrate efficacy. In addition, surgical debridement of
from the superior to the inferior border. B, Three-dimensional reconstruc- ORN was used often to remove diseased bone in early-stage
tion of CBCT demonstrating full-thickness osteolysis, including buccal and ORN, but this often led to further osseous insult and progression
lingual cortex with sparing of the mandibular condyle. of disease. It is clear that stage III osteoradionecrosis will almost
always progress to pathologic fracture or orocutaneous fistula,
which can result in significant impairment in function and quality
Stage 3: necrotic bone extending below the inferior alveolar nerve of life. There is a plethora of data supporting radical resection
canal, orocutaneous fistula, or pathologic fracture (Fig. 47.2). (segmental osseous resection) and immediate microvascular tissue
This patient’s ORN is classified as severe, or stage III, disease transfer of stage III ORN with a 95% to 100% success rate in
given the full-thickness mandibular involvement. It is also very complete resolution of disease. It is important to note that in
common for patients to experience paresthesia of the inferior patients with ORN, there is significant soft tissue radiation injury,

A B C
• Fig. 47.2 A, Stage III osteoradionecrosis of the left mandible of a different patient with a 3-cm area of
exposed necrotic bone. Note the presence of failing anterior mandibular mini-implants. B, The same pa-
tient with a draining orocutaneous fistula from full-thickness mandibular osteoradionecrosis of the jaw
(ORN) with pathologic fracture. C, Final reconstruction with an osteocutaneous free flap with externalized
skin paddle to resurface the neck. In patients with orocutaneous fistula from mandibular ORN, it is nearly
impossible to close the neck skin after resection. The radiation injury and fibrosis along with chronic in-
flammation from the fistula require the addition of imported vascularized tissue to close. In this case, the
skin paddle from a fibula osteocutaneous free flap was used.

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 CHAPTER 47 Osteoradionecrosis 229

making postoperative wounds, infections, and dehiscence more

common. The use of HBOT in the perioperative period may
improve wound healing in these instances but is not effective in
treating osteoradionecrosis.
In this patient, the treatment plan included left segmental hemi-
mandibulectomy with immediate reconstruction with an osteocu-
taneous fibula free flap, immediate dental implant placement, and
inferior alveolar nerve allograft. Because this patient had baseline
dysphagia from oropharyngeal cancer treatment and worsening
trismus, a gastrostomy tube was placed at the beginning of surgery.
As in most modern jaw resection and reconstructions, com-
puter-aided surgery is used to improve accuracy and predictability.
In this case, 1-cm osseous margins from radiographically necrotic • Fig. 47.3 Left mandibulectomy specimen demonstrating severe osteo-
bone were marked to ensure complete resection. The decision was radionecrosis of the jaw with pathologic fracture. Note the margins of the
made to preserve the mandibular condyle; if one can place two resection appear to have intact and visually unaffected bone. The coro-
screws in this segment, it is preferable to preserve viable condyle to noid process was removed en bloc to reduce temporalis scar contracture
prevent postoperative open bite or lateral migration of the recon- on the mandible.
structed mandible.
In cases of ORN, it is preferred to minimize soft tissue dissec-
tion because the tissue envelope is radiated and hypovascular.
Rather than a large apron neck incision or lip split for access,
transoral subperiosteal dissection with vestibular release is used to
expose the majority of the mandible to be resected. A conservative
neck incision is made over the planned recipient vessels for micro-
vascular anastomosis; this is also used to make the posterior man-
dibular osteotomy if needed. This combined approach minimizes
disruption of the cutaneous blood supply in an irradiated neck,
thereby reducing the risk of neck wound dehiscence or fistula
formation. The procedure used of cutting jigs with predictive
holes and custom patient specific reconstruction plates allows in-
set of the osseous free flap with minimal access. It is important to
design low-profile cutting jigs that can be adapted through tran- • Fig. 47.4 The proximal stump of the inferior alveolar nerve was prepared
soral or small cervical access. and anastomosed to an allogenic nerve graft using a collagen connector
Often, fibrotic tissue and scar must be sharply excised from the (Axogen Avance).
wound bed after the mandibulectomy to make sufficient space for
the flap inset. Unlike normal tissue, radiated tissue has little com-
pliance and does not stretch to adapt the free flap. If the soft tissue
envelope is too tight, compression of the flap and associated vas-
culature may lead to venous compromise and failure.
Although many patients with mandibular resection and recon-
struction can commence oral intake 2 to 5 days after surgery,
patients with ORN should maintain nothing by mouth status for
1 to 2 weeks postoperatively. As previously stated, wound dehis-
cence at the junction of radiated tissue is more common in this
population and may result in salivary leak, infection, or fistula. In
addition, patients who have been irradiated have some baseline
oral or pharyngeal muscle fibrosis. Postsurgical edema and inflam-
mation magnify this, resulting in significant dysphagia, at least
transiently. If the oral cavity tissue appears sealed on clinical ex-
amination at 1 to 2 weeks after surgery, oral trials with the aid of
a speech-language pathologist are initiated. The patient should
remain on a nonchew diet for 8 weeks to allow adequate time for
hard callous formation between the osseous flap and native jaw-
bone (Figs. 47.3 to 47.8).

Discussion
Osteoradionecrosis of the jaw is one of the most significant long-
term toxicities of head and neck radiation therapy and can result
in substantial morbidity that negatively impacts patients’ quality • Fig. 47.5 The distal anastomosis to the mental nerve was performed tran-
of life. The most widely accepted definition of ORN is the clinical sorally. Note the vestibular releasing incision, which aided in transoral oste-
presence of nonhealing exposed devitalized bone for more than 8 otomy for the mandibulectomy and subsequent osteosynthesis of the flap
weeks in a site previously irradiated and free of tumor. ORN most and plate. This obviates the need for a neck incision to cross the midline.

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230 S E C TI O N Head and Neck Pathology

• Fig. 47.6 A fibula osteocutaneous free flap was harvested, osteoto-

mized, and implanted with dental implants all while pedicled to the leg
using computer-aided surgery and three-dimensional printing cutting
jigs. The skin paddle was designed to originate from the inferior border
of the neomandible to allow for the creation of buccal vestibule and
prevent injury to the cutaneous perforators from dental implant place-
ment. Healing abutments are placed primarily on the dental implants to B
aid in location under the skin paddle when the patient is ready for dental
restoration.
• Fig. 47.8 A, One-month postoperative reconstruction orthopantomo-
gram demonstrating adequate osseous geometry, fixation, and positioning.
B, Nine-month postoperative orthopantomogram with final implant-
retained dental restoration and resolution of osteoradionecrosis of the jaw.

commonly occurs after oral surgical procedures in the postradia-

tion setting but can also happen spontaneously or secondary to
microtrauma and must be distinguished from metastatic or pri-
mary malignant disease of the jaws.
Marx first described a model for the definition and pathogen-
esis of ORN in 1983. He described ORN with the “three H”
hypothesis of hypoxia, hypocellularity, and hypovascularity and
proposed a treatment protocol based on HBOT. Since Marx’s
theory of pathogenesis, other theories have been proposed, in-
cluding a mechanism of radiation-induced fibroatrophy of endo-
thelium by direct and indirect (free radical) damage as well as
radiation-induced osteoclast dysfunction.
A Marx initially proposed three stages of ORN related to HBOT
response, and in 1987, Epstein et al. proposed three stages with
subdivisions considering the presence of pathologic fracture. Later
classifications proposed by Schwartz et al. and Notani et al. were
more based on imaging and clinical findings.
Radiation therapy as a treatment modality for head and neck
cancer can be used with or without chemotherapy as definitive
therapy or as an adjunct to primary surgical management. Exter-
nal-beam radiotherapy techniques are most common, and of
these, intensity-modulated radiation therapy (IMRT) is the cur-
rent standard of care. IMRT uses a complex multibeam delivery
that can escalate the dose to the tumor and at-risk tissues while
sparing healthy tissues. Intensity-modulated proton therapy
(IMPT) uses protons that deliver most of their dose at their Bragg
peak or distal range, thereby sparing tissues beyond this. Both
B
IMRT and IMPT contribute to a reduction in the risk of ORN
• Fig. 47.7 A, Final inset of the skin paddle into the oral soft tissue defect. by reducing the dose to the tooth-bearing bone of the jaws and by
The use of interrupted horizontal mattress sutures helps to create a wa- sparing salivary gland tissue and thereby reducing the risk of
tertight seal between the mouth and neck. B, Closure of the conservative odontogenic disease. Intrinsic radiation therapy or brachytherapy
left neck incision. is less commonly used and can carry a higher risk of ORN if the

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 CHAPTER 47 Osteoradionecrosis 231

radioactive seeds are implanted in close proximity to the bone of Clinical Presentation
the jaws. Although historically, rates of ORN in the literature
have been high, more recent data support the reduction in risk The clinical presentation of ORN is characterized by nonhealing
with improved radiotherapy techniques. Gomez et al. reported exposed necrotic bone in a previously irradiated site. Infection, if
retrospectively on a group of 168 patients in which only two pa- present, is considered secondary, and primary or secondary ma-
tients with floor-of-the-mouth cancer developed ORN (1.2%), lignancy should be ruled out. ORN is more common in the
and Ben David et al. reported zero cases of ORN in 176 patients mandible than the maxilla and can present asymptomatically or
treated with IMRT between 1996 and 2005. In a recent review, with pain or dysesthesia or paresthesia. It can progress to cause
Peterson et al. reported weighted prevalences of ORN in patients loosening of involved teeth, pathologic fracture of the jaw and
treated with conventional radiotherapy of 7.4%, 5.2% with orocutaneous fistula, or less commonly oroantral communica-
IMRT, 6.8% with chemoradiotherapy, and 5.3% with brachy- tion formation. Radiographically, ORN can present with irregu-
therapy. lar rarefaction of osseous trabeculation, loss or irregularity of
crestal and cortical bone, and widened periodontal ligaments.
Sequestration of bone may be seen in lytic areas.
Risk Factors for the Development of Prevention of dental disease and therefore prevention of postra-
Osteoradionecrosis of the Jaw diation tooth extractions is the single most important factor in
ORN risk reduction. Meticulous preradiation dental treatment
Patients with increased risk of ORN include those with a complex planning by a dentist trained in oncology is the standard of care.
medical history; poor nutritional status; history of trauma to the Dental risk factors such as extent, type, and state of repair of exist-
jaws; history of tobacco and alcohol use; and most important, ing restorations; caries status; and periodontal status must be
poor oral health or advanced dental disease. considered with regard to the long-term prognosis of the dentition.
Disease-related risk factors for ORN are related to tumor size Also important in preradiation dental treatment planning is the
and location, with larger T3 and T4 tumors resulting in higher anticipation of future prosthodontic rehabilitation. Supraerupted
radiation doses to especially the mandibular bone. Tumors lo- teeth without opposing dentition and exostoses or tori should be
cated in the oral cavity, specifically the tongue, floor of the considered for removal. All of these factors should be evaluated
mouth, and retromolar trigone are associated with a higher risk with the details of the patient’s oncologic disease and treatment in
of ORN, thought to be because of the position of the mandible mind. Knowledge of anticipated radiation doses to dentate areas
directly in or adjacent to the radiation field and because surgical helps in proper treatment planning. Factors such as the extent of
management of these tumors often involves resection of man- surgical morbidity and trismus play a role in the patient’s ability to
dibular bone. In a similar fashion, radiation risk factors include maintain their dentition after their oncologic treatment is com-
the field of radiation and its proximity to the jaws and thereby plete. Low rates of ORN attributed to meticulous prophylactic
the dose of radiation delivered to the bone of the jaws. Hyper- dental care have been reported: Sulaiman et al. reported a 2.14%
and hypofractionation techniques have an impact on the effective incidence of ORN in 1194 patients seen between 1988 and 2001,
dose or biologic equivalent dose, but the significance of these and Ben David et al. reported zero cases of ORN in 176 patients
techniques on the incidence of ORN remains unclear. It is widely treated with IMRT between 1996 and 2005.
accepted that the risk of developing ORN is increased in areas of
the bone receiving more than 50 to 60 Gy. The mandible is at Treatment
higher risk for development of ORN than the maxilla, and this
is thought to be because of the lower vascularity present in man- Treatment of ORN has historically been based on staging. In
dibular bone. early-stage I and II ORN, conservative management, consisting of
It has been shown that dental extractions after radiotherapy systemic and local application of antibiotics for secondary infec-
are less likely to cause ORN if they are outside the field of high- tion; basic wound care, including an antiseptic mouth rinse such
dose radiation. For this reason, it is important to understand the as chlorhexidine; and removal of loose sequestra, is recommended.
dose specific to the postradiation surgical area and use this infor- The use of pentoxifylline and tocopherol in the conservative
mation to inform prophylactic measures and educate the patient management of ORN is also recommended. Pentoxifylline is
regarding their specific risk. With IMRT and IMPT, detailed known to promote vascular dilation and increased erythrocyte flex-
radiation dosimetry maps can be obtained after radiation ther- ibility as well as having an anti–tumor necrosis factor-a effect. To-
apy. Of note, preradiation extractions can also contribute to the copherol is an antioxidant that is capable of scavenging reactive
risk of ORN; however, an atraumatic surgical technique and oxygen species. Clodronate is a nonnitrogenous bisphosphonate
adequate healing time before radiation have been associated with that has been shown to promote osteoblast activity. These agents
a reduced risk of ORN. This risk associated with preradiation have been used in combination in trials showing encouraging re-
extractions is important to take into consideration when plan- sults. Delanian et al. prescribed pentoxifylline 400 mg twice daily
ning treatment for patients with head and neck cancer. Extrac- and tocopherol 1000 IU daily to 18 patients with ORN for 6 to 24
tions are best done during oncologic surgery to allow for several months. Patients with severe ORN also received 1600 mg of clo-
weeks of healing before radiation therapy. If the patient is not a dronate 5 days a week. In a later trial, 54 patients were given doses
surgical candidate and will be receiving definitive chemoradia- of 800 mg of pentoxifylline, and prednisone and ciprofloxacin were
tion therapy, certain teeth may be better treated with observation added, with all patients experiencing complete resolution. It was
or endodontic therapy if feasible. Comprehensive evaluation be- concluded that the treatment was well tolerated and effective.
fore radiation therapy and appropriate preradiation dental treat- McLeod et al. reported a more moderate response in 12 patients.
ment and patient education have been shown to significantly The use of HBOT in the management of patients with ORN
reduce the risk of ORN. is controversial, and there is a lack of conclusive evidence on the

t.me/Dr_Mouayyad_AlbtousH
232 S E C TI O N Head and Neck Pathology

subject. HBOT can be used prophylactically before postradiation which mandibular resection or reconstruction is needed. This is be-
extractions, therapeutically for existing ORN, or as an adjunct to the cause of HBOT exerts an effect on viable, not necrotic, tissue.
surgical treatment of ORN. Although Marx’s original study showed In advanced stage III cases of ORN with pathologic fracture or
a positive response to HBOT, more recent studies have shown fewer orocutaneous fistula involvement, surgical resection and recon-
positive effects. Annane et al. conducted a large randomized con- struction with a vascularized flap is recommended as described
trolled trial that was stopped because of potentially poor outcomes earlier in this chapter.
in the HBOT arm. Based on the new understanding of the patho-
physiology of ORN, HBOT is not recommended as primary ther- ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
apy for patients with ORN but as adjunctive therapy for cases in complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 232.e1

Bibliography radiation therapy for base of tongue cancer, Oral Surg Oral Med Oral
Pathol Oral Radiol 114(2):e50-e54, 2012. doi:10.1016/j.oooo.2012.
01.024.
Annane D, Depondt J, Aubert P, et al: Hyperbaric oxygen therapy for Jacobson AS, Buchbinder D, Hu K, et al: Paradigm shifts in the manage-
radionecrosis of the jaw: a randomized, placebo-controlled, double- ment of osteoradionecrosis of the mandible, Oral Oncol 46(11):795-
blind trial from the ORN96 study group, J Clin Oncol 22(24):4893- 801, 2010. doi:10.1016/j.oraloncology.2010.08.007.
4900, 2004. doi:10.1200/jco.2004.09.006. Marx RE: Osteoradionecrosis: a new concept of its pathophysiology,
Ben-David MA, Diamante M, Radawski JD, et al: Lack of osteoradione- J Oral Maxillofac Surg 41(5):283-288, 1983.
crosis of the mandible after intensity-modulated radiotherapy for Marx RE, Johnson RP, Kline SN: Prevention of osteoradionecrosis: a
head and neck cancer: likely contributions of both dental care and randomized prospective clinical trial of hyperbaric oxygen versus
improved dose distributions, Int J Radiat Oncol Biol Phys 68(2):396- penicillin, J Am Dent Assoc 111(1):49-54, 1985.
402, 2007. McCaul JA: Pharmacologic modalities in the treatment of osteoradione-
Bessereau J, Annane D: Treatment of osteoradionecrosis of the jaw: the crosis of the jaw, Oral Maxillofac Surg Clin North Am 26(2):247-252,
case against the use of hyperbaric oxygen, J Oral Maxillofac Surg 2014. doi:10.1016/j.coms.2014.02.002.
68(8):1907-1910, 2010. doi:10.1016/j.joms.2010.02.005. McLeod NM, Pratt CA, Mellor TK, et al: Pentoxifylline and tocopherol
Chrcanovic BR, Reher P, Sousa AA, et al: Osteoradionecrosis of the in the management of patients with osteoradionecrosis, the Ports-
jaws—a current overview—part 1: physiopathology and risk and pre- mouth experience, Br J Oral Maxillofac Surg 50(1):41-44, 2012.
disposing factors, Oral Maxillofac Surg 14(1):3-16, 2010. doi:10.1007/ doi:10.1016/j.bjoms.2010.11.017.
s10006-009-0198-9. Notani K, Yamazaki Y, Kitada H, et al: Management of mandibular os-
Chuang SK: Limited evidence to demonstrate that the use of hyperbaric teoradionecrosis corresponding to the severity of osteoradionecrosis
oxygen (HBO) therapy reduces the incidence of osteoradionecrosis in and the method of radiotherapy, Head Neck 25(3):181-186, 2003.
irradiated patients requiring tooth extraction, J Evid Based Dent Pract doi:10.1002/hed.10171.
12(suppl 3):248-250, 2012. doi:10.1016/s1532-3382(12)70047-7. Peterson DE, Doerr W, Hovan A, et al: Osteoradionecrosis in cancer
Curi MM, Dib LL: Osteoradionecrosis of the jaws: a retrospective study patients: the evidence base for treatment-dependent frequency, cur-
of the background factors and treatment in 104 cases, J Oral Maxil- rent management strategies, and future studies, Support Care Cancer
lofac Surg 55(6):540-544, 1997; discussion 545-546. 18(8):1089-1098, 2010. doi:10.1007/s00520-010-0898-6.
Delanian S, Chatel C, Porcher R, et al: Complete restoration of refrac- Peterson DE, Ohrn K, Bowen J, et al: Systematic review of oral cryother-
tory mandibular osteoradionecrosis by prolonged treatment with a apy for management of oral mucositis caused by cancer therapy, Support
pentoxifylline-tocopherol-clodronate combination (PENTOCLO): a Care Cancer 21(1):327-332, 2013. doi:10.1007/s00520-012-1562-0.
phase II trial, Int J Radiat Oncol Biol Phys 80(3):832-839, 2011. Polce S, Gogineni E, Antone J, et al: Dental radiation dosimetric maps
doi:10.1016/j.ijrobp.2010.03.029. from intensity-modulated radiation therapy planning for head and neck
Delanian S, Depondt J, Lefaix JL: Major healing of refractory mandible cancers, Head Neck 43(5):1428-1439, 2021. doi:10.1002/hed.26611.
osteoradionecrosis after treatment combining pentoxifylline and to- Polyzois I, Ekanayake K, et al: The management of osteoradionecrosis of
copherol: a phase II trial, Head Neck 27(2):114-123, 2005. doi:10. the jaws—a review, Surgeon 13(2):101-109, 2015. doi:10.1016/j.surge.
1002/hed.20121. 2014.07.003.
Delanian S, Lefaix JL: Complete healing of severe osteoradionecrosis Reuther T, Schuster T, Mende U, et al: Osteoradionecrosis of the jaws as
with treatment combining pentoxifylline, tocopherol and clodronate, a side effect of radiotherapy of head and neck tumour patients—a
Br J Radiol 75(893):467-469, 2002. doi:10.1259/bjr.75.893.750467. report of a thirty year retrospective review, Int J Oral Maxillofac Surg
Delanian S, Lefaix JL: The radiation-induced fibroatrophic process: 32(3):289-295, 2003. doi:10.1054/ijom.2002.0332.
therapeutic perspective via the antioxidant pathway, Radiother Oncol Schwartz HC, Kagan AR: Osteoradionecrosis of the mandible: scientific
73(2):119-131, 2004. doi:10.1016/j.radonc.2004.08.021. basis for clinical staging, Am J Clin Oncol 25(2):168-171, 2002.
Deshpande SS, Thakur MH, Dholam K, et al: Osteoradionecrosis of the Sulaiman F, Huryn JM, Zlotolow IM: Dental extractions in the irradi-
mandible: through a radiologist’s eyes, Clin Radiol 70(2):197-205, ated head and neck patient: a retrospective analysis of Memorial
2015. doi:10.1016/j.crad.2014.09.012. Sloan-Kettering Cancer Center protocols, criteria, and end results,
Epstein JB, Wong FL, Stevenson-Moore P: Osteoradionecrosis: clinical J Oral Maxillofac Surg 61(10):1123-1131, 2003.
experience and a proposal for classification, J Oral Maxillofac Surg Wahl MJ: Osteoradionecrosis prevention myths, Int J Radiat Oncol Biol
45(2):104-110, 1987. Phys 64(3):661-669, 2006. doi:10.1016/j.ijrobp.2005.10.021.
Gomez DR, Zhung JE, Gomez J, et al: Intensity-modulated radiotherapy Wong JK, Wood RE, McLean M: Conservative management of osteora-
in postoperative treatment of oral cavity cancers, Int J Radiat Oncol Biol dionecrosis, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 84(1):
Phys 73(4):1096-1103, 2009. doi:10.1016/j.ijrobp.2008.05.024. Hansen 16-21, 1997.
HJ, Maritim B, Bohle GC III, et al: Dosimetric distribution to the tooth-
bearing regions of the mandible following intensity-modulated

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48
Dentoalveolar Trauma
Clinical Review of Oral and Maxillofacial Surgery
PAT R IC K J . LOU IS , A N T H O N Y B. P. M O R L A N DT, a n d S O M S A K S IT T ITAVO R N WO N G

CC is no mastoid ecchymosis noted (Battle’s sign, significant for oc-

cult skull base fracture). The orbits, midface, and mandible are
A 22-year-old male presents to the oral and maxillofacial surgery without step deformity or crepitus on palpation. Cranial nerves II
office complaining of anterior facial pain, swelling, oral bleeding, through XII are intact.
and mobile teeth. Intraoral. There is a 1-cm abrasion of the upper lip skin with-
out significant laceration. Intraorally, there is profound ecchymosis
HPI of the upper lip mucosa with a laceration extending into the sub-
labial vestibule (Fig. 48.1). Teeth #7 and #8 are mobile as a single
The patient reports that he was riding his mountain bike when an unit with displacement of the buccal cortical plate on manipula-
abrupt bump resulted in his striking his lower face against the tion. Tooth #9 is grossly mobile and subluxed several millimeters.
handlebars. He dismounted the bicycle without other injuries and It also demonstrates an oblique coronal fracture with pinpoint
drove himself to an outside emergency department (ED). He de- pulp exposure (Ellis class III). In addition, tooth #9 is sensitive to
nies loss of consciousness, nausea, vomiting, visual disturbances, mechanical stimulation with a cotton-tipped applicator and tender
or headache (indicative of head trauma with intracranial injury). to percussion. There is occlusal prematurity with interference of
He further denies stridor, dyspnea, or increased work of breathing the maxillary anterior teeth on attempted intercuspation.
(suggestive of foreign body aspiration resulting from dislodged
teeth, dental restorations, or orthodontic appliances). He notes
several dental fractures, profound mobility of the lower teeth, and
gingival bleeding. He undergoes primary and secondary surveys,
according to the Advanced Trauma Life Support (ATLS) protocol,
and the results are found to be negative. A computed tomography
(CT) scan is obtained, and the patient is given instructions to
report by private car to your office for evaluation.

PMHX/PDHX/Medications/Allergies/SH/FH
The patient denies any significant cardiac, pulmonary, renal, he-
patic, or neurologic diseases.

Examination
General. The patient is a well-developed, well-nourished adult
male in mild distress secondary to pain and oral bleeding. He is
neurologically intact.
Maxillofacial. There are no lacerations, contusions, or abra-
sions of the scalp, midface, or chin. The pupils are equal at 4 mm,
round, and reactive to light and accommodation. The nasal dor-
sum is midline and stable. There is no rhinorrhea (a concern for
violation of the cribriform plate with cerebrospinal fluid [CSF]
leakage) and no septal hematoma on speculum examination. The
ears are symmetric and without injury to the pinnae. Examination
of the external auditory meatus reveals no otorrhea (also a concern • Fig. 48.1 Maxillary alveolar segment fracture involving teeth #7, #8, and
for CSF leakage) or disruption of the tympanic membrane. There #9, with coronal fractures involving teeth #8 and #9.

235
t.me/Dr_Mouayyad_AlbtousH
236 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

Imaging
A maxillofacial CT scan demonstrates an alveolar segment fracture
involving teeth #7 and #8, with subluxation of tooth #9 and frac-
ture of the alveolar plate (Fig. 48.2). There are otherwise no inju-
ries to the maxillofacial skeleton, cervical spine, brain, or cranium.
The minimum radiographic study necessary for diagnosis of den-
toalveolar fractures is a periapical radiograph, although the diagno-
sis can often be made with a physical examination alone. Based on
availability, other radiographic studies may include:
• Computed tomography
• Cone-beam CT (CBCT)
• Periapical radiograph with a horizontally and laterally directed
central beam to evaluate traumatized roots for fractures
• Occlusal view
• Panoramic radiograph

Labs
A
No routine laboratory tests are indicated for the work-up and
diagnosis of dentoalveolar injuries in a healthy individual. If co-
agulopathy is suspected based on the medical history and physical
examination, a coagulation profile, including the prothrombin
time or partial thromboplastin time, international normalized
ratio, and platelet count, may be obtained.

Assessment B

Anterior maxillary alveolar segment fractures involving teeth #7 • Fig. 48.3 A, Maxillary alveolar segment fracture involving teeth #7, #8, and
through #9, with lateral luxation and an Ellis class III fracture of #9 reduced with an Erich arch bar and circumdental ligature wiring. B, Post-
tooth #9, and an intraoral laceration of the upper lip. operative radiograph after treatment of an alveolar segment fracture.

Treatment
Complications
Initial stabilization includes reduction of the teeth and splinting
(Fig. 48.3). With the current patient, bonded flexible wire splint- In the past, only about 25% to 40% of replanted, avulsed teeth
ing was not available, so the teeth were splinted with an arch bar. show periodontal ligament (PDL) healing. This has been attrib-
The occlusion was checked, and the teeth were not in occlusion uted to poor handling of the tooth. Three different types of post-
during maximum intercuspation. The patient’s tetanus status was traumatic external root resorption have been distinguished in the
up to date. He was given a prescription for amoxicillin and literature: surface resorption (repair-related root resorption), in-
chlorhexidine and discharged home. The teeth were splinted for 8 flammatory resorption (infection-related root resorption), and
weeks because of the alveolar segment fracture. Root canal ther- replacement resorption (ankylosis-related root resorption). Sur-
apy was initiated on day 10 with calcium hydroxide therapy. face resorption has no significant clinical consequences and can be
observed. However, the other types of resorption can ultimately
result in tooth loss. In the avulsed tooth, if the PDL that is still
attached to the tooth does not dry out, the cells can remain viable
for an extended period, depending on the storage medium. After
the tooth has been reimplanted and stabilized, the viable PDL
cells reattach to the PDL within the socket. When the injury to
the cementum of the root is localized, there is minimal destructive
inflammation, allowing for new cementum to be laid down after
the inflammation resolves. When there is poor handling of the
avulsed tooth (e.g., drying or storage in nonphysiologic solu-
tions), damage and necrosis of the PDL occur. Subsequently,
there is a large area of inflammation to remove the damaged PDL
and cementum. This must be replaced by new tissue. The slower
moving cementoblasts compete with the osteoblasts in the re-
placement process, resulting in some areas of the root surface be-
ing replaced by bone. Over time, through osseous remodeling,
this can result in osseous or replacement resorption. Internal root
• Fig. 48.2 Axial computed tomography scan showing displacement of resorption can occur through persistent inflammation or meta-
teeth #7, #8, and #9 caused by alveolar segment fracture. plastic replacement of normal pulp tissue. This can result in late

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 48 Dentoalveolar Trauma 237

The cause of dentoalveolar trauma varies among different

demographics, but it generally results from falls, playground ac-
cidents, domestic violence, bicycle accidents, motor vehicle ac-
cidents, assaults, altercations, and sports injuries. Gassner and
colleagues reported an incidence of 48.25% in all facial injuries,
57.8% in play and household accidents, 50.1% in sports acci-
dents, 38.6% in accidents at work, 35.8% in acts of violence,
34.2% in traffic accidents, and 31% in unspecified accidents.
Falling is the primary cause of dentoalveolar trauma in early
childhood. Andreasen reported a bimodal trend in the peak in-
cidence of dentoalveolar trauma in children aged 2 to 4 and 8 to
10 years.
Dentoalveolar injuries have been classified by the International
Association of Dental Traumatology, which regularly reviews and
updates guidelines. These guidelines and are published online at
https://dentaltraumaguide.org. Broadly, the discrete categories of
dentoalveolar injury include:
• Injuries to the periodontium
• Injuries to the dental crown and root
• Injuries to the supporting alveolar bone

Injuries to the Periodontium and the

• Fig. 48.4 Computed tomography scan showing complex trauma with
anterior mandibular alveolar segment fracture Recommended Treatment
Injuries to the periodontium resulting from forces directed
through the tooth and to the surrounding bone and periodontal
tooth fractures. Root surface treatments and root canal therapy attachment are the most common types of dental trauma in the
are directed toward prevention of this complication. Ideal man- primary dentition.
agement of dentoalveolar trauma may have to be delayed because
of life-threatening injuries that must be managed first (Fig. 48.4). Concussion
This may result in resorptive complications.
With concussion, there is no visible trauma to tooth or alveolar
Discussion structures, but there is pain on percussion. Treatment is conserva-
tive, with no chew diet only and surveillance of pulpal vitality for
Appropriate diagnosis is critical in identifying and treating pa- at least a year but preferably longer.
tients with dentoalveolar injuries, which are known to affect
one-fourth of all children and one-third of all adults. Depending Subluxation
on the mechanism of injury, a number of maxillofacial injuries
may present with concomitant intracranial or cervical spine inju- Subluxation is increased mobility of the tooth without disloca-
ries despite normal neurologic findings on physical examination. tion. Treatment is conservative, though a flexible splint may be
After a thorough physical examination that follows the ATLS applied for patient comfort up to 2 weeks. The pulp condition
protocol, attention is directed to the head and neck. Contami- should be monitored for at least 1 year but preferably longer.
nated facial wounds should be irrigated with normal saline if
available, although tap water has been shown to be as effective as Extrusion
saline. Patients with grossly contaminated wounds or facial inju-
ries caused by dog or human bites should be considered for teta- Extrusion is coronal dislocation of the tooth caused by separation
nus immunization based on their vaccination history. If an adult of the PDL without alveolar bone disruption. Clinically, the tooth
has an ambiguous immunization history or has received fewer appears elongated and demonstrates mobility. Treatment involves
than three prior doses of tetanus toxoid, they should receive teta- repositioning the tooth into the socket; stabilizing the tooth for 2
nus immune globulin and the tetanus–diphtheria or tetanus– weeks with a nonrigid, flexible splint; and performing root canal
diphtheria–acellular pertussis (Tdap) vaccine. Prior tetanus therapy in teeth with closed apices. If the marginal alveolar bone
disease is inadequate at providing immunity because a small demonstrates radiographic signs of breakdown at follow-up, pro-
amount of the highly potent toxin is sufficient to cause clinical longed splinting is recommended, up to 6 weeks after the injury.
neuromuscular weakness and airway compromise. Antibiotic If the pulp becomes necrotic and infected, endodontic treatment
coverage must be based on the mechanism and extent of injury. appropriate to root development is indicated.
It is indicated in contaminated wounds with significant soft tis-
sue injury, luxated teeth, avulsed teeth, pulp exposures, root Lateral Luxation
fractures, and alveolar fractures. Amoxicillin is usually chosen
unless the patient is allergic to penicillin; in such cases, clindamy- Lateral luxation is tooth displacement with fracture of the alveolar
cin can be substituted. Chlorhexidine oral rinse is an excellent process. Treatment involves repositioning to its original position
choice for most oral injuries to help prevent infection. and flexible splinting for 4 weeks. If the marginal alveolar bone

t.me/Dr_Mouayyad_AlbtousH
238 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

demonstrates radiographic signs of breakdown at follow-up, pro- • Teeth reimplanted at the scene of the accident: If the tooth can
longed splinting is recommended, up to 6 weeks after the injury. be found at the time of the accident, it can be reimplanted at
For teeth with incomplete root formation, spontaneous pulp the scene. If the tooth is dirty, rinse it gently in milk or saline
revascularization may occur. When there are signs of pulpal ne- or in the patient’s saliva and replant or return it to its original
crosis or infection or inflammatory external resorption, root canal position in the jaw. It can be held into position with light pres-
treatment should be started. Endodontic procedures suitable for sure. The patient should go immediately to the urgent care fa-
immature teeth should be used. Teeth with complete root forma- cility or to the dental office depending on the type of accident
tion will likely develop pulpal necrosis and must undergo root and other injuries. The tooth can be realigned or repositioned,
canal therapy 2 weeks after injury. Root canal therapy should if in the wrong location, for up to 48 hours after the injury. The
initially be performed using a corticosteroid–antibiotic or calcium tooth must be stabilized with a flexible splint, wire, and com-
hydroxide as an intracanal medication. posite for 2 weeks. In cases of associated alveolar segment frac-
ture or maxillary or mandibular fracture, a more rigid splint is
Intrusion indicated and should be left in place for about 4 weeks. The
patient is prescribed antibiotics and chlorhexidine, and tetanus
This is apical dislocation of the tooth, with crushing injury of vaccination status is assessed and treated accordingly. The pulp
supporting alveolar bone. The tooth is clinically immobile, and is monitored for possible root canal therapy depending whether
may resemble ankylosis on percussion. the tooth apes is closed or the tooth is still developing.
• Repositioning: For teeth with incomplete root formation, al- • For a tooth stored in physiologic solution or nonphysiologic
low several weeks for passive eruption. If no spontaneous solution with less than 1 hour extraoral dry time:
movement may be appreciated, orthodontic repositioning Closed apex: The socket is irrigated to remove any coagulum
should be started after 4 weeks of conservative treatment. For or debris. Any socket fractures are reduced. The tooth is
teeth with complete apical development, the clinician should gently reimplanted. The tooth is stabilized with flexible
allow for re-eruption without intervention if the tooth is in- wire and composite, for 2 weeks. In cases of associated al-
truded less than 3 mm. If no eruption within 8 weeks, the veolar segment fracture or maxillary or mandibular frac-
tooth must be repositioned surgically and splinted for 4 weeks ture, a more rigid splint is indicated and should be left in
with a passive and flexible splint. Alternatively, the tooth could place for about 4 weeks. Endodontic treatment should be
be repositioned orthodontically before ankylosis develops. If initiated within 2 weeks after replantation. Calcium hy-
the tooth is intruded 3 to 7 mm, the tooth should preferably droxide is recommended as an intracanal medicament for
be repositioned surgically. Alternatively, the tooth could be up to 1 month followed by root canal filling. (When corti-
repositioned orthodontically. If the tooth is intruded beyond 7 costeroid or an corticosteroid–antibiotic mixture is used as
mm, the tooth should be repositioned surgically. an antiinflammatory and antiresorptive intracanal medica-
• Endodontic treatment: For teeth with incomplete root forma- tion, it should be placed immediately or shortly after re-
tion, spontaneous pulp revascularization may occur. When plantation and left in place for at least 6 weeks. Calcium
there are signs of pulpal necrosis or infection or inflammatory hydroxide is an effective antimicrobial agent that decreases
external resorption, root canal treatment should be started. resorption and promotes healing. The more alkaline envi-
Endodontic procedures suitable for immature teeth should be ronment in the dentin slows the resorptive cells and pro-
used. Teeth with complete root formation that are intruded mote hard tissue formation. It is recommended that the
will likely develop pulpal necrosis and must undergo root canal calcium hydroxide not be changed frequently because it can
therapy 2 weeks after injury or as soon as the position of the also injure cells needed for root repair. The root canal can
tooth allows. Root canal therapy should initially be performed now be obturated with the final filling material, such as
using a corticosteroid-antibiotic or calcium hydroxide as an gutta percha.
intracanal medication. Open apex: For teeth with an open apex, the goal is to encour-
age revascularization, continued root formation, and apex
Avulsion or Exarticulation closure. The tooth is stabilized with a flexible wire and
composite for 2 weeks. The tooth is monitored for signs of
This is the complete loss of tooth from alveolar supporting bone. pulpal necrosis. If spontaneous revascularization does not
• Replantation: Successful long-term tooth retention and function occur, apexification, pulp revitalization or revascularization,
depend greatly on the steps performed in the first critical min- or root canal treatment should be initiated as soon as pulp
utes after injury. The most commonly avulsed tooth is the max- necrosis and infection is identified. Apexification therapy
illary central incisor, and it most often affects children 7 to 10 should be performed with calcium hydroxide therapy.
years of age. In most cases, replantation of avulsed permanent • For an extraoral dry time longer than 60 minutes:
teeth should be attempted. If it is a primary tooth, reimplanta- Closed apex: Teeth that have been out of the mouth for longer
tion should not be attempted. It is important to take a complete than 1 hour and not in a storage medium will have a ne-
medical history before treatment. Contraindications to replanta- crotic PDL and a poorer prognosis, with a greater risk of
tion include immunosuppressed patients after transplant surgery root resorption. The socket is irrigated to remove any co-
and patients with cardiac valve replacement. When possible, the agulum or debris. Any socket fractures are reduced. The
teeth should be positioned back into the socket immediately and tooth is gently reimplanted. The tooth is stabilized with
stabilized. If this is not possible, the prognosis of the avulsed flexible wire and composite for 2 weeks. In cases of associ-
tooth is dependent on how it was handled. The prognosis is ated alveolar segment fracture or maxillary or mandibular
improved if there is no dry time, the tooth is stored in physio- fracture, a more rigid splint is indicated and should be left
logic solution, milk, Hanks Balanced Salt Solution (HBSS) or in place for about 4 weeks. Endodontic treatment should be
saliva, and replantation is within 1 hour. initiated within 2 weeks post replantation. A study using

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 CHAPTER 48 Dentoalveolar Trauma 239

Emdogain (Straumann) has shown some beneficial effects • BOX 48.1 Splinting Schedule
for teeth with extended dry times. Emdogain is an enamel
matrix protein that has been shown to make the root more • Subluxation: flexible splint for up to 2 weeks for patient comfort only
resistant to resorption and stimulate new PDL formation • Extrusive luxation: flexible splint for 2 weeks
from the socket. • Lateral luxation: flexible splint for 4 weeks and up to 6 weeks if there is
Open apex: For teeth with an open apex, the goal is to en- marginal alveolar bone breakdown
• Intrusive luxation
courage revascularization, continued root formation and
• Incomplete root formation: eruption without intervention. If there is no
apex closure. The tooth is stabilized with a flexible wire movement within 4 weeks, orthodontics (if intruded .7 mm reposition
and composite for 2 weeks. The tooth is monitored for surgically or with orthodontics).
signs of pulpal necrosis. If spontaneous revascularization • Complete root formation: If ,3 mm of intrusion, eruption without inter-
does not occur, apexification, pulp revitalization/revascu- vention. If there is no movement within 2–4 weeks, reposition surgically
larization or root canal treatment should be initiated as or with orthodontics (before ankylosis develops). If .3 mm of intrusion,
soon as pulp necrosis and infection is identified. Apexifi- the tooth should be repositioned surgically, with or without orthodontics.
cation therapy should be performed with calcium hydrox- Stabilize with orthodontics or surgically repositioned tooth with a flexi-
ide therapy. ble splint for 4–8 weeks.
• Pediatric considerations: Prominent maxillary central incisors • Alveolar segment: flexible splinting for 4 weeks. For more severe injuries,
rigid stabilization for longer periods may be required.
that protrude beyond the confines of the upper lip are associ- • Avulsed teeth: flexible splint for 2 weeks
ated with a higher incidence of dental trauma in these chil- • Root fracture: flexible splint for 4 weeks. If there is a fracture near the cer-
dren. Children are more challenging to examine and treat and vix, stabilize for 4 months.
require cooperation from parents. Intrusion of the primary
dentition results in crown deformation of enamel hypoplasia
of the underlying permanent teeth. For these reasons, primary
teeth, if avulsed, should not be replanted for fear of injury to
the underlying permanent teeth. The main disadvantage of this technique is that dental bonding
• Storage media and other solutions: Avulsed teeth should be materials are not always available in urgent care facilities. The
placed back into the socket directly when in the field, prefer- clinician must also possess the skills to perform this technique,
ably within the first 15 to 20 minutes. However, this can re- which requires a cooperative or sedated patient. Arch bars are
sult in aspiration in pediatric patients or patients with other more rigid and provide better stabilization for alveolar segment
injuries. This is the most physiologic for the tooth. Transport fractures and severe large, comminuted areas. They may be less
media is not always readily available. HBSS can help to main- technically challenging to place. They are available as wire- or
tain the PDL. Organ transport solution can also be used but light-cured devices. Wire-retained devices are usually available in
may be more difficult to obtain. When these solutions are not the ED. The disadvantages are that it produces an eruptive or
available, consider the use of other physiologic solutions such extrusive force because of the placement of the wire beneath the
as the patient’s own saliva or cow’s milk. Organ transport so- height of contour of the tooth, and the rigid nature of this tech-
lution allows the PDL cells to survive for 1 week, and HBSS nique can facilitate ankylosis and resorption.
allows cells to survive for 24 hours, but milk only allows 6 An Essix appliance (suck-down splint) requires an impression
hours of survival. Water is a poor storage media for teeth be- and vacuform machine to create these appliances. This is usually
cause it is a hypotonic solution. It results in rapid lysis of not practical in the ED or when the teeth are grossly mobile. The
the PDL cells. Tetracycline has antiresorptive and antimicro- device must be taken out to clean, which could place detrimental
bial properties. Tetracycline has a direct inhibitory effect forces on the tooth. This device has limited application, and pa-
on collagenase activity and osteoclasts. Its antimicrobial ef- tients would have to be carefully chosen.
fects help to eliminate bacteria that have contaminated the
alveolus, PDL, and pulpal tissues. Although animal studies Prognosis of Teeth After Injuries to the
have been promising, human studies have failed to demon-
strate improved pulp revascularization when teeth are soaked Periodontium
in topical antibiotics. Thus, its routine use is not currently Favorable outcomes of periodontal injuries reflect pulpal vitality
recommended. at follow-up, measured by electric and cold pulp testing. Intruded
• Splinting (Box 48.1): Splinting after injuries to the periodon- or laterally luxated teeth may also demonstrate the high-pitched,
tium, root injuries, and alveolar segment fractures immobilizes metallic stigmata of root ankylosis on percussion testing. Asymp-
the tooth or segment after it has been reduced into proper tomatic teeth, which respond positively to pulp testing and show
position and allows for PDL healing; bony segment healing; radiographic evidence of intact lamina dura and continued root
and in some situations, revascularization of the tooth. Several growth and development (if immature), portend a positive prog-
techniques have been described for various injuries. These nosis. Symptomatic, nonvital teeth with radiographic evidence of
splinting techniques have their advantages and disadvantages external or replacement resorption, periapical radiolucency, or
and thus must be tailored to the fixation needs. The bonded arrested root development (if immature) are associated with a
composite with flexible wire is the treatment of choice for in- poor prognosis.
juries to the periodontium and root fractures. This technique
allows flexible stabilization that allows some movement of the Follow-up
tooth in relation to the alveolus. This in turn allows for healing
of the PDL and reduces the risk of ankylosis or resorption. The Follow-up is recommended at 2 to 4 weeks initially, then 6 to
recommended fixation time for an injury to the periodontium 8 weeks, followed by 6 months, 1 year, then annually for 5 years
is 2 weeks. with radiographic surveillance for root destruction.

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240 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

Injuries to the Dental Crown and Root Teeth that are mobile must be splinted for 12 weeks or extracted.
Fractures in the cervical third are usually extracted. Crown length-
Dental and Pulpal Injuries and Their Treatment ening or orthodontic extrusion may also be performed.
• Ellis classification of fractures
• I: within enamel Crown– Root Fracture Without Pulp Exposure
• II: fractures that involve the enamel and dentin This is a fracture involving enamel, dentin, and cementum. Re-
• III: fractures that involve the enamel, dentin and extends moval of the coronal or mobile fragment and subsequent restora-
into the pulp chamber tion should be considered. The exposed dentin should be covered
• IV: root fracture with glass ionomer or a bonding agent and composite resin should
• Other dental fractures be used. Other treatment options include orthodontic extrusion,
• Crown fractures that extend onto root without pulp exposure surgical extrusion, root canal therapy, root submergence, inten-
• Crown fractures that extend onto root with pulp exposure tional reimplantation, extraction, or autotransplantation.
Crown fractures are common, and many times treatment is
delayed to manage more severe injuries. Treatment is based on the
extent of the crown–root involvement or pulpal involvement. Crown– Root Fracture With Pulp Exposure
Pulpal fractures are discussed later. Crown fractures that extend This is a fracture involving the enamel, dentin, cementum, and
longitudinally onto the root below the level of the bone may re- pulp. In immature teeth with incomplete root formation, it is
quire extraction. Crown lengthening or orthodontic extrusion can advantageous to preserve the pulp by performing a partial pulp-
be used to save some teeth. otomy. In mature teeth with complete root formation, removal of
the pulp is usually indicated. In mature teeth with complete root
Enamel Infraction formation, removal of the pulp is usually indicated. The exposed
dentin should be covered with glass ionomer or a bonding agent
Enamel infraction is an incomplete fracture (crack or crazing) of and composite resin should be used. Other treatment options
the enamel, without loss of tooth structure. No treatment is usu- include orthodontic extrusion, surgical extrusion, root canal
ally necessary, but in case of severe infractions, etching and sealing therapy, root submergence, intentional reimplantation, extrac-
with bonding resin should be considered. tion, or autotransplantation.

Enamel Fracture Root Fractures

This is a coronal fracture involving enamel only with loss of tooth This is a fracture of the root involving the dentin, pulp, and
structure. If the tooth fragment is available, it can be bonded onto the cementum. If displaced, the coronal fragment should be reposi-
tooth. Other options include smoothing or repair with composite. tioned as soon as possible and the repositioning check radio-
graphically. The mobile coronal segment should be stabilized
Enamel– Dentin Fracture with a passive and flexible splint for 4 weeks. If the fracture is
located cervically, stabilization for a longer period of time for up
This is a coronal fracture involving enamel and dentin with loss of to 4 months may be needed. Root canal therapy should be de-
tooth structure. If the tooth fragment is available, it can be layed. Monitoring of the root fracture and the pulp should be
bonded on to the tooth. The fragment should be rehydrated for performed for at least 1 year. Pulp necrosis and infection usually
20 minutes in water or saline. Other options include smoothing occurs in the coronal fragment only. Endodontic treatment of
or repair with composite. If the exposed dentin is within 0.5 mm the coronal segment only is indicated while the apical segment
of the pulp, place a calcium hydroxide lining and cover with a is monitored; the segment usually remains viable. In teeth with
material such as glass ionomer. a closed apex in which the cervical fracture line is located above
the alveolar crest and the coronal fragment is very mobile, the
Enamel-Dentin Fracture With Pulp Exposure coronal fragment is removed followed by root canal therapy and
restoration.
This is a fracture confined to enamel and dentin with pulp expo-
sure. For teeth with incomplete root development or an open apex,
partial pulpotomy or pulp capping is recommended to promote
Injuries to the Supporting Alveolar Bone
further root development. This is also the preferred treatment in
teeth with completed root development. Nonsetting calcium hy-
Classification of Alveolar Injuries
droxide or nonstaining calcium silicate cements are suitable mate- • Comminution of the alveolar socket: crushing and comminu-
rials to be placed on the pulp wound. Alternatively, root canal tion can be isolated or associated with intrusive and lateral
therapy can be performed when indicated. If the tooth fragment is luxation
available, it can be bonded on to the tooth. The fragment should • Fracture of the alveolar socket wall: fracture of the alveolar
be rehydrated for 20 minutes in water or saline. Other options socket isolated to the facial or lingual wall
include covering the exposed dentin with glass ionomer or using a • Fracture of the alveolar process: fracture of the alveolar process
bonding agent and composite resin. isolated or associated with the socket wall
Treatment of root fractures has its own set of challenges. • Fractures of the mandible or maxilla: fracture involving the
Horizontal root fractures in the apical one-third have the best base of the mandible or maxilla combined with the alveolar
prognosis. If the tooth is stable, it may not require treatment. process

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 CHAPTER 48 Dentoalveolar Trauma 241

Alveolar Segment Fractures are usually self-limiting and do not require special care. If a
hematoma is present, drainage is usually indicated.
These injuries can be isolated or associated with dental luxation •braAsion: denuding of the epithelial surface that can be super -
injuries or maxillary or mandibular fractures. Alveolar fractures ficial or deep. These injuries can be caused by a variety of
associated with intrusion or luxation are managed by immediate objects and may result in the introduction of foreign and
closed reduction of the fracture to realign the segments, reduce contaminated material into the wound. Treatment must
the teeth, and set the teeth into the best occlusion. The segment include local cleansing, especially removal of foreign material
is stabilized by splinting the teeth with a passive and flexible splint imbedded in the wound, to prevent tattooing and reduce the
for 4 weeks. In isolated alveolar segment fractures with no associ- bacterial load.
ated luxation injury, closed reduction is performed followed by • Laceration: a deep cut or tear in the mucosa. Repair is per-
fixation with a single arch bar and 26- or 28-gauge wire for formed to reduce the risk of infection. Local anesthesia is per-
4 weeks. Large-span crush and comminuted injuries that are dif- formed first to reduce pain and improve patient cooperation.
ficult to stabilize may also require fixation with an arch bar and Careful inspection of the lacerations is performed to determine
wire for longer periods. Rigid fixation with titanium mini-plates the extent of the injury and remove any foreign bodies. Devital-
and screws is generally reserved for alveolar fractures that are as- ized tissues should be excised conservatively, especially at the
sociated with fractures that involve the basal bone fractures that keratinized gingival level. The tissue is reapproximated with
are treated with open repair. The pulp condition of all teeth in- slow resorbing suture (e.g., polylactic acid) to reapproximate
volved should be monitored to determine if endodontic treatment deeper structures such as muscle. The mucosa is closed with a
is indicated. faster resorbing material such as gut.
Antibiotic coverage must be based on mechanism and extent
Injuries to the Gingiva or Oral Mucosa of injury. It is indicated in contaminated wounds with significant
soft tissue injury. It is usually not indicated for contusions. Anti-
• Laceration of gingiva or oral mucosa: linear wound in the biotics are indicated for contaminated and extensive abrasions
mucosa from penetrating or blunt trauma and lacerations. Amoxicillin is usually chosen unless the patient is
• Contusion of gingiva or mucosa: blunt trauma resulting in allergic to penicillin; then clindamycin or clarithromycin can be
hemorrhage or swelling without a break in the mucosa. substituted. Chlorhexidine oral rinse is an excellent choice for
•braAsion of gingiva or oral mucosa: superficial wound pro - most oral injuries to help prevent infection. Grossly contaminated
duced by rubbing or scraping of the mucosa resulting in a raw, wounds or facial injuries caused by dog or human bites should be
bleeding surface considered for tetanus immunization based on their vaccination
• Contusion: usually from blunt trauma and generally results in history as discussed in an earlier section.
bleeding or swelling in the submucosal tissue without a surface
epithelial break. If the bleeding is significant and accumulates ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
in a confined location, a hematoma can result. These injuries complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 241.e1

dental injuries: 3. Injuries in the primary dentition, Dent Traumatol

Bibliography 36(4):343-359, 2020.
Diangelis AJ, et al: International Association of Dental Traumatology
Andersson L, Andreasen JO, Day P, et al: International Association of guidelines for the management of traumatic dental injuries: 1. Frac-
Dental Traumatology guidelines for the management of traumatic tures and luxations of permanent teeth, Dent Traumatol 28(1):2-12,
dental injuries: 2. Avulsion of permanent teeth, Dent Traumatol 2012.
28(2):88-96, 2012. Elias H, Baur DA: Management of trauma to supporting dental struc-
Andersson L, Friskopp J, Blomlof L: Fiber-glass splinting of traumatized tures, Dent Clin North Am 53(4):675-689, 2009, vi.
teeth, ASDC J Dent Child 50(1):21-24, 1983. Filippi A, Pohl Y, von Arx T: Treatment of replacement resorption with
Andreasen JO, et al: Dental trauma guide, 2012 [cited 2012]. Available Emdogain—preliminary results after 10 months, Dent Traumatol 17(3):
at: www.dentaltraumaguide.org. 134-138, 2001.
Andreasen JO, Farik B, Munksgaard EC: Long-term calcium hydroxide Fouad AF, Abbott PV, Tsilingaridis G, et al: International Association of
as a root canal dressing may increase risk of root fracture, Dent Trau- Dental Traumatology guidelines for the management of traumatic
matol 18:134-137, 2002. dental injuries: 2. Avulsion of permanent teeth, Dent Traumatol
Andreasen FM, Pedersen BV: Prognosis of luxated permanent teeth—the 36(4):331-342, 2020.
development of pulp necrosis, Endod Dent Traumatol, 1(6):207-220, Fuss Z, Tsesis I, Lin S: Root resorption—diagnosis, classification and
1985. treatment choices based on stimulation factors, Dent Traumatol 19(4):
Andreasen JO: Effect of extra-alveolar period and storage media upon 175-182, 2003.
periodontal and pulpal healing after replantation of mature perma- Gassner R, et al: Prevalence of dental trauma in 6000 patients with facial
nent incisors in monkeys, Int J Oral Surg 10(1):43-53, 1981. injuries: implications for prevention, Oral Surg Oral Med Oral Pathol
Andreasen JO, et al: Replantation of 400 avulsed permanent incisors. 1. Oral Radiol Endod 87(1):27-33, 1999.
Diagnosis of healing complications, Endod Dent Traumatol 11(2): Gonda F, et al: Replantation: an analysis of 29 teeth, Oral Surg Oral Med
51-58, 1995. Oral Pathol 70(5):650-655, 1990.
Andreasen JO, et al: Replantation of 400 avulsed permanent incisors. 4. Leathers RD, Gowans RE: Management of alveolar and dental fractures.
Factors related to periodontal ligament healing, Endod Dent Traumatol In Larsen P (ed): Peterson’s Principles of Oral and Maxillofacial Surgery,
11(2):76-89, 1995. Shelton, CT, 2012, People’s Medical Publishing House, pp 387-407.
Andreasen JO, et al: Replantation of 400 avulsed permanent incisors. 2. Hiltz J, Trope M: Vitality of human lip fibroblasts in milk, Hanks bal-
Factors related to pulpal healing, Endod Dent Traumatol 11(2):59-68, anced salt solution and Viaspan storage media, Endod Dent Traumatol
1995. 7(2):69-72, 1991.
Andreasen JO, Borum MK, Andreasen FM: Replantation of 400 avulsed Iqbal MK, Bamaas N: Effect of enamel matrix derivative (EMDOGAIN)
permanent incisors. 3. Factors related to root growth, Endod Dent upon periodontal healing after replantation of permanent incisors in
Traumatol 11(2):69-75, 1995. beagle dogs, Dent Traumatol 17(1):36-45, 2001.
Andreasen JO: Textbook and Color Atlas of Traumatic Injuries to the Teeth, Jamal BT, et al: The pattern of combined maxillofacial and cervical spine
ed 4, Oxford, 2007, Blackwell Munksgaard, p 897. fractures, J Oral Maxillofac Surg 67(3):559-562, 2009.
Andreasen JO: Traumatic Dental Injuries: A Manual, ed 3, Chichester, Kahler B, Rossi-Fedele G, Chugal N, et al: An evidence-based re- view of
UK, 2011, Wiley-Blackwell. the efficacy of treatment approaches for immature perma- nent teeth
Association of Dental Traumatology guidelines for the management of with pulp necrosis, J Endod 43:1052-1057, 2017.
traumatic dental injuries: general introduction, Dent Traumatol Katner DR, Brown CE: Mandatory reporting of oral injuries indicating
36(4):309-313, 2020. possible child abuse, J Am Dent Assoc 143(10):1087-1092, 2012.
Atkinson W, Wolfe S, Hamborsky J, editors: Center for Disease Control and Kehoe JC: Splinting and replantation after traumatic avulsion, J Am Dent
Prevention of Vaccinated Preventable Disease, 12th ed. Washington DC: Assoc 112(2):224-230, 1986.
Public Health Foundation; 2011. Kim SG, Malek M, Sigurdsson A, et al: Regenerative endodontics: a
Barrett EJ, Kenny DJ: Avulsed permanent teeth: a review of the literature comprehensive review, Int Endod J 51(12):1367-1388, 2018.
and treatment guidelines, Endod Dent Traumatol 13(4):153-163, 1997. Kloss F, et al: Traumatic intracranial haemorrhage in conscious patients
Blomlof L: Milk and saliva as possible storage media for traumatically with facial fractures—a review of 1959 cases, J Craniomaxillofac Surg
exarticulated teeth prior to replantation, Swed Dent J Suppl 8:1-26, 36(7):372-377, 2008.
1981. Lee R, Barrett EJ, Kenny DJ: Clinical outcomes for permanent incisor
Bourguignon C, Cohenca N, Lauridsen E, et al: International Associa- luxations in a pediatric population. II. Extrusions, Dent Traumatol
tion of Dental Traumatology guidelines for the management of trau- 19(5):274-279, 2003.
matic dental injuries: 1. Fractures and luxations, Dent Traumatol Lengheden A, Blomlof L, Lindskog S: Effect of delayed calcium hydrox-
36(4):314-330, 2020. ide treatment on periodontal healing in contaminated replanted teeth,
Bystrom A, Claesson R, Sundqvist G: The antibacterial effect of cam- Scand J Dent Res 99(2):147-153, 1991.
phorated paramonochlorophenol, camphorated phenol and calcium Lengheden A, Blomlof L, Lindskog S: Effect of immediate calcium hy-
hydroxide in the treatment of infected root canals, Endod Dent Trau- droxide treatment and permanent root-filling on periodontal healing
matol 1(5):170-175, 1985. in contaminated replanted teeth, Scand J Dent Res 99(2):139-146,
Chen JW: Cervical spine injuries, Oral Maxillofac Surg Clin North Am 1991.
20(3):381-391, 2008. Malmgren B, et al: International Association of Dental Traumatology
Cohenca N, et al: Clinical indications for digital imaging in dento- guidelines for the management of traumatic dental injuries: 3. Injuries
alveolar trauma. Part 1: traumatic injuries, Dent Traumatol 23(2): in the primary dentition, Dent Traumatol 28(3):174-182, 2012.
95-104, 2007. Mithani SK, et al: Predictable patterns of intracranial and cervical spine
Cvek M, et al: Effect of topical application of doxycycline on pulp revas- injury in craniomaxillofacial trauma: analysis of 4786 patients, Plast
cularization and periodontal healing in reimplanted monkey incisors, Reconstr Surg 123(4):1293-1301, 2009.
Endod Dent Traumatol 6(4):170-176, 1990. Needleman HL: The art and science of managing traumatic injuries to
Cvek M, et al: Pulp revascularization in reimplanted immature monkey primary teeth, Dent Traumatol 27(4):295-299, 2011.
incisors—predictability and the effect of antibiotic systemic prophy- Powers MP, Reynolds JS, Reynolds MT: Diagnosis and management of
laxis, Endod Dent Traumatol 6(4):157-169, 1990. dentoalveolar injuries. In Fonseca RJ, Barber HD, Powers MP, et al
Day PF, Flores MT, O’Connell AC, et al: International Association of (eds): Oral and Maxillofacial Trauma, St. Louis, Missouri, 2005,
Dental Traumatology guidelines for the management of traumatic Elsevier Saunders, pp 427-477.

t.me/Dr_Mouayyad_AlbtousH
241.e2

Rosenberg B, Murray PE, Namerow K: The effect of calcium hydroxide Trope M: Root resorption of dental and traumatic origin: classification
root filling on dentin fracture strength, Dent Traumatol 23:26-29, 2007. based on etiology, Pract Periodontics Aesthet Dent 10(4):515-522, 1998.
Sjogren U, et al: The antimicrobial effect of calcium hydroxide as a short- Tsilingaridis G, Malmgren B, Skutberg C, et al: The effect of topical
term intracanal dressing, Int Endod J 24(3):119-125, 1991. treatment with doxycycline compared to saline on 66 avulsed perma-
Soder PO, et al: Effect of drying on viability of periodontal membrane, nent teeth–a retrospective case-control study, Dent Traumatol 31:
Scand J Dent Res 85(3):164-168, 1977. 171-176, 2015.
Tronstad L, et al: pH changes in dental tissues after root canal filling with Valente JH, et al: Wound irrigation in children: saline solution or tap
calcium hydroxide, J Endod 7(1):17-21, 1981. water? Ann Emerg Med 41(5):609-616, 2003.
Trope M, Friedman S: Periodontal healing of replanted dog teeth stored Wolfe RM: Update on adult immunizations, J Am Board Fam Med
in Viaspan, milk and Hank’s balanced salt solution, Endod Dent 25(4):496-510, 2012.
Traumatol 8(5):183-188, 1992. Yanpiset K, Trope M: Pulp revascularization of replanted immature dog
Trope M: Avulsion and replantation, Refuat Hapeh Vehashinayim 19(2): teeth after different treatment methods, Endod Dent Traumatol
6-15, 76, 2002. 16(5):211-217, 2000.

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49
Subcondylar Mandibular Fracture
E VA N B U SB Y, D E E PAK G O PA L A K R IS HN AN , a n d S TE PH E N M ORE N O

CC Examination
A 21-year-old male comes to the local emergency department General. The patient is a well-developed and well-nourished male
(ED), stating, “I fell and cut my chin.” You are consulted to in no apparent distress.
evaluate this patient. Maxillofacial. There is a 3-cm hemostatic laceration at the
Subcondylar fractures are more commonly seen with falls as submental region with no foreign body or signs of underlying
than other fracture patterns. The role of the dentition and the influ- fracture. The mandible deviates to the right upon opening, which
ence of open versus closed mouth position are likely of minor im- is commonly caused by the unopposed contralateral lateral ptery-
portance. The force from direct blunt trauma to the symphysis in a goid muscle and impaired rotation and translation on the affected
fall is transmitted to the condylar region, and given the reduced side. The maximal incisal opening (MIO) is limited to 20 mm,
cross-sectional area, a fracture is most likely to occur at this site. with associated pain. There are edema of the right preauricular
region, no deformity of the ear, no blood at the external auditory
HPI canal (EAC), no hemotympanum, and normal auditory acuity.
(Hemotympanum and blood at the EAC may indicate perfora-
The patient reports that while riding a skateboard to class, he fell tion of the anterior tympanic plate.) There is no otorrhea or Bat-
and landed on his chin and right hand. He presents to the local tle’s sign (which may indicate basilar skull fracture and cerebrospi-
ED for the deep laceration on his chin. He also complains of an nal fluid leakage). Palpation of the right preauricular region also
inability to fully open his mouth and pain in front of his right ear. elicits pain. (Pain in the preauricular area with a history of trauma
The patient denies loss of consciousness, dizziness, nausea or vom- to the symphysis is highly suggestive of a subcondylar fracture.)
iting, or visual changes. There is no dyspnea, stridor, or inability Intraoral. Left lateral excursive movement is limited to 2 mm.
to manage secretions. The patient states that his bite is not repro- (Excursive movement of the mandible to the left requires the
ducible, and he feels intense pain when attempting excursive function of the right lateral pterygoid against an intact condylar
movements. There are no neurosensory changes in the lip, chin, neck.) There are no associated intraoral lacerations and no dental
tongue, or midface. trauma. (Fractures of the teeth are not uncommon with forceful
Advanced Trauma Life Support should be standard protocol closure of the mandible at the time of trauma.) Occlusal examina-
when evaluating trauma patients. A thorough review of systems is tion shows premature contacts on the right side, with a left poste-
essential to identify further injuries. Traumatic force to the man- rior open bite (secondary to collapse of the vertical height of the
dible may be transmitted to the skull base. A review of symptoms mandible on the right). The airway is patent with no obstruction
related to intracranial injury and closed head injury allows the or reduction in airflow.
surgeon to determine additional studies, evaluations, or referrals. Extremities. There is pain during passive range of motion
The association between mandibular fractures and cervical spine (ROM) of the right wrist. A palpable radial pulse and normal
injuries is well established (although these two types of injuries capillary refill in the nail beds are present. (Vascular compromises
infrequently occur together). Any neck pain warrants further from a distal radial fracture, a carpal bone fracture, or in the com-
evaluation and is routinely completed during the primary survey. partment system are surgical emergencies.)
In addition, the surgeon must evaluate for signs of concomitant
mandibular fractures because more than half of fractures are as- Imaging
sociated with contralateral parasymphysis or body or angle frac-
ture. A significant impact to the chin, as occurred in the current Depending on the facility, initial imaging for evaluation of the
patient, raises concern for bilateral subcondylar fracture with the mandible may include a computed tomography (CT) scan, cone-
potential for airway compromise; therefore, a review of symptoms beam CT scan, panoramic radiograph, or plain view mandibular
related to airway obstruction must be performed. series that includes lateral and posteroanterior cephalometric
films, a reverse Towne’s view, and oblique views of the mandible.
PMHX/PDHX/Medications/Allergies/SH/FH Many rural hospitals still use a plain view series of the mandible.
Most hospitals use a CT scan, which has become the gold stan-
Noncontributory. dard imaging modality. A CT scan allows the entire face to be

242
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 CHAPTER 49 Subcondylar Mandibular Fracture 243

evaluated in one study. The mandible can also be evaluated in

several different anatomic planes. The axial and coronal planes are
the two most used views, although the sagittal view should not be
missed. The coronal plane can be very helpful for condylar process
fractures and for determining the degree of medial displacement
and orientation; the axial planes are useful for intracapsular frac-
tures and the remainder of the mandible. Direct coronal imaging
requires hyperextension of the neck and should not be obtained
in patients with a suspicion of cervical spine injury. Three-dimen-
sional reconstructions are extremely valuable and allow preopera-
tive planning in a more sophisticated manner for complex cases
such as gunshot wounds or severely comminuted fractures. A
panoramic film is the single best plain film for evaluating the en-
tire mandible at once. In combination with a reverse Towne’s
view, the sensitivity for detecting a condylar process fracture in-
creases. All modalities have limitations, and surgeons should use
imaging studies based on individual cases and available resources.
For the current patient, a CT scan was obtained as the initial
study. It demonstrated a right subcondylar fracture on coronal
and axial views (Fig. 49.1). A plain wrist film was also obtained, A
which revealed a right-sided fracture of the distal radius (Colles’
fracture).

Labs
No routine laboratory testing is indicated unless dictated by the
medical history.

Assessment
A 21-year-old male with a right medially displaced subcondylar frac-
ture of the mandible and associated chin laceration after a fall; Colles’
fracture of the right wrist; Facial Injury Severity Scale score of 1.

Treatment
The treatment of fractures of the mandibular condyle is one of the
most widely debated topics in the maxillofacial literature. Several
variables should be considered when determining treatment and B
predicting the prognosis, including the level of fracture, degree
and direction of displacement, age and medical status of the pa- • Fig. 49.1 A, Coronal view of the ramus and condyle showing anterome-
tient, concomitant injuries, and status of the dentition. Assael has dially displaced subcondylar fracture on the right side. B, Axial view at the
level of the glenoid fossae. Notice the absence of the condyle from the
developed a comprehensive list of patient specific variables affect- fossa on the right.
ing treatment selection and outcome, all of which should be in-
cluded in the evaluation of the patient before the surgery. Age,
gender, medical status, compliance, associated injuries, and frac-
ture type are a few examples of these variables. The treatment options are categorized into surgical and non-
The primary goal in the treatment of any fracture is adequate surgical modalities. Surgical treatment includes open reduction
stabilization that allows for fracture healing and primary osseous with or without internal fixation. Many agree that if an open ap-
union. In the treatment of mandibular condyle and subcondylar proach is taken, fixation should be applied. Endoscopic reduction
fractures, the goals of treatment are: and fixation of condylar fractures has gained popularity during
• Pain-free mouth opening with return to an acceptable MIO the past decade. The use of this technique requires familiarity with
• Pain-free functional movement an endoscope and the ability to convert the procedure to an open
• Restoration of occlusion method if endoscopic reduction fails to successfully complete the
• Facial and jaw symmetry and establishment of facial height procedure. The options for nonsurgical treatment include closed
• Minimal visible scarring reduction (closed treatment) with maxillomandibular fixation
Preinjury alignment of the mandibular condyle within the (MMF) and dietary modification with ROM exercises. In the
glenoid fossa is not essential for adequate rehabilitation. The pull treatment of facial fractures, patients older than 10 years are
of the lateral pterygoid muscle characteristically displaces the treated in a manner similar to that for adults; however, it is rarely
condyle anteriorly and medially. Closed reduction (more correctly advocated that children and teenagers undergo open reduction of
termed “closed treatment”) typically does not reduce the condyle condylar fractures. A soft diet with mobilization is the initial
into its original position. treatment of choice in patients 15 years or younger. If the

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244 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

occlusion is unstable and not reproducible, a short period of in- ORIF is the preferred approach. In 2022, Bera et al. conducted a
termaxillary fixation (2 weeks) can be advocated. This can be systematic review considering closed versus open treatment; their
followed with guiding elastics if needed. findings were consistent with those of Brandt and Haug. They
For the current patient, the occlusion was reestablished easily also concluded that the efficacy of endoscopic over open approach
with minimal manipulation, and after extensive discussion of has not been validated. In 2021, when reviewing pediatric man-
procedures, alternatives, risks, and benefits, the patient was placed dible fractures, Bansal et al. determined the mainstay of treatment
in MMF for 4 weeks. After the 4 weeks, an aggressive posttreat- to be closed reduction unless faced with a displaced mandible
ment physiotherapy program was instituted, with active and pas- fracture, particularly with a coexisting condylar fracture, to be
sive ROM exercises. Return to full function occurred within 4 ORIF. In 2009, Ellis developed a method for determining which
weeks of release from MMF. There were no postoperative compli- patients would benefit from ORIF using preoperative imaging
cations because the patient returned to full function with stable and intraoperative clinical evaluation. This method demonstrated
and repeatable occlusion. that patients with fractures that maintained a reasonable occlu-
sion with digital pressure would not require open reduction. In-
Complications stead, they can be treated with elastics to attain an acceptable
occlusion.
The complications of treating fractures of the mandibular condyle Haug and Assael described the indications and contraindica-
are well described in the literature and are often used as the basis tions for open treatment of condylar fractures in 2001. Their abso-
of comparison for surgical and nonsurgical treatment. One of the lute indications for ORIF are patient preference (when no absolute
most severe late complications can be temporomandibular joint or relative contraindications coexist); cases in which manipulation
(TMJ) ankylosis (fusion between the mandibular condyle and the and closed reduction cannot reestablish pretraumatic occlusion or
glenoid fossa). Patients with TMJ ankylosis often have a history excursion; cases in which rigid internal fixation is used to address
of facial trauma. Prevention of ankylosis was discussed by Zide other fractures, affecting the occlusion; the rare instance of intracra-
and Kent in 1983. They advocated appropriate physiotherapy nial impaction of the proximal condylar segment; and cases in
early in the phase of nonsurgical treatment. Other types of late which stability of the occlusion is limited. Among the absolute
mandibular dysfunction have been cited as complications of contraindications are condylar head fractures (including single frag-
closed reduction. These include chronic pain, malocclusion, inter- ment, comminuted, and medial pole) and patients in whom medi-
nal derangement, asymmetry, limited mobility, and gross radio- cal illness or systemic injury adds undo risk to an extended general
graphic abnormalities. (However, radiographic abnormalities in anesthesia. Condylar neck fractures were among the relative contra-
the absence of pain or functional impairment have no clinical indications.
significance.) Long-term complications of open reduction and With nonsurgical techniques, there is no consensus on the use
internal fixation (ORIF) are scar perception, facial nerve palsy or or duration of immobilization. Literature is available supporting
paralysis, loss or failure of fixation, Frey’s syndrome, avascular anywhere from 0 to 6 weeks of closed treatment. A period of
necrosis, TMJ dysfunction, and facial asymmetry. The early com- MMF is typically instituted for one of three reasons:
plications are few and can include early failure of fixation, maloc- 1. Patient comfort
clusion, pain, and infection. Complications are a high yield por- 2. To promote osseous union and restore premorbid occlusion
tion of board review. 3. To help reduce the fractured segment
One method for treating fractures with no occlusal distur-
Discussion bances, acceptable ROM, and minimal pain is to place the patient
in early full function, along with functional physiotherapy. If the
As is common with most traumatic injuries, fractures of the man- patient demonstrates occlusal discrepancy, Erich arch bars can be
dibular condyle mainly occur in males (78%) between the ages of placed for MMF or guiding elastics. For pediatric patients in a
20 and 39 years (60%). Most of the fractures are unilateral (84%); mixed dentition stage who demonstrate an occlusal discrepancy,
fewer are bilateral (16%); 14% of fractures are intracapsular, 24% there may be a need for circum-mandibular wires or circumzygo-
are in the condylar neck, and 62% are subcondylar fractures. matic or piriform wires to obtain adequate stabilization.
Whereas adults have a relatively narrow condylar neck and thick Regardless of the type of treatment, patients should undergo
articular surface, children have a relatively broad condylar neck postoperative physical therapy. Functional therapy is needed to
and thin articular surface in an active osteogenic phase. (Fractures improve ROM, asymmetric movements, scarring within the joint,
in children are discussed later in the chapter.) or other TMJ dysfunctions. If there is limitation in mouth open-
Many studies have compared various outcomes of surgical and ing, tongue blades or other sequentially enlarging devices to
nonsurgical therapy, with most of the debate centering on ORIF gradually improve the range of mandibular opening can be used.
and closed treatment. The outcomes studied included perception For patients with asymmetric mouth opening, it is recommended
of pain, occlusal function, asymmetry, MIO and ROM, muscle that they function on the contralateral side. Patients can be en-
activity, malocclusion, midline deviation, radiographic changes, couraged to observe their opening and closing in the mirror and
and nerve dysfunction. Brandt and Haug in 2003 conducted a to use their hand to help correct any asymmetric movement. The
review of the literature (Table 49.1) regarding open versus closed overall goal is to achieve early full function and restoration to
treatment and suggested indications for closed and open reduc- symmetric, pain-free mandibular motion.
tion. If a patient has an acceptable ROM, good occlusion, and When the decision is made to use ORIF, many advocate a
minimal pain, observation or closed treatment is preferred regard- retromandibular approach. This approach affords excellent expo-
less of the level of the fracture. They also suggested that condylar sure to the ramus–condyle unit for reduction and fixation. The
displacement and ramus height instability are the only orthopedic approach was first described by Hinds and Girotti in 1967 and
indications for ORIF of condylar fractures. Based on their review, later adapted for use in the treatment of mandibular condylar
they concluded that under similar indications and conditions, fractures. An incision of 2 cm is made parallel to the posterior

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 CHAPTER 49 Subcondylar Mandibular Fracture 245

TABLE
49.1 Open Versus Closed Treatment of Mandibular Subcondylar Fractures: Review of the Literature

Authors Total Number of Patients Follow-Up Results

Hidding et al. 20 ORIF; 54 CR-MMF 5 yr Deviation: 64% CR-MMF; 10% ORIF
Anatomic reconstruction: 93% ORIF; 7% CR-MMF
No differences in headaches, mastication, or MIIO
Konstantinovic and 26 ORIF; 54 CR-MMF 2.5 yr ORIF: 100% were 81%–100% of ideal
Dimitrijevic CR-MMF: 77.7% were 81%–100% of ideal
No difference in deviation or MIIO
Oezman et al. 20 ORIF; 10 CR-MMF 2 yr ORIF: MRI revealed 10% disc displacement
CR-MMF: MRI revealed 30% disc displacement; also, MRI revealed 80% of CR-MMF with
maligned or deformed condyles
Worsae and Thorn 61 CR-MMF; 40 ORIF 2 yr CR-MMF: 39% complication rate (asymmetry, malocclusion, reduced MIIO, headaches, pain)
ORIF: 4% complication rate (malocclusion, impaired mastication, pain)
Haug and Assael 10 CR-MMF; 10 ORIF 6 yr ORIF/CR-MMF: no statistically significant differences in ROM, occlusion, contour, or motor
or sensory function
ORIF: associated with perceptible scars
CR-MMF: associated with chronic pain
Throckmorton et al. 14 CR-MMF; 62 ORIF 3 yr ORIF/CR-MMF: no perceivable differences in mandibular motion or muscle activity
Palmieri et al. 74 CR-MMF; 62 ORIF 3 yr ORIF: greater mobility
Ellis et al. 65 CR-MMF 6 wk Position of condylar process is not static
Ellis et al. 61 ORIF 6 mo Anatomic reduction possible, but changes in condylar process position may result from
loss of fixation
Ellis et al. 77 ORIF; 65 CR-MMF 3 yr CR-MMF: significantly greater percentage of malocclusion
Ellis and Throck- 81 CR-MMF; 65 ORIF 3 yr CR-MMF: shorter posterior facial and ramus heights on injured side
morton
Ellis et al. 93 ORIF; 85 CR-MMF 3 yr ORIF: 17.2% facial nerve weakness at 6 wk with 0% at 6 mo and 7.5% scarring judged
as hypertrophic
Ellis and Throck- 91 CR-MMF; 64 ORIF 3 yr ORIF/CR-MMF: no difference noted in maximum bite forces
morton

CR-MMF, Closed reduction with maxillomandibular fixation; MIIO, maximal interincisal opening; MRI, magnetic resonance imaging; ORIF, open reduction and internal fixation; ROM, range of motion.
From Brandt MT, Haug RH: Open versus closed reduction of adult mandibular condyle fractures: a review of the literature regarding the evolution of current thoughts on management, J Oral Maxillofac
Surg 61:1324-1332, 2003.

border of the mandible starting 1 cm below the earlobe. Dissec- double miniplates have shown to be stable for fixation. It has also
tion proceeds through skin, subcutaneous tissue, and the superfi- been shown that resorbable plates are effective and provide reliable
cial musculoaponeurotic system down to the parotid capsule. stability in ORIF of condylar fractures. Many surgeons recommend
Next, the decision is made to complete a transparotid or retropar- that fixation be applied with the use of one or two 2-mm plates
otid approach using blunt dissection. The posterior mandible and with two or three bicortical screws on both sides of the fracture. Lag
pterygomasseteric sling are identified. The periosteum at the screw fixation can be used in appropriate situations (Fig. 49.2).
posterior border of the mandible is incised and dissected in a As is true for most conditions, the treatment of pediatric pa-
subperiosteal plane. Both sides of the fracture are exposed to fa- tients requires special consideration. Up to 40% of mandibular
cilitate reduction and fixation. A similar approach can be used fractures in pediatric patients involve the condyle. Anatomically,
with endoscopy. This approach allows excellent exposure to the pediatric patients have a relatively broad condylar neck and a thin
ramus–condyle unit, minimal visible scarring, and a low inci- articular surface, which accounts for the fact that 41% of the
dence of facial nerve damage. Other surgical approaches to the fractures are intracapsular. Clinical suspicion and accurate diag-
mandibular condyle include a preauricular (or endaural) incision, nosis are crucial in the early stages because a missed or delayed
intraoral incision, or Risdon-type incision, depending on the diagnosis may not be apparent until further growth leads to mor-
fracture pattern and location. phologic or occlusal disturbance. Because pediatric patients are
Multiple modalities have been used to rigidly fixate mandibular often in the mixed dentition stage, occlusal changes may not be as
condylar fractures. Studies have evaluated the biomechanical be- readily detected. Imaging of children is of particular concern.
havior of dynamic compression plates, locking plates, mini– Panoramic imaging is useful, but coronal CT has been found to
dynamic compression plates, adaptation plates, and single or be highly diagnostic in the pediatric population. Historically,
double miniplates. Both mini–dynamic compression plates and nonsurgical treatment of condylar fractures has involved MMF

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246 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

1/3 1/3
1/3

15–20 mm

15 mm

B C
• Fig. 49.2 A, Diagrammatic representation of lag screw technique. B, Intraoperative view. C, Postoperative
panoramic radiograph showing excellent reduction using the lag screw technique. (From Fonseca RJ,
Barber HD, Powers MP: Oral and maxillofacial trauma, ed 4, St. Louis, 2013, Saunders.)

followed by physiotherapy. Given the greater osteogenic potential condylar and subcondylar fractures being treated more often with
and faster healing rates in children than in adults, the duration of resorbable hardware. In the rare case that open reduction is indi-
MMF has been decreasing over time and often is not even used. cated, there should be consideration for the use of resorbable
We recommend that a soft diet, aggressive physiotherapy, and hardware because there is a higher chance of elective removal of
growth monitoring be used and that closed treatment be reserved rigid titanium fixation. A thorough informed consent is imperative
for open bite or malocclusion. because the US Food and Drug Administration has not approved
Although closed treatment is preferred in the pediatric popula- resorbable hardware for load-bearing indications unless used in
tion, many are proponents of open reduction in the case of severely conjunction with traditional rigid fixation. Irrespective of the type
displaced or unfavorable fractures. A 30-year systematic review of fixation, growth disturbances have been associated with pediat-
comparing resorbable versus titanium rigid fixation has shown ric condylar fractures, and growth surveillance should be provided
comparative complication rates in the pediatric population, with for all patients after these injuries.

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 CHAPTER 49 Subcondylar Mandibular Fracture 247

Airway Conclusion
Acute airway obstruction may occur after bilateral mandibular The treatment of patients with condylar and subcondylar fractures
fractures because of collapse of the genioglossus and intrinsic requires consideration of many factors. The choice between open and
tongue musculature, leading to obstruction of the oropharynx. closed treatment largely comes down to surgeon preference, but in
Medical personnel involved in primary and secondary surveys are displaced or unfavorable fractures, open reduction should be consid-
often concerned about airway obstruction in patients with bilat- ered. Ultimately, the best course is to use the simplest approach with
eral condylar fractures. Although the airway should be rapidly the lowest risk of morbidity to accomplish the goals of treatment.
and continuously evaluated in all patients with maxillofacial in-
juries, condylar injuries have not shown to be a cause of airway ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
obstruction. complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 247.e1

Bibliography Ellis EE: Method to determine when open treatment of condylar process
fractures is not necessary, J Oral Maxillofac Surg 67:1685, 2009.
El-Sheikh MM, Medra AM, Warda MH: Bird face deformity secondary
Assael LA: Open versus closed reduction of adult mandibular condyle to bilateral temporomandibular joint ankylosis, J Craniomaxillofac
fractures: an alternative interpretation of the evidence, J Oral Maxil- Surg 24:96, 1996.
lofac Surg 61:1333-1339, 2003. Eppley BL: Use of resorbable plates and screws in pediatric facial frac-
Bansal A, Yadav P, Bhutia O, et al: Comparison of outcome of open re- tures, J Oral Maxillofac Surg 63(3):385-391, 2005.
duction and internal fixation versus closed treatment in pediatric Goth S, Sawatari Y, Peleg M: Management of pediatric mandible frac-
mandible fractures-a retrospective study, J Craniomaxillofac Surg tures, J Craniofac Surg 23(1):47-56, 2012.
49(3):196-205, 2021. Haug RH, Assael LA: Outcomes of open versus closed treatment of
Bansal A, Yadav P, Bhutia O, et al: Comparison of outcome of open re- mandibular subcondylar fractures, J Oral Maxillofac Surg 59:370-375,
duction and internal fixation versus closed treatment in pediatric 2001.
mandible fractures-a retrospective study, J Craniomaxillofac Surg Haug RH, Gilman PP, Goltz M: A biomechanical evaluation of man-
49(3):196-205, 2021. doi:10.1016/j.jcms.2020.12.013. dibular condyle fracture plating techniques, J Oral Maxillofac Surg
Beekler DM, Walker RV: Condylar fractures, J Oral Surg 27:563, 1969. 60:73-80, 2002.
Behnia H, Motamedi MHK, Tehranchi A: Use of activator appliances in Hinds EC, Girotti WJ: Vertical subcondylar osteotomy: a reappraisal,
pediatric patients treated with costochondral grafts for temporoman- Oral Surg Oral Med Oral Pathol Oral Radiol Endod 80:394-397, 1967.
dibular joint ankylosis: an analysis of 13 cases, J Oral Maxillofac Surg Ikemura K: Treatment of condylar fractures associated with other man-
55:1408, 1997. dibular fractures, J Oral Maxillofac Surg 43:810, 1985.
Bera RN, Anand Kumar J, Kanojia S, et al: How far we have come with Ivy RH, Curtis L: Fractures of the jaws, Philadelphia, 1931, Lea & Fe-
the management of condylar fractures? A meta-analysis of closed ver- biger, p 78.
sus open versus endoscopic management, J Maxillofac Oral Surg Manisali M, Amin M, Aghabeigi B, et al: Retromandibular approach to
21(3):888-903, 2022. doi:10.1007/s12663-021-01587-0. the mandibular condyle: a clinical and cadaveric study, Int J Oral
Brandt MT, Haug RH: Open versus closed reduction of adult mandibu- Maxillofac Surg 32:253-256, 2003.
lar condyle fractures: a review of the literature regarding the evolution Pontell ME, Niklinska EB, Braun SA, et al: Resorbable versus titanium
of current thoughts on management, J Oral Maxillofac Surg 61:1324- rigid fixation for pediatric mandibular fractures: a systematic review,
1332, 2003. institutional experience and comparative analysis, Craniomaxillofac
Chacon GE, Dawson KH, Myall RW, et al: A comparative study of two Trauma Reconstr 15(3):189-200, 2022.
imaging techniques for the diagnosis of condylar fractures in children, Posnick JF, Wells M, Pron GE: Pediatric facial fractures: evolving patterns
J Oral Maxillofac Surg 61:668, 2003. of treatment, J Oral Maxillofac Surg 51:836, 1993.
Chatzistavrou EK, Basdra EK: Conservative treatment of isolated condy- Schüle H: Injuries of the temporomandibular joint. In Krüger E, Schilli
lar fractures in growing patients, World J Orthod 8:241, 2007. W (eds): Oral and Maxillofacial Traumatology, vol 2, Chicago, 1986,
Choi BH, Yi CK, Yoo JH, et al: Clinical evaluation of three types of plate Quintessence, pp 45-70.
osteosynthesis for fixation of condylar neck fractures, J Oral Maxillo- Silovennoinen U, Iizuka T, Lindqvist C, et al: Different patterns of con-
fac Surg 59:734-737, 2001. dylar fractures: an analysis of 382 patients in a 3-year period, J Oral
Chossegros C, Cheynet F, Blanc JL, et al: Short retromandibular approach Maxillofac Surg 50:1032, 1992.
of subcondylar fractures: clinical and radiologic long-term evaluation, Suzuki T, Kawamura H, Kasahara T, et al: Resorbable poly-L-lactide
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 82:248-252, 1996. plates and screws for the treatment of mandibular condyle process
Chrcanovic BR: Open versus closed reduction: mandibular condyle frac- fractures: a clinical and radiologic follow-up study, J Oral Maxillofac
tures in children, Oral Maxillofac Surg 16:245, 2012. Surg 62:919-924, 2004.
Ellis E, McFadden D, Simon P, et al: Surgical complications with open Thoren H, Hallikainen D, Iizuka T, et al: Condylar process fractures in chil-
treatment of mandibular condylar process fractures, J Oral Maxillofac dren: a follow-up study of fractures with total dislocation of the condyle
Surg 58:950, 2000. from the glenoid fossa, J Oral Maxillofac Surg 59:768-773, 2001.
Ellis EE, Dean J: Rigid fixation of mandibular condyle fractures, Oral Villareal PM, Monje F, Junquera LM, et al: Mandibular condyle frac-
Surg Oral Med Oral Pathol Oral Radiol Endod 76:6-15, 1993. tures: determinants of outcome, J Oral Maxillofac Surg 62:155-163,
Ellis EE, Throckmorton GS: Treatment of mandibular condylar process frac- 2004.
tures: biologic considerations, J Oral Maxillofac Surg 63:115-134, 2005. Zide MF, Kent JN: Indications for open reduction of mandibular con-
Ellis E, Simon P, Throckmorton GS: Occlusal results after open or closed dyle fractures, J Oral Maxillofac Surg 41(2):89-98, 1983.
treatment for fractures of the mandibular condylar process, J Oral Maxil-
lofac Surg 58(3):260–268, 2000.

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50
Combined Mandibular Parasymphysis
and Angle Fractures
E VA N B U SB Y, D E E PAK G O PA L A K R IS HN AN , a n d S TE PH E N M ORE N O

HPI Secondary Survey

An unhelmeted 27-year-old male was involved in a motorcycle crash Neurologic. Alert and oriented 33. Glasgow Coma Scale score is 15.
(MCC) earlier today. He was able to get up from the scene and drive Maxillofacial. The facial structures are grossly symmetric with
himself to the emergency department (ED). He denies loss of con- edema in the lower third. Examination of the eyes (pupils, visual
sciousness. He explains that he has pain in his lower face and jaw, his acuity, visual fields, and extraocular movements) reveals no
teeth do not occlude correctly, and his left lip is anesthetic. changes from the patient’s baseline. External ears are without
Assault, motor vehicle accidents, and sporting injuries are the deformity. Tympanic membranes are clear. (Hemotympanum,
most common causes of mandibular fractures. Malocclusion is a external auditory canal lacerations, tympanic plate rupture, and
significant indicator of mandibular or dentoalveolar fracture. Par- fracture of the posterior wall of the joint should be ruled out.) The
esthesia of the distribution of the third division of the trigeminal remainder of the facial bones are stable except for the mandible,
nerve (V3) is common and can be caused by neuropraxia, axonot- which demonstrates mobility in the parasymphysis region on the
mesis, or neurotmesis of the mental or inferior alveolar nerve at right and in the left angle region. The mobility of the fractured
the fracture site. segments causes pain and malocclusion. Facial edema is present
bilaterally, with tenderness to palpation at the fracture sites. Cra-
PMHX/PDHX/Medications/Allergies/SH/FH nial nerves II through XII are intact, except for anesthesia of V3
on the left side. The neck is nontender and demonstrates full
The patient smokes one pack of cigarettes a day and drinks alco- range of active movement without pain (it is important to rule
hol on the weekends. He denies all other habits. (Both alcohol out cervical spine injury).
and tobacco use have been associated with an increased risk of Intraoral. The dentition is in moderate repair. The patient has
infectious complications with mandibular fractures.) obvious steps in the occlusal plane between teeth #25 and #26
and distal to tooth #18. There are multiple lacerations involving
the gingiva in the associated areas. The occlusal steps and mobility
Examination of segments characterize the patient’s malocclusion. There is he-
Primary Survey (Advanced Trauma Life Support) matoma formation in the anterior floor of the mouth.

Airway and cervical spine control. The patient speaks without Imaging
difficulty. (In cases of multiple fragmented mandibular fractures,
the upper airway can become acutely compromised because of Most practitioners consider computed tomography (CT) scans to
posterior collapse of the tongue with loss of a stable genioglossus be the gold standard imaging modality for evaluation of man-
insertion at the genial tubercles.) The cervical spine examination is dibular fractures. A CT scan allows the entire face to be evaluated
unremarkable. (Haug and colleagues report an association between in one study. Facial bones, including the mandible, can be evalu-
cervical spine injuries and mandibular fractures. The stability of ated in several different anatomic planes. The axial and coronal
the cervical spine is crucial throughout the care of the patient.) planes are the two commonly used views. The coronal plane can
Breathing and oxygenation. Unlabored. Oxygen saturation be useful for viewing condylar fractures, and axial views are useful
of 97% on room air. to assess the remainder of the mandible. Patients with suspicion
Circulation. Pulse and capillary refill are unremarkable. No of cervical spine injury should not have their necks hyperextended
active bleeding. for direct coronal imaging. Instead, digitally reconstructed coro-
General. Supine on the ED bed with O2. nal images can be used.
Vital signs. Blood pressure is 116/78 mm Hg, heart rate is Despite the popularity of CT imaging, in many facilities, the
70 bpm, respirations are 12 breaths per minute, and temperature initial imaging studies may consist of a panoramic radiograph or
is 37°C. a plain view series of the mandible (posteroanterior, reverse

248
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 CHAPTER 50 Combined Mandibular Parasymphysis and Angle Fractures 249

Towne’s, bilateral lateral oblique radiographs). Many hospitals Labs

still use a plain view series of the mandible; therefore, familiarity
with plain radiographs remains important. Routine laboratory testing is not mandatory before surgical cor-
A panoramic radiograph is the imaging modality of choice for rection of mandibular fractures unless dictated by underlying
patients presenting at the surgeon’s office. This radiograph is inex- medical conditions. In cases of infected mandibular fractures, a
pensive and is the single best plain film for evaluation of the entire white blood cell count should be obtained.
mandible. However, nondisplaced or minimally displaced frac-
tures of the condyle or the symphyseal area may be difficult to Assessment
detect on a panoramic radiographs. The combination of a reverse
Towne’s view and an anteroposterior (AP) radiograph of the man- A 27-year-old male after an MCC with open mandibular fractures
dible results in a sensitivity and specificity like that of a CT scan. at the right parasymphysis (nondisplaced) and left angle (displaced).
The decision to order different imaging modalities should be Facial Injury Severity Scale score of 4. Also, an associated injury to the
based on available resources, physical examination findings, and left inferior alveolar nerve most consistent with neurotmesis or a Sun-
the knowledge of limitations related to particular studies. When derland’s class 5 injury.
available, in-office cone-beam CT scans are excellent for evaluat-
ing mandibular fractures. Treatment
For the current patient, a panoramic radiograph demonstrates
fractures at the left angle and in the right parasymphysis region The treatment of mandibular fractures has a long history, dating
(Fig. 50.1A). An AP view of the mandible shows severe displace- back to 1600 bc. The mandible is the foundation of the lower
ment at the left angle (which explains the anesthesia of the left third, requiring special attention for various aspects of treatment
V3) and fracture at the right parasymphysis (Fig. 50.1B); note (occlusion, esthetics, function) to achieve a good result.
that the degree of lateral displacement is not evident on the pan- Mandibular fractures with overlying lacerations or involving
oramic radiograph. the tooth-bearing segments are considered open fractures. Treat-
ment tends to be rendered in a timely fashion; however, studies

B
• Fig. 50.1 A, Panoramic radiograph demonstrating a fracture at the left angle and right parasymphysis
area. B, Anteroposterior radiograph of the skull showing severe lateral displacement of the mandibular
angle on the left. The fracture at the right parasymphysis is also evident.

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250 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

show that delayed surgery may not affect the rate of complications.
Preoperative antibiotics have been shown to decrease the incidence
of postoperative infectious complications and should be consid-
ered regardless of the time interval before definitive surgery can be
completed. The use of postoperative antibiotics remains largely
practitioner dependent, and no good evidence exists guiding its
necessity and potential benefits or the duration of treatment.
Whereas rigid fixation eliminates interfragmentary movement
when load is applied, semirigid or nonrigid fixation allows for
adequate union of bone but is not sufficient to prevent interfrag-
mentary movement. Rigid fixation is adequate fixation allowing
the patient to return to optimal function. Movement at the frac-
ture site not only increases the chance of infection but also the
development of fibrous union, malunion, or nonunion. Nonrigid • Fig. 50.2 Postoperative panoramic radiograph demonstrating rigid fixa-
fixation techniques, when correctly applied, can also provide a tion of the fracture segments.
successful outcome. Lag screws are an acceptable form of rigid
fixation but are not applicable to all fractures. Applicable exam-
ples include fixation at a symphyseal fracture.
Rigid fixation is indicated in the treatment of complex man-
dibular fractures. Two important concepts, load bearing and load
sharing, are taken into consideration when discussing rigid fixa-
tion. Whereas load-bearing fixation bears the functional forces at
the fracture sites, load-sharing fixation is unable to bear all func-
tional load. In the latter, stress across fracture repair is shared by
fixation technique and by the bone. An example of a load-bearing
fixation is the use of a locking reconstruction plate. Locking fixa-
tion plates should be used if the screw or plate-to-bone interface
is not seamlessly adapted. The use of a nonlocking screw will
displace the mandibular fracture if the plate is not seamlessly
adapted; therefore, a locking screw is indicated.
Closed reduction of mandibular fractures continues to be an
acceptable form of treatment. Indications for closed reduction
include high condylar fractures, favorable or nondisplaced frac-
tures, and select pediatric fractures. Closed reduction does not
offer the benefit of early function, and the patient must tolerate a
prolonged period of intermaxillary fixation. Contraindications to
closed reduction include intellectual disability, psychiatric disor-
ders, alcoholic abuse, seizure disorder, nutritional concerns, respi-
ratory disease, obstructive sleep apnea, and unfavorable fractures. • Fig. 50.3 Anteroposterior plain radiograph demonstrating fixation on a
While sequencing repair of multiple mandibular fractures, at- similar fracture using an alternative form of rigid fixation with load-bearing
locking reconstruction plates along the inferior border of the mandible with
tention is directed to fixation of the dentate fractured segment
three screws on either side of fracture.
first. Reestablishing the patient’s native occlusion will allow ap-
propriate reduction of nondentate segments.
The patient was treated under general anesthesia in an ambula-
tory care facility with open reduction and internal fixation The fracture at the angle was anatomically reduced and fixated
(ORIF) (Fig. 50.2). Nasoendotracheal intubation was performed using rigid fixation plates at the superior and inferior borders.
to allow for maxillomandibular fixation. Erich arch bars were ap- (Alternative plating choices take muscle pull, favorable or unfavor-
plied to the maxilla and the mandible with 24-gauge wires, rees- able fractures, and degree of displacement into account.) Noncari-
tablishing the arch form while reducing the fractured segments. ous impacted third molars, if not obstructing the reduction of the
Cautery was used to make a transoral incision in mandibular fracture, are left in place. The patient was released from MMF, and
vestibule to expose the parasymphysis and angle fractures. Care occlusion was deemed stable and repeatable. No postoperative
was taken to expose the right mental foramen and mental nerve. MMF was used. The patient was allowed to function and maintain
With the condyles seated in the fossa, the patient was placed a soft-chew diet. The use of antibiotics consisted of immediate
in maxillomandibular fixation (MMF) with 24-gauge wires. Fixa- preoperative intravenous cephalosporin. The patient was sent
tion at the parasymphysis was completed by placing a plate at the home with a prescription for chlorhexidine rinse and oral analge-
superior border (zone of tension) and a plate at the inferior border sics. The postoperative course was otherwise uncomplicated.
(zone of compression), although an Erich bar can be considered a
form of tension band. An alternative form of rigid fixation would Complications
be a load-bearing locking reconstruction plate along the inferior
border of the mandible with three screws on either side of fracture Mandibular angle fractures are generally more prone to the devel-
(Fig. 50.3). opment of complications compared with the body, symphyseal, or

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 CHAPTER 50 Combined Mandibular Parasymphysis and Angle Fractures 251

parasymphyseal areas. Common complications include loose

hardware, necessitating removal, infection, malocclusion, delayed
union, and fibrous union. Damage to the inferior alveolar and
lingual nerves can be a complication of the initial injury or a
consequence of treatment. Infection rates for angle fractures re-
portedly range from 2% to more than 19%.

Discussion
There are a variety of options for the treatment of mandibular
fractures, and these options primarily differ in the method of
fixation (number, size, and location of fixation plates and screws).
Traditionally, mandibular fractures have been successfully treated
with closed reduction using intermaxillary fixation. This method
results in relatively few complications. However, it is associated
with a delay in functional rehabilitation compared with ORIF
and rigid fixation techniques.
Open reduction and internal fixation failed to attain wide-
spread use before the 1960s mainly because of early reports of
metal corrosion of steel plates and screws, metal fatigue, and screw
loosening. The advent of biocompatible materials (e.g., vitallium • Fig. 50.4 Different methods of fixation using dynamic compression
and titanium), along with orthopedic biomechanical studies de- plating (shown here) (Schmoker and Spiessl). Other methods include a
scribing the benefits of compression osteosynthesis, increased in- monocortical noncompression miniplate (Michelet et al.) and a superior
terest in open treatment of mandibular fractures. Today many border mandibular angle plate (Champy et al.).
practitioners prefer open to closed reduction of parasymphysis or
angle fractures of the mandible. The treatment of subcondylar sometimes be seen because of muscle pull as previously described;
fractures has caused a series of controversies that are addressed in however, the superior border remains grossly intact.
a separate chapter. In the 1970s, Niederdellmann et al. described the use of lag
Considerable variation is seen among different methods of screws for the treatment of mandibular angle fractures, with
fixation. For example, dynamic compression plating (Schmoker placement of the screw through the impacted third molar, if pres-
and Spiessl), monocortical non-compression miniplate (Michelet ent, and subsequent removal of the tooth and screw after healing.
et al.), superior border mandibular angle plate (Champy et al.) Because of technique sensitivity and difficulty, the Niederdell-
(Fig. 50.4), lag screw (Niederdellmann and colleagues), and rigid mann et al. lag screw technique remains less popular.
locking reconstruction plate techniques have all been described in Several studies have found an increased risk of angle fractures
the literature. Consensus on the optimal treatment of mandibular associated with the presence of impacted third molars. Manage-
parasymphysis/angle fractures remains elusive. Each method has ment of teeth in the line of fracture had previously sparked some
its pros and cons, and few prospective, randomized trials have controversy. Extraction is undoubtedly indicated when the tooth
been performed for direct comparison. in the line of fracture is deeply carious, harbors periodontal or
Angle fractures have the highest frequency of complications pericoronal infection, prevents bony reduction of the fracture,
among mandibular fractures. Infection, malunion, nonunion, demonstrates severe root exposure, or is fractured. However, in
and damage to adjacent structures (nerve, tooth) all plague reduc- the absence of these conditions, extraction of the tooth has not
tion of this anatomic site. Thus, many practitioners advocate for been shown to have a statistically significant benefit. Ellis reported
rigid fixation of the bony segments for rapid, uncomplicated heal- a relatively increased (but statistically insignificant) risk of postop-
ing. Early on, the Arbeitsgemeinschaft für Osteosynthesefragen erative complications (namely, infection) with teeth left in the line
(Association for the Study of Internal Fixation) established prin- of fracture, resulting in the need for infection management or
ciples recommending superior and inferior border dynamic com- removal of hardware. Other studies recommend that tooth buds
pression plates. On the other end of the spectrum, Champy et al. in the line of fracture be preserved unless infection occurs, requir-
recommended a single noncompression miniplate at the superior ing subsequent removal.
border for angle fractures based on their studies demonstrating Overall, mandibular angle fractures are common and relatively
the tendency of the superior border to separate from unfavorable easily treated with a variety of conventional techniques. The sur-
muscle pull (tension zone) and the inferior mandibular border to geon should keep in mind the potential complications and adhere
compress (compression zone), with an interposed neutral zone or strictly to sound principles of treatment regardless of the tech-
“line of zero force.” Contrary to the principles of interfragment nique selected.
rigidity for optimal healing, some studies describe decreased com-
plications with less rigid techniques, such as the Champy et al. ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
technique (see Fig. 50.4). Displacement along inferior border can complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 251.e1

Bibliography Michelet FX, Dessus B, Benoit JP, et al: Mandibular osteosynthesis with-
out blocking by screwed miniature stellite plates, Rev Stomatol Chir
Maxillofac 74:239-245, 1973.
Alpert B: Complications in the treatment of facial trauma, Oral Maxil- Murthy A, Lehman J: Symptomatic plate removal in maxillofacial
lofac Clin North Am 11(2):255, 1999. trauma: a review of 76 cases, Ann Plast Surg 55:603, 2005.
Barber DH, Smith BM, Deshmuck DD, et al: Mandibular fractures. In Niederdellmann H, Akuamoa-Boateng E, Uhlig G: Lag-screw osteosyn-
Fonseca RJ, Barber HD, Walker RV, et al. (eds): Oral and Maxillofacial thesis: a new procedure for treating fractures of the mandibular angle,
Trauma, ed 4, St. Louis, 2013, Elsevier, pp 293-330. J Oral Surg 39:938, 1981.
Champy M, Lodde JP, Schmitt R, et al: Mandibular osteosynthesis by Niederdellmann H, Schilli W, Düker J, et al: Osteosynthesis of man-
miniature screwed plates via a buccal approach, J Maxillofac Surg dibular fractures using lag screws, Int J Oral Surg 5(3):117-121, 1976.
6(1):14-21, 1978. Potter J, Ellis E: Treatment of mandibular angle fractures with a malleable
Ellis E: Treatment methods for fractures of the mandibular angle, J Cra- noncompression miniplate, J Oral Maxillofac Surg 57:288, 1999.
niomaxillofacial Trauma 2:28, 1996. Prein J (ed): Manual of Internal Fixation in the Cranio-facial Skeleton,
Ellis E: Lag screw fixation of mandibular fractures, J Craniomaxillofac Heidelberg, 1998, Springer Verlag.
Trauma 3:16, 1997. Schmoker R, Spiessl B: Excentric-dynamic compression plate. Experi-
Ellis E: Outcomes of patients with teeth in the line of mandibular angle mental study as contribution to a functionally stable osteosynthesis in
fractures treated with stable internal fixation, J Oral Maxillofac Surg mandibular fractures, SSO Schweiz Monatsschr Zahnheilkd 83(12):
60:863, 2002. 1496-1509, 1973. German.
Ellis E, Walker L: Treatment of mandibular angle fractures using two Schmoker R, Spiessl B, Tschopp HM, et al: Functionally stable osteosyn-
noncompression miniplates, J Oral Maxillofac Surg 52:1032, 1994. thesis of the mandible by means of an excentric dynamic compression
Gear A, Apasova E, Schmitz JP, et al: Treatment modalities for mandibu- plate. Results of a follow-up of 25 cases, SSO Schweiz Monatsschr
lar angle fractures, J Oral Maxillofac Surg 63:655, 2005. Zahnheilkd 86(2):167-185, 1976. German.
Halmos D, Ellis E, Dodson TB: Mandibular third molars and angle Tate GS, Ellis E, Throckmorton G: Bite forces in patients treated for
fractures, J Oral Maxillofac Surg 62:1076, 2004. mandibular angle fractures: implications for fixation recommenda-
Haug RH, Wible RT, Likavec MJ, et al: Cervical spine fractures and tions, J Oral Maxillofac Surg 52:734, 1994.
maxillofacial trauma, J Oral Maxillofac Surg 49:725, 1991. Lee UK, Rojhani A, Herford AS, et al: Immediate versus delayed treatment
Lamphier J, Ziccardi V, Ruvo A, et al: Complications of mandibular frac- of mandibular fractures: a stratified analysis of complications, J Oral
tures in an urban teaching center, J Oral Maxillofac Surg 61:745, 2003. Maxillofac Surg 74(6):1186-1196, 2016. doi:10.1016/j.joms.2016.
Leonard MS: History of the treatment of maxillofacial trauma, Oral 01.019.
Maxillofac Clin North Am 2(1):1, 1990.

t.me/Dr_Mouayyad_AlbtousH
51
Zygomaticomaxillary Complex Factures
C H R I S T O P H ER B E RN AR D an d K AR L K. C UDDY

CC reveals no evidence of traumatic optic neuritis, retinal artery

hemorrhage, vitreous hemorrhage, or retinal detachment. There is
An 80-year-old male presents by himself to the emergency depart- no dorsal nasal deflection, edema, or crepitation. There is no sep-
ment (ED) after a mechanical fall at home the evening earlier with tal deviation or hematoma and no evidence of anterior (Kiessel-
discomfort in the left midface. bach’s plexus) or posterior (Woodruff’s plexus) nasal hemorrhage.
The oropharynx is symmetrical and trachea is midline.
HPI Maxillofacial. There is mild left malar edema and loss of left
malar projection (flattening). There is no facial laceration. There
The patient was walking up a carpeted staircase at home and is tenderness over the left malar process with subcutaneous crepi-
missed a step while ascending. He denies any loss of conscious- tation (emphysema). A step defect is palpable along the left infe-
ness, amnesia, nausea, vomiting, or neck tenderness. rior orbital rim and along the left zygomatic arch. There is mild
left maxillary vestibular ecchymosis (Guerin’s sign). The occlusion
PMHX/PDHX/Medications/Allergies/SH/FH is stable and reproducible with no occlusal plane steps, gingival
lacerations, or floor-of-mouth elevation. There are no luxated or
The patient has hypertension for which he takes indapamide. He fractured teeth. Moderate trismus is present with a soft end-feel
does not take any anticoagulants. He has no known drug allergies. (Fig. 51.1).
He is a lifelong nonsmoker with minimal alcohol intake. He Targeted neurologic examination. Cranial nerves II to XII
maintains an active lifestyle. are intact, but there is hypoesthesia of the left infraorbital (termi-
nal branch of maxillary division of trigeminal nerve entering the
Clinical Examination orbit via the inferior orbital fissure before entering infraorbital
groove and exiting infraorbital foramen 5–7 mm below inferior
General assessment. The patient was approached with consider- orbital rim) and zygomatic distribution (another terminal branch
ation to primary survey Advanced Trauma Life Support (ATLS) of maxillary nerve entering orbital cavity via inferior orbital fis-
principles. Bedside assessment revealed a healthy-appearing older sure, traversing laterally along the lateral orbital wall and giving
adult male resting comfortably in an ambulatory assessment area off a communicating branch of postganglionic parasympathetic
of the ED. The patient is awake, alert, and oriented and in no fibers from the pterygopalatine ganglion to the lacrimal branch of
apparent distress. Introductory conversation with request to ex- the ophthalmic nerve before exiting the zygomatic bone via the
amine confirms a Glasgow Coma Scale score of 15 with orienta-
tion to person, place, and time. He is hemodynamically stable.
Cervical spine. No midline tenderness; no limitation in cervical
rotation, flexion, or extension (Canadian C-spine rule, National
Emergency X-Radiography Utilization Study [NEXUS] criteria).
HEENT. No scalp lacerations, contusions, or steps. No Battle’s
sign or mastoid tenderness (associated with basilar skull fracture).
No otorrhea or rhinorrhea (associated with cerebrospinal fluid
leak or dural tear). Extraocular movements are intact. Pupils are
equally round and reactive to light with intact accommodation
and consensual response. Visual acuity is intact (Snellen chart),
and peripheral fields are intact. There is no monocular or binocu-
lar diplopia at neutral or extremes of gauze (Goldman chart).
There is no enophthalmos, proptosis, or hypoglobus (Hertel or
Naugle exophthalmometer). There is mildly increased scleral
show on the left (mechanical ectropion) with swelling of the left
periorbital region noted. Intraocular pressures are 13 mm Hg in
both eyes (tonometer). There are no corneal lacerations, subcon-
junctival hemorrhage, hyphema, or lens dislocation. Fundoscopy • Fig. 51.1 Bird’s eye view 2 weeks after injury showing left malar flattening.

252
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 CHAPTER 51 Zygomaticomaxillary Complex Factures 253

zygomaticofacial and zygomaticotemporal [ZT] foramina as Assessment

respective terminal nerves).
An 80-year-old male presenting with an isolated left zygomaticomax-
Labs illary complex (ZMC), also known as orbitozygomaticomaxillary
complex (OZMC) fracture secondary to a low-energy blunt mecha-
Routine laboratory investigations are generally not specific to the nism (Facial Injury Severity Score of 1).
workup of isolated facial trauma, though they may be pursued in the
workup of a presenting trauma patient if there are concerns for sig- Treatment
nificant blood loss, toxicology, metabolic derangements, acute coro-
nary syndromes, or assessment of renal function before intravenous Beyond application of ATLS principles in the approach to the in-
contrast administration. A complete blood count and electrolytes were jured patient, ophthalmologic emergencies must be ruled out as
ordered and were within normal limits. Point-of-care glucose was the first step in the setting of ZMC trauma. The ZMC demarcates
normal. An electrocardiogram was ordered given the history of a fall the lateral aspect and part of the inferior rim and wall of the osse-
(important if not overtly mechanical in nature to evaluate for potential ous orbital cavity, rendering characteristic fracture patterns of the
causative arrythmia), which also revealed normal sinus rhythm. ZMC on the spectrum of orbital trauma. Therefore, orbital com-
partment syndrome, entrapment of the ocular musculature, and
Imaging persisting oculocardiac reflex are examples of ocular emergencies
warranting urgent intervention that can significantly influence
Noncontrast multidetector computed tomography (CT) with bone ophthalmologic outcomes. Direct globe, lens, retinal, and optic
and soft tissue windowing showed mild cerebral atrophy and nerve injuries must be screened for, worked up when suspected,
patchy low attenuation in the subcortical region consistent with managed, and documented accurately in the posttraumatic, pre-
small vessel disease with unremarkable brain parenchyma, ventricu- treatment setting with ophthalmologic consultation. These base-
lar system, and basal cisterns. There is no evidence of intracranial line data aid in delineation between mechanism-related morbidity
hemorrhage, and no skull fractures were identified. There is emphy- and treatment-related morbidity, offers patients the greatest chance
sema in the left malar and preseptal soft tissue, as well as retroseptal for improved ophthalmologic outcomes, and facilitates objective
extraconal fat. No retrobulbar hematoma was identified. There are findings to track over time. After these critical findings have been
fractures of the left lateral orbital wall and rim, orbital floor, and ruled out, OZMC management must consider the functional and
inferior orbital rim with comminution of the anterior and postero- esthetic deficits caused by the trauma weighed against the associ-
lateral walls of the maxilla. There is no orbital wall blowout fracture, ated risks of surgical intervention. Functional deficits may be in
adnexal herniation, or muscular entrapment. The pterygoid plates the form of limited temporomandibular joint range of motion
are intact. The remainder of the image is unremarkable (Fig. 51.2). caused by coronoid or temporalis muscular impingement; altered
eyelid position; altered globe position; altered extraocular muscular
range of motion caused by impingement; altered sensorium in the
infraorbital, zygomaticofacial, or zygomaticomaxillary (ZM) nerve
distribution; or altered lateral canthal ligament positioning. Es-
thetic considerations are principally caused by changes in facial
width, malar projection, contour, eyelid position, and globe posi-
tion. The patient’s perception of such functional or esthetic deficits
also warrants serious consideration in the decision to treat OZMC
fractures operatively or nonoperatively.
This patient had no functional limitations but was concerned
with the loss of left malar projection after a 2-week observation
period to allow resolution of edema and thus opted for operative
A B intervention. He was brought to the operating room for open
reduction and internal fixation (ORIF). The left zygoma was ap-
proached through a left maxillary vestibular incision. A Seldin
retractor was used to perform reduction of the left zygoma. The
inferior orbital rim and zygomaticofacial suture were palpated,
and malar projection could be visualized from the bird’s eye view
quite well clinically because of the delayed timing of operative
intervention and resultant minimal perioperative edema. Insuffi-
cient postreduction stability of the ZMC was confirmed by easy
displacement of the zygoma at the ZM buttress with digital pres-
sure on the zygomatic body; thus, one-point fixation was intro-
duced across the ZM buttress (Fig. 51.3). After internal fixation
C D with a curvilinear titanium miniplate was applied, stability of the
anatomically reduced zygoma was verified with digital pressure
• Fig. 51.2 Preoperative CT images demonstrating left zygomaticomaxillary
complex fracture. A, Axial CT image demonstrating anteroposterior displace-
testing; therefore, no further surgical exposures were deemed nec-
ment of the zygoma; B, Coronal CT image demonstrating medial displacement essary. A forced duction test was then performed, which revealed
of the zygoma; C, Coronal CT image demonstrating medial displacement of the normal ocular motility. The intraoral wound was closed with re-
zygoma; D, Sagittal CT image demonstrating buckling of the anterior maxillary sorbable sutures, and the procedure was concluded in approxi-
wall and minimal displacement of the orbital floor. mately 30 minutes of operating time.

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A B
• Fig. 51.5 Three dimensional rendering of right zygomaticomaxillary complex
fracture. A, Inferior frontal view of right posteriorly displaced ZMC fracture;
B, Submental view demonstrating loss of projection of the right ZMC.

moderately displaced fracture (see Figs. 51.1 and 51.2) is more chal-
• Fig. 51.3 One-point fixation across the zygomaticomaxillary buttress. lenging. In the shared decision-making process between the patient
and practitioner, a decision to treat nonoperatively must be accom-
panied by the mutual understanding that surgical options for the
Discussion correction of posttraumatic deformities of the ZMC are markedly
different than ORIF in the acute setting and are associated with
Orbitozygomaticomaxillary complex fractures are among the most increased complexity and decreased likelihood of restoration of the
common midfacial fractures, most commonly occurring in males be- ideal pretraumatic facial form and globe positioning. If nonopera-
tween ages 20 and 30 years of age as a result of interpersonal violence tive management is elected, several weeks of sinus precautions are
(46.6%), falls (22.4%), and motor vehicle accidents (13.3%), though advocated, along with a soft diet to minimize further malar dis-
there are regional differences in these distributions. Isolated left-sided placement from masseteric muscular contraction and the recom-
fractures are more common than right among patients presenting mendation to avoid further pressure on the affected side such as
secondary to assault, which is hypothesized to be because of the higher sleeping in the supine position or with head elevated with analgesics
prevalence of right-handed individuals. The left-sided distribution is as deemed appropriate. There is no evidence to support routine use
not uniform among all OZMC mechanisms. There is no universally of prophylactic antibiotics in the context of nonoperative midface
agreed on classification system for OZMC fractures, but countless fracture management. Close follow-up for the first several weeks is
classification systems proposed including but not limited to those advocated to allow resolution of soft tissue edema, which may un-
proposed by Zingg et al.; Knight and North; Manson, and AOCMF mask more significant posttraumatic facial asymmetry and motivate
(Arbeitsgemeinschaft für Osteosynthesefragen—Craniomaxillofacial the patient to seek surgical correction in the subacute timeframe.
Surgery). The clinical applicability of any given classification system is Operative intervention for the purpose of decompression of the
of less importance than the ability to understand and communicate infraorbital nerve is not supported, though earlier intervention may
the extent of involvement of the articulations of the zygoma, degree of have a positive impact on neurosensory recovery.
displacement, degree of comminution of the associated sutures, status When operative management is chosen, several decisions must
of the internal orbital walls, and status of the zygomatic arch. be made in the preoperative and perioperative period regarding
Although more displaced fractures (Figs. 51.4 and 51.5) clearly surgical exposure, reduction techniques, verification of reduction,
benefit from operative repair, the decision to operate on a mild to fixation, and the decision whether or not to explore the internal

A B
• Fig. 51.4 Three dimensional rendering of CT scan demonstrating comminuted left zygomaticomaxillary
complex fracture. A, Left lateral view of three dimensional reconstruction; B, right lateral view of three
dimensional reconsutrction demonstrating lateral displacement of comminuted segments.

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 CHAPTER 51 Zygomaticomaxillary Complex Factures 255

orbit. A variety of incisions can be used depending on the amount

of exposure needed to facilitate adequate reduction or fixation.
These include percutaneous malar stab incision to facilitate the use
of a Carroll-Girard screw (or similar T screw); maxillary vestibular
(Keen) incision; temporal (Gillies) incision; and a periorbital inci-
sions including upper blepharoplasty, lateral brow, transconjuncti-
val, subciliary, subtarsal (mid-eyelid), and infraorbital incisions.
A hemi- or bicoronal incision may be required if there are other
associated midfacial injuries that require its use, there is extensive
comminution of the body of zygoma that is not amenable to re-
duction or reconstruction using more sparing incisions, there is
significant instability or comminution of the zygomatic arch, or
immediate nonvascularized bone graft reconstruction is needed.
Each of these incisions is associated with cosmetic and functional
risks related to scar perception, eyelid position, and canthal posi-
tion and must be weighed against the benefit that the additional
exposure provides in achieving the desired outcome. Preexisting
lacerations may be used if present. The degree of involvement or
displacement of the ZMC articulations (zygomaticofrontal [ZF],
zygomaticosphenoid [ZS], ZT, and ZM sutures), presence of com-
minution of the zygomatic body, status of the orbital rim, stability
of the malar complex after reduction, status of the zygomatic arch,
and status of the internal orbital walls are important factors to
consider when planning for surgery.
A variety of instruments are available for fracture reduction, in-
cluding but not limited to multipurpose instruments such as the #9
periosteal elevator, Seldin retractor, Goldman elevator, bone hooks,
or urethral dilators (e.g., Hegar dilator). Purpose-specific instru-
ments include the Rowe zygomatic elevator (Fig. 51.6) and Carroll- • Fig. 51.7 Carroll-Girard screw.
Girard (or similar T-shaped) screw (Fig. 51.7). Regardless of the
instrumentation used, the most common movement required for

restoration of anatomy is an upward and outward force vector to

reduce the zygoma into its premorbid position, often necessitating
protective stabilization of the head and neck. Extreme caution must
be exercised to avoid levering off adjacent structures such as the
maxillary alveolus or dentition when instrumenting from below or
the temporal bone when instrumenting from above, which can
readily introduce supraphysiologic force vectors and result in frac-
ture of these structures.
After gross reduction is performed, the surgeon must verify
anatomic reduction. Visualization from the bird’s eye view and
oblique lateral views is accompanied by palpation of the inferior
orbital rim and ZF suture region initially. The ZS suture is the
most representative suture line to verify malar reduction in three
dimensions compared with the use of the ZM, zygomaticofacial,
or inferior orbital rim in isolation and can be visualized via sub-
periosteal dissection of the lateral orbital wall intraorbitally or
extra-orbitally by reflecting the temporalis muscle. Visualization
at multiple articulations in combination may be required to verify
reduction of the spatially complex articulations of the zygoma in
the absence of intraoperative imaging availability. If intraoperative
three-dimensional (3D) imaging such as CT or cone-beam CT
(CBCT) imaging is available, accurate assessment of reduction of
the zygoma or reconstruction of the internal orbital walls can be
performed while avoiding the necessity for additional surgical
exposure. Additionally, intraoperative imaging can minimize the
risk of reoperation for inadequate restoration of the zygomatic
width, projection, or reconstruction of the orbital floor. Not all
patients benefit from intraoperative 3D imaging. The ZYGO-
MAS algorithm was proposed to guide the use of intraoperative
CT and 3D imaging, advocating its use in OZMC fractures
• Fig. 51.6 Rowe zygoma elevator. requiring orbital floor reconstruction, those associated with

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256 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

adjacent fractures requiring fixation, and those that are displaced

greater than 5 mm in two or more axes. Ultrasonography may
offer useful information in select instances but is inferior to CT
or CBCT in evaluating suture or fracture alignment and floor
reconstruction. Patient-specific implants can be fabricated based
on virtually reduced zygomatic anatomy to aid in ensuring ana-
tomic positioning of the fractured segments. Most ZMC fractures
can be managed adequately without the added cost of patient
specific implants; these implants are more valuable in situations of
severe comminution and displacement or avulsive trauma requir-
ing more extensive reconstruction.
The number of points required for stable fixation of OZMC
fractures and necessity of internal orbital exploration are two areas
of controversy. Historically, reduction alone was believed to be
adequate, or it could be augmented by intraosseous wiring, antral
packing with gauze or a balloon catheter, or external pin fixation.
The use of K-wire fixation has also been described. The necessity
of one-, two-, three, or four-point fixation must be prescribed on
• Fig. 51.8 Six-week postoperative bird’s eye view showing restoration of
a case-by-case basis based on the severity of the fracture and associ- malar projection.
ated amount of displacement, comminution, and postreduction
instability. One-point fixation may be adequate if anatomic reduc-
tion can be achieved with sufficient postreduction stability of the plus or minus fixation of OZMC fractures without orbital floor
zygoma and an absence of comminution of the lateral orbital rim. exploration is adequate treatment when there are minimal disrup-
A stepwise approach beginning with one-point fixation, most fre- tion of the internal orbital walls and no soft tissue herniation.
quently at ZM buttress, with additional points of fixation being After completion of ORIF of OZMC fractures, a forced duction
pursued as needed to maintain reduction stability has been pro- test is paramount before emergence from general anesthesia. In the
posed and adapted for scenarios when intraoperative CBCT is or immediate postoperative setting, bedside ocular assessment should
is not available. The frontozygomatic suture is the next most fre- be performed frequently for the first 24 hours to monitor for
quently fixated site. In comminuted or significantly mobile ZMC changes in visual acuity, pupil reactivity, extraocular movement,
fractures, it is often ideal to start fixation at the ZF suture to and globe position to screen for perioperative globe injury, optic
maintain the vertical position of the fractured segment, using the nerve injury, oculomotor nerve injury, or orbital compartment
oral or lower eyelid approaches to restore anteroposterior and lat- syndrome secondary to retrobulbar hemorrhage. Head elevation,
eral projection. After reduction and fixation of the ZMC is com- ice packs, sinus precautions, and a short course of postoperative
plete, the decision to explore the internal orbital walls must be intravenous glucocorticoids should be considered. The patient
made. Orbital floor exploration and reconstruction is not required should be followed during the postoperative period, with the gross
in the majority of OZMC fractures. Criteria for selective manage- soft tissue drape and globe position anticipated by 2 to 3 months
ment of the orbital rim and floor in OZMC fractures have been (Fig. 51.8). The final neurosensory status of V2 distribution may
proposed by Shumrick et al. and follow similar clinical and radio- take 12 to 18 months, beyond which further resolution becomes
graphic indicators to those applied to orbital blowout fractures. unlikely. Revision procedures may be required because of scarring;
These criteria include persisting diplopia failing to resolve 7 or inadequate anatomic reduction leading to decreased malar projec-
more days after injury that are accompanied by a positive forced tion or increased orbital volume with resultant ocular dystopia;
duction test result, clinically significant enophthalmos associated unresolved trismus caused by ongoing coronoid impingement; or
with large orbital floor (with or without medial wall) fractures or changes in eyelid position such as ectropion, entropion, changes in
with significant soft tissue herniation, significant comminution or scleral show, or antimongoloid slanting of the palpebral fissure. In
displacement of the orbital rim, comminution of the zygomatic the event of an objectively unsatisfactory result, a variety of revision
body, and clinical or radiographic evidence of exophthalmos options can be considered based on the underlying cause of the
caused by internally displaced fracture segments. Ellis et al. com- deficit and may include malar augmentation with alloplastic im-
pared the status of the internal orbit before and after reduction of plants, revision of internal orbital reconstruction, osteotomies of
ZMC fractures and found that the size of internal orbital defects the ZMC, or a variety of eyelid revision procedures.
increased slightly after reduction of the OZMC fracture but was
not accompanied by increased orbital volume or precipitation of ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
soft tissue herniation into the sinus, concluding that reduction complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 256.e1

Bibliography Manson PN, Markowitz B, Mirvis S, et al: Toward CT-based fracture

treatment, Plast Reconstr Surg 85:202, 1990.
McGalliard RJ, Kimpton J, McLeod NMH: Ophthalmic outcomes of
Bezuhly M, Lalonde J, Alqahtani M, et al: Gillies elevation and percuta- fractured zygomas, Br J Oral Maxillofac Surg 55(4):363-366, 2017.
neous Kirschner wire fixation in the treatment of simple zygoma Mundinger GS, Borsuk DE, Okhah Z, et al: Antibiotics and facial frac-
fractures: long-term quantitative outcomes, Plast Reconstr Surg tures: evidence-based recommendations compared with experience-
121(3):948-955, 2008. based practice, Craniomaxillofac Trauma Reconstr 8(1):64-78, 2015.
Cornelius CP, Audigé L, Kunz C, et al: The comprehensive AOCMF Raghoebar II, Rozema FR, de Lange J, et al: Surgical treatment of frac-
classification system: midface fractures—level 3 tutorial, Craniomaxil- tures of the zygomaticomaxillary complex: effect of fixation on repo-
lofac Trauma Reconstr 7(1):S68-S91, 2014. sitioning and stability. A systematic review, Br J Oral Maxillofac Surg
Cuddy K, Dierks EJ, Cheng A, et al: Management of zygomaticomaxillary 60(4):397-411, 2022.
complex fractures utilizing intraoperative 3-dimensional imaging: the Sato A, Imai Y, Muraki K, et al: Reliability of ultrasound-guided one-
ZYGOMAS protocol, J Oral Maxillofac Surg 79(1):177-182, 2021. point fixation for zygomaticomaxillary complex fractures, J Craniofac
de Ruiter BJ, Levin A, Nash D, et al: Defining the zygomaticosphenoidal Surg 30(1):218-222, 2019.
angle as a guide to anatomic zygomaticomaxillary complex fracture Shokri T, Sokoya M, Cohn JE, et al: Single- point fixation for noncom-
reduction, J Craniofac Surg 30(7):2030-2033, 2019. minuted zygomaticomaxillary complex fractures—a 20-year experi-
Dubron K, Verbist M, Shaheen E, et al: Incidence, aetiology, and associ- ence, J Oral Maxillofac Surg 78(5):778-781, 2020.
ated fracture patterns of infraorbital nerve injuries following zygo- Shumrick KA, Kersten RC, Kulwin DR, et al: Criteria for selective man-
maticomaxillary complex fractures: a retrospective analysis of 272 agement of the orbital rim and floor in zygomatic complex and mid-
patients, Craniomaxillofac Trauma Reconstr 15(2):139-146, 2022. face fractures, Arch Otolaryngol Head Neck Surg 123(4):378-384,
Ellis E, El-Attar A, Moos KF: An analysis of 2,067 cases of zygomatico- 1997. Available at: https://jamanetwork.com/.
orbital fracture, J Oral Maxillofac Surg 43(6):417-428, 1985. Tabrizi R, Neamati M, Rajabloo S, et al: Does the lag time between in-
Ellis E, Perez D: An algorithm for the treatment of isolated zygomatico- jury and treatment affect recovery of infraorbital nerve disturbances in
orbital fractures, J Oral Maxillofac Surg 72(10):1975-1983, 2014. zygomaticomaxillary complex fractures? Craniomaxillofac Trauma
Ellis E, Reddy L: Status of the internal orbit after reduction of zygo- Reconstr 13(2):105-108, 2020.
maticomaxillary complex fractures, J Oral Maxillofac Surg 62(3):275- van Hout WMMT, van Cann EM, Muradin MSM, et al: Intraoperative
283, 2004. imaging for the repair of zygomaticomaxillary complex fractures: a
Gülicher D, Krimmel M, Reinert S: The role of intraoperative ultraso- comprehensive review of the literature, J Craniomaxillofac Surg
nography in zygomatic complex fracture repair, Int J Oral Maxillofac 42(8):1918-1923, 2014.
Surg 35(3):224-230, 2006. Yoon T, Choi Y, Cho J, et al: Primary infraorbital foramen decompres-
Jazayeri HE, Khavanin N, Yu JW, et al: Fixation points in the treatment sion for the zygomaticomaxillary complex fracture: is it essential?
of traumatic zygomaticomaxillary complex fractures: a systematic re- J Craniofacial Surg 27(1):61-63, 2016.
view and meta-analysis, J Oral Maxillofac Surg 77(10):2064-2073, Zachariades N, Mezitis M, Anagnostopoulos D: Changing trends in the
2019. treatment of zygomaticomaxillary complex fractures: a 12-year evalu-
Kim JH, Lee JH, Hong SM, et al: The effectiveness of 1-point fixation for ation of methods used, J Oral Maxillofac Surg 56(10):1152-1157,
zygomaticomaxillary complex fractures, Arch Otolaryngol Head Neck 1998.
Surg 138(9):828-832, 2012. Available at: https://jamanetwork.com/ Zingg M, Laedrach K, Chen J, et al: Classification and treatment of zy-
Knight JS, North JF: The classification of malar fractures: an analysis of gomatic fractures: a review of 1,025 cases, J Oral Maxillofac Surg
displacement as a guide to treatment, Br J Plast Surg 13:325-339, 1961. 50(8):778-790, 1992.
Lauder A, Jalisi S, Spiegel J, et al: Antibiotic prophylaxis in the manage- Zosa BM, Elliott CW, Kurlander DE, et al: Facing the facts on prophy-
ment of complex midface and frontal sinus trauma, Laryngoscope lactic antibiotics for facial fractures: 1 day or less, J Trauma Acute Care
120(10):1940-1945, 2010. Surg 85(3):444-450, 2018.

t.me/Dr_Mouayyad_AlbtousH
52
Zygomatic Arch Fracture
A N D R E W LO M B AR D I and K AR L K . C UDDY

HPI chemosis, or subconjunctival hemorrhage. The supraorbital and in-

fraorbital rims are intact with no palpable step deformities. The pa-
A 48-year-old male presents to the emergency department with tient denies retrobulbar pain. There is no orbital dystopia. Nasal
nonresolving left facial pain after an assault 2 weeks earlier. The airflow is subjectively unchanged bilaterally. There is no crepitus,
patient reports he was repeatedly punched in the left face during mobility, or steps of the bony and cartilaginous nasal structures. The
an altercation. The mechanism of injury is an important consider- nasal septum is deviated right on anterior rhinoscopy. There is no
ation because the direction and magnitude of force help to direct septal hematoma or perforation. There is no tenderness to palpation
the clinical examination. The patient denies loss of consciousness overlying the cervical vertebrae; there is no palpable adenopathy; and
or amnesia. He has not experienced dizziness, headaches, nausea, head flexion, extension, and rotation are grossly normal. Maximum
or vomiting since the altercation. He reports initial swelling and interincisal opening is 15 mm (arch impingement on the temporalis
bruising of the left cheek that has resolved. Since the assault, he has muscle and coronoid process). The maxilla, mandible, and dentoal-
had difficulty opening his mouth and has had throbbing left facial veolar segments are stable with no signs of trauma. The occlusion is
pain on function, both while eating and speaking. The patient stable bilaterally. There are no mucosal defects intraorally, and there
denies visual acuity changes; has no alteration in hearing; and has is no visible ecchymosis of the maxillary vestibule or palate. The
had no discharge from the ears, eyes, or nose. oropharynx is patent and symmetrical. The floor of the mouth is soft
and not elevated.
PMHX/PDHX/Medications/Allergies/SH/FH
Imaging
The patient has a past medical history significant for hypertension
controlled with ramipril. He denies additional medications, has The emergency department team obtained a computed tomogra-
no known drug allergies, and has no past surgical history. He is a phy (CT) scan of the facial bones with 1-mm slices (Figs. 52.1
general laborer, reports 30 units of alcohol weekly and a 20 pack- and 52.2) demonstrating a displaced left zygomatic arch fracture.
year history of smoking, and denies the use of recreational drugs. There was no evidence of a ZMC fracture, orbital fracture, or
concomitant mandibular fracture. A variety of imaging modalities
Examination are available to evaluate zygomatic arch fractures. CT remains the
gold standard to comprehensively evaluate the maxillofacial skel-
Although the patient has an old injury, the appropriate Advanced eton in the setting of facial trauma. Coronal, sagittal, and axial
Trauma Life Support protocol has been completed with no signifi- views allow the examiner to determine the fracture planes, degree
cant findings other than the maxillofacial injuries you have been of displacement, and amount of comminution. Before the advent
consulted to manage. Cervical spine and intracranial extension of of CT imaging, plain film radiography was used routinely to as-
the injury have been ruled out by the trauma team. The patient is sess zygomatic arch fractures. The Waters view provides imaging
hemodynamically stable, resting comfortably on examination, and is of the midface, including the orbital rims, body of the zygoma,
awake, alert, and oriented with a Glasgow Coma Scale score of 15. and zygomatic arch, and the submentovertex (jug-handle) images
Maxillofacial. There are no findings suggestive of basal skull the submandibular region to vertex of skull, allowing visualization
fracture (rhinorrhea, otorrhea, Battle’s sign, raccoon eyes) and no vis- and identification of zygomatic arch fractures.
ible lacerations, abrasions, or contusions. Cranial nerves II to XII are
intact bilaterally (left maxillary nerve hypoesthesia would indicate Assessment
potential orbital floor or zygomaticomaxillary complex [ZMC] frac-
tures). There is facial asymmetry with a visible and palpable depres- A 48-year-old male with an isolated displaced left zygomatic arch
sion of the left zygomatic arch that that is tender when examined. fracture after repeated strikes to the left face during an altercation
A palpable bony step defect can be appreciated. There are no hearing approximately 2 weeks ago.
deficits. On otoscopic examination, the tympanic membrane is
intact, and the external auditory canal is clear with no hemotympa- Discussion
num. All visual fields are intact with symmetric and normal extra-
ocular movement and no diplopia or changes in visual acuity. The The zygoma is a quadrangular-shaped bone that articulates
pupils are equal, round, and reactive to light. There is no hyphema, with the maxillary, frontal, sphenoid, and temporal bones. The

257
t.me/Dr_Mouayyad_AlbtousH
258 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

• Fig. 52.1 Axial computed tomography image demonstrating an isolated

and displaced left zygomatic arch fracture.

• Fig. 52.3 Preoperative clinical photograph. Note the left lateral midfacial
depression in the region of the zygomatic arch.

fractures may impinge the coronoid process, resulting in trismus

and associated functional limitations. Long-term functional con-
sequences of poorly managed arch fractures include persistent
impaired mouth opening, ankylosis of the coronoid process and
fractured segments, and facial nerve palsy. Aesthetic concerns
resulting from displaced zygomatic arch fractures include lateral
midface depression (Fig. 52.3) and facial asymmetry. Depending
on the patient’s compliance and comorbidities as well as con-
comitant injuries, those with zygomatic arch fractures can be
treated under local anaesthetic, intravenous sedation, or general
anesthesia.

Treatment
The goals during treatment of zygomatic arch fractures are to re-
store midfacial symmetry and function (including mandibular
• Fig. 52.2 Axial computed tomography image demonstrating impinge- range of motion). Treatment is dictated by the degree of displace-
ment of the coronoid process by the medially displaced zygomatic arch ment. Incomplete or minimally displaced fractures that are as-
fracture. ymptomatic with no functional or esthetic deficits are managed
nonsurgically. Zygomatic arch fractures with significant displace-
ment benefit from reduction, and if grossly comminuted or un-
zygomaticotemporal (ZT) suture is formed by the articulation of stable, application of rigid internal fixation may be indicated.
the temporal process of the zygomatic bone and the zygomatic Reduction can be achieved by several intraoral and transcutaneous
process of the temporal bone. The zygomatic arch contributes to approaches. The workhorse approaches described by Gillies et al.
facial width and serves as an attachment for the masseter muscle. and Keen remain widely used today. The Gillies et al. approach
The point in the arch that is least resistant to fractures is located involves a temporal hairline incision with a dissection plane su-
roughly 1.5 cm posterior to the ZT suture. Zygomatic arch frac- perficial to the temporalis muscle and deep to the deep temporal
tures commonly occur in combination with fractures of the fascia or temporalis fascia. An elevator is placed deep to the zygo-
ZMC. Isolated zygomatic arch fractures are reported to occur in matic arch and directed laterally to reduce the fracture. This
5% to 14% of all zygomatic fractures. Displaced zygomatic arch technique minimizes scarring and the risk of facial nerve damage.

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 52 Zygomatic Arch Fracture 259

The Keen approach involves a full-thickness maxillary vestibular

incision that is dissected in the subperiosteal plane to the zygo-
maticomaxillary buttress and along the deep aspect of the zygo-
matic arch. The arch fractures are identified with an elevator and
reduced by applying an anterolateral force. An incision along the
ascending ramus and external oblique ridge followed by dissection
lateral to the coronoid process superficial to the temporalis
tendon can allow for lateral reduction of the medially displaced
zygomatic arch. Upper blepharoplasty and lateral eyelid incisions
can be used to approach the displaced zygomatic arch and allow
for reduction with a gently curved elevator or urethral sound.
Percutaneous approaches using bone hooks, mosquitos, or towel
clips to reduce arch fractures have been described (Figs. 52.4 and
52.5) and were used for the patient presented in this clinical case.
Although less commonly used as first-line alternatives, these are
effective techniques for one’s surgical armamentarium. Successful
reduction of the segments can be confirmed clinically by palpa-
tion, visual inspection, or auditory cues such as a “pop” or “click”
into the premorbid position. New techniques use intraoperative
imaging and navigation via CT, cone-beam CT, endoscopy, or • Fig. 52.5 Intraoperative clinical photograph demonstrating final towel
ultrasonography to confirm reduction. Many fractures are stable clip tine positioning before lateral reduction forces were applied.
after reduction and do not routinely require fixation. Adjacent
muscle of mastication and fascia contribute to the postreduction arch stability. Some surgeons advocate for fixation after reduction
to maintain stability and avoid relapse of the reduced segments.
When indicated, surgeons can achieve internal fixation by applica-
tion of miniplates or direct wiring with Kirschner wires. Internal
fixation of arch fractures with Foley catheters, Penrose drains, na-
sogastric tubes, and tracheal tubes have been described. Various
methods of external fixation and splinting have been reported in
the literature, including aluminum orthopedic splints, eye shields,
aqua splints, endotracheal tubes, and three-dimensional printed
zygoma masks. Risks of external fixation include facial nerve palsy
(compression), skin necrosis, infection, bleeding, and hematoma
formation (sutures or needles passed deep to arch). Open reduc-
tion and internal fixation (ORIF) is indicated for comminuted and
unstable arch fragments that are unable to be reduced with open
reduction alone. These arch fractures are often a result of high-
impact ZMC fractures or panfacial fractures. ORIF is rarely indi-
cated for isolated arch fractures because the surgical risks of the
approach (most commonly a coronal incision) outweigh the ben-
efits of improved stabilization using miniplate fixation. The coro-
nal approach requires longer operative time and risks higher
complication rates (nerve damage, infection, alopecia, higher reop-
eration rates) compared with other more isolated local approaches.

• Fig. 52.4 Intraoperative clinical photograph with the inferior towel clip ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
tine located deep to the zygomatic arch. complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 259.e1

Bibliography Kaastad E, Freng A: Zygomatico-maxillary fractures late results after

traction-hook reduction, J Craniomaxfac Surg 17:210-214, 1989.
Keen W: Surgery: its principles and practice, Philadelphia, 1909, Saunders.
Adam AA, Zhi L, Bing LZ, et al: Evaluation of treatment of zygomatic doi:10.1002/BJS.1800093626.
bone and zygomatic arch fractures: a retrospective study of 10 years, Kim DK, Kim SK, Lee JH, et al: Aqua splint suture technique in isolated
J Maxillofac Oral Surg 11:171-176, 2012. zygomatic arch fractures, Eur Arch Otorhinolaryngol 271:707-711, 2014.
Ash DC, Mercuri LG: External fixation of the unstable zygomatic arch Menon A, Karikal A, Shetty V: Does C-arm guidance improve reduction
fracture, J Oral Maxillofac Surg 42:621-622, 1984. of zygomatic arch fractures?—a randomized controlled trial, J Oral
Buller J, Zirk M, Kreppel M, et al: Intraoperative ultrasound control of Maxillofac Surg 76:2376-2386, 2018.
zygomatic arch fractures: does additional imaging improve reduction Mezitis M, Stathopoulos P, Rallis G: Use of a curved mosquito for reduc-
quality? J Oral Maxillofac Surg 77:769-776, 2019. ing isolated zygomatic arch fractures, J Craniofacial Surg 21:1281-
Carter TG, Bagheri S, Dierks EJ: Towel clip reduction of the depressed 1283, 2010.
zygomatic arch fracture, J Oral Maxillofac Surg 63:1244-1246, 2005. Orabona GD, Abbate V, Maglitto F, et al: Postoperative management of
Cohn JE, Othman S, Bosco S, et al: Management of isolated zygomatic zygomatic arch fractures: in-house rapid prototyping system for the
arch fractures and a review of external fixation techniques, Cranio- manufacture of protective facial shields, J Craniofac Surg 30:2057-
maxillofac Trauma Reconstr 13:38-44, 2020. 2060, 2019.
Czerwinski M, Lee C: Traumatic arch injury: indications and an endo- Pedemonte C, Sáez F, Vargas I, et al: C-arm as intraoperative control in
scopic method of repair, Facial Plast Surg 20:231-238, 2004. reduction of isolated zygomatic arch fractures: a randomized clinical
Czerwinski M: C-arm assisted zygoma fracture repair: a critical analysis trial, Oral Maxillofac Surg 20:79-83, 2016.
of the first 20 cases, J Oral Maxillofac Surg 73:692.e1-692.e8, 2015. Ravi Raja Kumar S, Venkata Raju K, Sunanda K: Stabilization of the
Gillies HD, Kilner TP, Stone D: Fractures of the Malar-zygomatic com- isolated zygomatic arch fracture using Foley’s balloon catheter, J Max-
pound: with a description of a new X-ray position, Br J Surg 14:651- illofac Oral Surg 9:407-409, 2010.
656, 1927. Rodríguez-Vegas JM, Pérez CC: Inexpensive custom-made external splint
Güven O: Stabilisation of the delayed zygomatic arch fracture, Int J Oral for isolated closed zygomatic arch fractures, Plast Reconstr Surg
Maxillofac Surg 16:445-447, 1987. 113(5):1517-1518, 2004. Available at: https://doi.org/10.1097/01.
Hindin DI, Muetterties CE, Mehta C, et al: Treatment of isolated zygo- PRS.0000110764.50411.2D.
matic arch fracture: improved outcomes with external splinting, Plast Singh AK, Dhungel S, Yadav M: Intraoperative ultrasound imaging in
Reconstr Surg 139:1162e-1171e, 2017. the closed reduction of zygomatic arch fracture: getting it right the
Hussain K, Wijetunge DB, Grubnic S, et al: A comprehensive analysis of first time, Oral Maxillofac Surg Cases 6(4):100202, 2020.
craniofacial trauma, J Trauma 36:34-47, 1994. Turan A, Kul Z, Haspolat Y, et al: Use of tracheal tube in isolated frac-
Hwang K, Kim DH: Analysis of zygomatic fractures, J Craniofac Surg tures of the zygomatic arch, Plast Reconstr Surg 114:1005-1006, 2004.
22:1416-1421, 2011. Ungari C, Filiaci F, Riccardi E, et al: Etiology and incidence of zygomatic
Imai T, Michizawa M, Fujita G, et al: C-arm-guided reduction of zygo- fracture: a retrospective study related to a series of 642 patients, Eur
matic fractures revisited, J Trauma 71:1371-1375, 2011. Rev Med Pharmacol Sci 16:1559-1562, 2012.
Johner JP, Wiedemeier D, Hingsammer L, et al: Improved results in Xie L, Shao Y, Hu Y, et al: Modification of surgical technique in isolated
closed reduction of zygomatic arch fractures by the use of intraopera- zygomatic arch fracture repair: seven case studies, Int J Oral Maxillofac
tive cone-beam computed tomography imaging, J Oral Maxillofac Surg 38:1096-1100, 2009.
Surg 78:414-422, 2020. Zaworski RE: A simple support for unstable fractures of the zygomatic
Jones GM, Speculand B: A splint for the unstable zygomatic arch frac- arch, Plast Reconstr Surg 65:673, 1980.
ture, Br J Oral Maxillofac Surg 24:269-271, 1986.

t.me/Dr_Mouayyad_AlbtousH
53
Nasal Fracture
GAL IT AL M O S N I N O, ER I C P. H O L MG R EN , a n d R YA N E. LI T T L E

CC • Preinjury appearance can be assessed by patient or by photo-

graphs that the patient may be able to provide.
A 26-year-old male presents to the emergency department after an
altercation at a bar with evidence of recent epistaxis and trouble PMH/PSH/Medications/Allergies/SH/FH
breathing through his nose.
Nasal bone fractures are the most common facial fractures The patient has an unremarkable medical history. There is no
because of the relatively minimal force required to fracture these previous history of facial fractures, nasal surgeries, or preexisting
thin bones and the prominent position of the nose relative to nasal deformities. He denies a prior history of chronic nasal ob-
other facial structures. These fractures commonly occur in males struction. He denies prior nasal or sinus surgery. He denies any
in the second and third decades of life but also account for about history of cocaine use.
30% of pediatric facial fractures. The most common cause of Key points:
nasal fractures is blunt trauma to the face from interpersonal vio- • It is essential to ask about preexisting nasal form and function
lence, motor vehicle collisions (MVCs), falls, and sporting inju- as well as prior nasal obstruction, trauma, and surgeries. This
ries. Septal fractures have been associated with nasal bone fracture will help with surgical planning and setting expectations after
in 42% to 96% of cases. Left untreated, nasal bone and septal surgical intervention.
fractures can have a significant impact not only on cosmetic ap- • Cocaine compromises nasal mucosal blood flow, which can
pearance but also on nasal airway function. lead to ischemic necrosis and subsequent septal perforation.

HPI Examination
The patient was involved in an altercation at a bar several hours The patient’s Advanced Trauma Life Support primary survey is
before presentation. He received a single blow from a right fist to negative, and his Glasgow Coma Scale score is 15.
the left side of his nose. He denies any subsequent falls or loss of General. The patient is a well-developed and well-nourished
consciousness. Immediately after his injury, he noted approximately male in mild distress from pain and nasal obstruction.
30 minutes of brisk epistaxis, which eventually resolved with exter- Eyes. Pupils are equal, round, and reactive to light and accom-
nal pressure. His pain is localized to his external nose and has been modation; extraocular muscles are intact. Visual acuity is 20/20 in
consistent in severity since the injury. He endorses difficulty breath- both eyes. Visual fields are intact by confrontation, without mon-
ing through his left nare but otherwise denies diplopia, visual ocular or binocular diplopia. There is no evidence of hyphema
changes, clear rhinorrhea, facial weakness, excessive tearing, and (blood in the anterior chamber of the eye), chemosis (subconjunc-
paresthesia. On further questioning, he also denies neck or back tival edema), or subconjunctival hemorrhage or epiphora (exces-
pain, headache, nausea, vomiting, dizziness, and malocclusion. He sive tearing). The patient exhibits bilateral infraorbital edema that
thinks his nose appears crooked compared with before the injury. is more severe on the left. The intercanthal distance is normal,
Key points during the history taking: measuring 31 mm (range, 30–33 mm).
• Knowing the mechanism of facial trauma is key in the initial Maxillofacial. There is minimal edema of the nose with an
workup. Compared with an isolated blow to the nasal com- obvious deviation of the dorsum to the right (Fig. 53.1) The bony
plex, for example, a patient presenting with facial injuries after nasal dorsum is tender to palpation, with bony crepitus over the
an MVC should prompt suspicion for more severe injuries and radix and upper dorsum. The alar base appears normal and coin-
multiple facial fractures. cident with the remainder of the face. Nasal tip projection is
• Symptoms such as telecanthus, diplopia, vision loss, clear rhi- adequate, though the columella does collapse with downward
norrhea, malocclusion, facial weakness, and facial numbness palpation on the tip. There is no clear rhinorrhea suggesting cere-
may indicate more severe injuries. brospinal fluid (CSF) leak (and thus no obvious indication of
• It is important to include questions about symptoms sugges- skull base fracture).
tive of possible intracranial or ocular injuries in your review Intranasal. Using a fine suction, several blood clots were
of systems. This includes headache, nausea, vomiting, and evacuated from both nares. Nasal speculum examination using
dizziness. a headlight and prior application of a topical vasoconstrictor

260
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 53 Nasal Fracture 261

• Fig. 53.2 Axial computed tomography scan demonstrating fracture of

the nasal bones and septal deviation to the left.

• Fig. 53.1 Preoperative photograph (bird’s eye view) showing displace-

ment of the nasal complex to the right. physical examination), plain film radiographs have not shown to add
value in regard to treatment planning. More so, plain films have a
low specificity (false-positive rates as high as 66%) and are limited in
(oxymetazoline [Afrin] spray or 4% cocaine) reveals a 2-cm left their ability to distinguish old from new fractures (only 15% of nasal
nostril mucosal laceration over the cartilaginous septum with obvi- bone fractures heal by ossification). They cannot detect cartilaginous
ous lateral displacement. The septum is otherwise symmetric with- injuries, which occur more often in the pediatric population.
out significant edema or ecchymosis. On gentle palpation with In cases in which imaging is indicated (clinical examination
pinky finger, there is no fluctuance on either side of the septum, limited because of extensive edema or additional fractures of the
thus confirming no septal hematoma. The inferior turbinates are face or skull base suspected), computed tomography (CT) of the
visualized and intact, and the inferior meatus is identified. face has become the gold standard for evaluation of the nasal
Key points to consider specifically for nasal injury include: bones and paranasal sinuses. That being said, recent literature
1. Intracanthal distance: An increased distance can indicate a shows that most surgeons do not believe imaging changes the
naso-ethmoid-orbital (NOE) complex fracture and should treatment plan in isolated nasal fractures.
prompt imaging. In the current patient, a facial CT scan demonstrated bilateral
2. Excessive tearing can be suggestive of lacrimal apparatus injury. nasal bone fracture with deviation to the right and bowing of the
3. Collapse of the columella should raise suspicion for a carti- septum (Fig. 53.2). Preinjury photographs and scans (if available)
laginous septal fracture. can be extremely helpful for delineating injury displacement and
4. Clear rhinorrhea (especially drainage that increases when pa- can serve as a guide in surgical correction.
tient bends over or strains) is indicative of possible CSF or
skull base fracture. The authors recommend obtaining a sam- Labs
ple for b2-transferrin and consider imaging for further man-
agement planning. Routine labs are not usually indicated for the diagnosis and man-
5. Septal edema that does not improve with topical decongestant agement of nasal fractures unless indicated by medical history. A
paired with fluctuance to palpation should raise high suspicion toxicology screen and blood alcohol level should be obtained in
for septal hematoma (blood collection between the perichon- cases in which drug or alcohol use has been reported or suspected.
drium and quadrangular cartilage). This can disrupt the blood In the event of persistent epistaxis that is not easily controlled
supply to the cartilage, resulting in septal necrosis, septal ab- with conservative management such as oxymetazoline spray, pres-
scess formation, and a subsequent saddle nose deformity. This sure or nasal packing, coagulation studies can be obtained to
type of injury requires immediate drainage. evaluate for underlying bleeding disorders (the most common
6. Consider endoscopic intranasal examination for a more com- bleeding disorder being von Willebrand disorder).
prehensive evaluation of the intranasal structures and septum.
This can be especially useful if the patient is having persistent Assessment
epistaxis from an unknown site.
Bilateral nasal bone and nasal septal fracture; Facial Injury Severity
Imaging Score of 1. There is no evidence of septal hematoma or skull base fracture.

Imaging studies are recommended in the setting of high force Treatment

trauma, especially in a patient with loss of consciousness (even if
brief ). In the setting of isolated nasal trauma without further evi- Treatment for nasal bone fractures begins with a detailed history
dence of other craniofacial injuries (based on thorough history and and, if present, control of hemorrhage. A history of nasal trauma,

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262 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

surgery, deviation, and obstruction should be obtained. The Closed reduction is most often performed with Boies elevator,
mechanism, including injuring agent, direction of blows, timing of which provides rigidity with minimal risk of mucosal trauma.
injury, and postinjury epistaxis, should be determined. A preinjury Other instruments (Asch forceps, Walsham’s forceps) can be used
photograph can be very helpful. Obtaining a detailed history al- as well based on surgeon preference.
lows the surgeon to better evaluate the extent of the injury, includ-
ing external deformity, septal deviation, or hematoma as well as Surgical Approach
any associated injury (including lacrimal system, NOE fracture,
and skull base injuries). The anticipated difficulty of reduction and In the current patient, the nasal bones and septum were treated
ability for patient to tolerate an awake procedure is an important with a standard closed reduction. The Boies elevator was used to
factor in the choice of anesthesia (local versus general). elevate the depressed nasal bone with concomitant medial pressure
on the opposite, lateralized nasal bone (Fig. 53.3). The nasal bony
Control of Epistaxis pyramid was subsequently straightened (Fig. 53.4). For the septal
fracture, the Asch forceps in combination with gentle finger ma-
In the event of persistent epistaxis despite the use of a topical va- nipulation were used to reset the cartilaginous septum at the nasal
soconstrictor and pressure, control can be achieved with choice of spine. The septum was splinted with Doyle splints and secured
nasal packings, with or without the use of hemostatic agents. The with a transseptal suture at the caudal septum. An Aquaplast dorsal
placement of anterior and posterior nasal packing should be pre- splint was then custom fit to the patient’s nasal dorsum.
cise, and the surgeon must be aware of potential complications, For severely comminuted fractures or open fractures, an open
such as infection, dehydration, and altered ventilation from ob- reduction approach is preferred. In patients with a prior history of
structive and physiologic derangements in pulmonary mechanics.
In the event of traumatic epistaxis resulting from diffuse mucosal
disruption or laceration, silver nitrate, or electrocautery is often
not sufficient to control the bleeding unless it is arising from a
punctate source and may actually contribute to further mucosal
irritation. Absorbable packing or topical hemostatic agents, such
as absorbable oxycellulose thrombogenic dressing (Surgicel) or
resorbable chitosan-based hemostatic splint (PosiSep), can be
used to pack off anterior bleeding. Additional agents, such as
topical thrombin-gelatin hemostatic matric (Floseal), can be
applied around absorbable packing for additional hemostasis.
Bleeding that persists despite anterior packing or bleeding in the
posterior oropharynx should raise suspicion for a posterior bleed.
Posterior bleeding may require a balloon (with anterior and pos-
terior component) as a means of tamponade. Nasal packs are
usually left in place for a minimum of 24 to 48 hours but can stay
in for up to 5 days if the bleeding was significant. The patient
should be prescribed antibiotics while the packing is in place to • Fig. 53.3 Postoperative photograph (bird’s eye view) 6 weeks after
avoid risk of toxic shock syndrome. Adequate control of blood closed reduction.
pressure and the patient’s pain can also assist in the management
of epistaxis.
A thorough external and internal nasal examination is essential
with a nasal speculum or ideally a rigid nasal endoscope. Unde-
tected and untreated septal injuries have been found to contribute
to postreduction nasal deformities and nasal obstruction. A thor-
ough examination should be done after adequate anesthesia and
decongestion of the nasal mucosa has been achieved with a topical
mixture of 4% lidocaine with oxymetazoline.
Treatment options include open or closed reduction. The tim-
ing of repair can be immediate or delayed. Immediate closed re-
duction should be done if there is no significant edema that
would compromise assessment and understanding of the extent of
injury or deformity. With significant edema, surgery should be
postponed to allow the edema to resolve (typically 3–5 days). It is
generally recommended that nasal bone fractures be treated
within 10 days of injury for optimal results. An uncomplicated
displaced nasal bone or septal fracture with no preexisting nasal or
septal deformity is most amenable to closed reduction.
Contraindications to closed reduction include severely com-
minuted fracture of the nasal bones and septum, open septal
fracture, delayed presentation (over 3 weeks after initial injury), • Fig. 53.4 Closed reduction of nasal fracture. An elevator is placed inside
nasal bone fracture that occurs with an NOE or Le Fort pattern the nostril to support the septum as the nasal bones are reduced toward
fracture, or anterior skull base fracture. the midline. (Courtesy of Dr. Benham Bohlouli.)

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 CHAPTER 53 Nasal Fracture 263

septal deviation or trauma, an open or endoscopic septoplasty problems, such as nasal airway obstruction (NAO), despite initial
may be considered. Nasal osteotomies are performed if there is acute management of the traumatic injury, further elective surgical
continued drift of the nasal bone fragments. The upper lateral intervention may be indicated. Patients should be counseled on elec-
cartilages can be released from the nasal septum if there continues tive septorhinoplasty but no earlier than 6 months after injury and
to be drift of the nasal structures. (The upper lateral cartilages even up to 1 year postinjury to allow for maturation of the scar and
splint bones toward the initial preexisting deformity; therefore, fracture and recovery of mucociliary function. When initial closed
release of the upper lateral cartilages from the septum allows the reduction improves nasal bone symmetry but NAO persists because
nasal bones to remain midline.) This can be followed by fracturing of dorsal or caudal septal fracture, open septorhinoplasty should be
of the bony septum (the anterior extension of the perpendicular considered no earlier than 6 months after initial treatment.
plate of the ethmoid and vomer) opposite the deviation by push-
ing the bony pyramid toward the contralateral lateral canthus.
The final attempt at correcting any residual deformity can be ac-
Discussion
complished with a cartilage camouflage graft in the depressed Anatomy
area. An external nasal splint, worn for 1 to 2 weeks, and the use
of endonasal packing for up to 1 week assist in further stabilizing The nasal bone is reported to be the most common facial fracture
the fractures. with motor vehicle collisions being the most common cause in
North America. The nose can be divided into three vaults. The
Complications upper vault is composed of the paired nasal bones, frontal pro-
cesses of the maxilla, and the perpendicular plate of the ethmoid
The most common and problematic postinjury or postoperative bone. This structure is also referred to as the bony pyramid. The
complication is a postreduction nasal deformity. Most authors middle vault includes the upper lateral cartilages and the midpor-
believe that an undiagnosed or untreated nasal-septal fracture or tion of the nasal septum (quadrangular cartilage). The lower carti-
deviation plays a significant role in causing this complication. The laginous vault includes the nasal tip, lower lateral (alar) cartilages,
incidence of posttraumatic nasal deformity has been reported at and the inferior portion of the nasal septum. These vaults can be
14% to 50%. The algorithm presented here is aimed at reducing tested individually for stability by applying digital pressure, which
the incidence of postreduction deformities with special attention will cause the vault to collapse if it is unstable.
to the nasal septum. Nasal obstruction caused by collapse of the It is important to remember that the nasal septum is attached to
nasal valve and formation of synechiae can cause significant both the bony nasal pyramid and the upper and lower lateral carti-
breathing and chronic sinus problems. lages. As such, any septal deformity has the potential to transmit
forces to the associated bony and cartilaginous portions of the nose
Septal Hematoma and cause a postreduction deformity. The nasal septum is composed
of the perpendicular plate of the ethmoid bone, vomer, nasal crests
Special attention should be given to presence of a septal hema- of the maxilla, palatine bones, and quadrangular cartilage.
toma because this complication requires immediate intervention
to reduce the risk of permanent blood flow compromise to the Surgical Approaches
septum. The mucosa overlying the nasal septum is highly vascular.
Kiesselbach’s plexus (Little’s area) is a vascular area in the anterior It is important to note that reduction of nasal fractures is not al-
septum where terminal branches of the internal and external ca- ways required. In the absence of a deformity or if the patient is
rotid arteries meet. This plexus is composed of the anterior eth- unconcerned about aesthetic appearance, reduction is not war-
moidal, septal branches of the superior labial, sphenopalatine, and ranted. That being said, swelling can often interfere with an ade-
greater palatine arteries. Injury to this area can cause a septal he- quate examination, in which case reassessment should be planned
matoma in the subperichondrial plane, thus disrupting the vascu- 5 to 7 days later. If indicated, reduction should occur within 3
lar supply to the septum. A septal hematoma requires immediate weeks of injury because manipulation after the nasal bones start
evacuation, with dependent drainage, intranasal packing, and to fixate will be difficult and may require more invasive tech-
close follow-up to ensure there is no reaccumulation. Undetected niques such as osteotomies to mobilize the bones.
or untreated septal hematomas can lead to abscess formation, Closed reduction for simple, isolated nasal or septal fractures
septal cartilage necrosis, and subsequent nasal dorsum depression has been showed to have a success rate of 60% to 90%. It is im-
(saddle-nose deformity). Management of septal hematoma in- portant to assess the patient’s ability to cooperate because this will
cludes adequate local anesthetic followed by a small incision at the largely dictate if local or general anesthesia will be required.
point of greatest fluctuance for drainage. The incision should be The indications for open reduction of nasal fractures include
kept open to allow for continued drainage and reduce the risk of the following:
accumulation. A quilting stitch can be placed along the septum to • Inability of the septum to remain in the reduced position
reduce the amount of dead space. Last, silicone stents or absorb- • Considerable displacement of cartilaginous structures
able packing, such as a resorbable chitosan-based hemostatic • Bilateral fractures with dislocation of the nasal dorsum and
splint (PosiSep), should be placed in both nares to maintain pres- septal pathology
sure along the septum and prevent reaccumulation. Patients with • Fractures of the cartilaginous pyramid, with or without dislo-
septal hematoma should have close follow-up (within a few days) cation of upper lateral cartilages
to reevaluate and ensure the hematoma has not reformed. • Anticipation of cartilage or bone grafting
Other late complications of nasal injury can include unremit- • Associated fractures, such as NOE complex fracture
ting epistaxis, synechiae formation, scar contracture, nasal airway In cases in which open reduction is required, a thorough discus-
obstruction, CSF rhinorrhea, anosmia, epiphora, or dacryocystitis. sion of expectations and anticipated postoperative course, including
In cases in which patients have cosmetic deformity or functional the duration of internal and external splints and activity restrictions,

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264 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

should be reviewed with the patient preoperatively. CT imaging Local anesthesia is appropriate for cooperative adult patients with
should be considered for cases in which more complicated fracture simple nasal fractures (which do not require an open approach to
patterns are suspected or for surgical planning when postinjury the nasal bone or septum). General anesthesia is a preferred choice
edema distorts the anatomy. for uncooperative or pediatric patients, severely displaced fractures,
and patients requiring an open approach.
Anesthesia
Conclusion
Multiple studies have attempted to compare outcomes after local
versus general anesthesia for nasal bone fracture reduction. Local Nasal bone and septal fractures should be diagnosed and treated
anesthesia has been determined to be safe, effective, and less costly, with careful consideration of function and aesthetics. The sim-
with outcomes comparable to reduction under general anesthesia. plicity of closed reduction techniques should not replace more
Not surprisingly, however, patients report lower postprocedure invasive surgical interventions in the absence of complicated
pain scores with general anesthesia, and general anesthesia is less injuries. Untreated septal injuries can significantly complicate
cost-effective and requires greater use of hospital resources. Al- airway flow and the aesthetic outcome and should be ruled out
though no significant difference has been found between the two before any intervention. Last, patients should be counseled
options in terms of outcomes, many authors have shown a trend on long-term complications of their injuries, with or without
toward patients preferring general anesthesia for comfort pur- intervention.
poses and greater reported satisfaction with aesthetic and func-
tional results. Ultimately, the choice between local and general ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
anesthesia lies with the patient as well as the resources available. complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 264.e1

Bibliography Kim KS, Lee HG, Shin JH, et al: Trend analysis of nasal bone fracture, Arch
Craniofac Surg 19(4):270-274, 2018. doi:10.7181/acfs.2018.02264.
Kopacheva-Barsova G, Arsova S: The impact of the nasal trauma in child-
Al-Moraissi EA, Ellis E III: Local versus general anesthesia for the man- hood on the development of the nose in future, Open Access Maced
agement of nasal bone fractures: a systematic review and meta-analy- J Med Sci 4(3):413-419, 2016. doi:10.3889/oamjms.2016.081.
sis, J Oral Maxillofac Surg 73(4):606-615, 2015. doi:10.1016/ Lange JL, Peeden EH, Stringer SP: Are prophylactic systemic antibiotics
j.joms.2014.10.013. necessary with nasal packing? A systematic review, Am J Rhinol Allergy
Alvi S, Patel BC: Nasal fracture reduction, [Updated October 24, 2022]. In: 31(4):240-247, 2017. doi:10.2500/ajra.2017.31.4454.
StatPearls [Internet], Treasure Island, FL, 2022, StatPearls Publishing. Lee DH, Jang YJ: Pediatric nasal bone fractures: does delayed treatment
Astaraki P, Baghchi B, Ahadi M: Diagnosis of acute nasal fractures using really lead to adverse outcomes? Int J Pediatr Otorhinolaryngol
ultrasound and CT scan, Ann Med Surg 78:103860, 2022. doi:10. 77(5):726-731, 2013. doi:10.1016/j.ijporl.2013.01.027.
1016/j.amsu.2022.103860. Lee M, Inman J, Callahan S, et al: Fracture patterns of the nasal septum,
Choi MH, Cheon JS, Son KM, et al: Long-term postoperative satisfac- Otolaryngol Head Neck Surg 143(6):784-788, 2010. doi:10.1016/j.
tion and complications in nasal bone fracture patients according to otohns.2010.08.027.
fracture type, site, and severity, Arch Craniofac Surg 21(1):7-14, 2020. Lifeng Li, Hongrui Zang, Demin Han, et al: London. Nasal bone frac-
doi:10.7181/acfs.2019.00626. tures: analysis of 1193 cases with an emphasis on coincident adjacent
Henry M, Hern HG: Traumatic injuries of the ear, nose and throat, fractures, Facial Plast Surg Aesthet Med 22(4):249-254, 2020. doi:10.
Emerg Med Clin North Am 37(1):131-136, 2019. 1089/fpsam.2020.0026.
Indreasano AT, Beckley ML: Nasal fractures. In Fonseca RJ (ed): Oral and Mondin V, Rinaldo A, Ferlito A: Management of nasal bone fractures,
Maxillofacial Trauma, ed 3, Philadelphia, 2004, Saunders, pp 737-750. Am J Otolaryngol 26(3):181-185, 2005.
Kang BH, Kang HS, Han JJ, et al: A retrospective clinical investigation Peterson BE, Doerr TD: Utility of computed tomography scans in pre-
for the effectiveness of closed reduction on nasal bone fracture, Maxil- dicting need for surgery in nasal injuries, Craniomaxillofac Trauma
lofac Plast Reconstr Surg 41(1):53, 2019. Reconstr 6(4):221-224, 2013. doi:10.1055/s-0033-1349206.
Kim J, Jung HJ, Shim WS: Corrective septorhinoplasty in acute nasal Reddy LV, Haithem EM: Nasal fractures. In Fonseca RJ (ed): Oral and
bone fractures, Clin Exp Otorhinolaryngol 11(1):46-51, 2018. doi:10. Maxillofacial Surgery, ed 2, St. Louis, 2009, Saunders, pp 270-282.
21053/ceo.2017.00346.

t.me/Dr_Mouayyad_AlbtousH
54
Frontal Sinus Fracture
JU S T I N E M O E , M A R T I N B. S T E E D, a n d S H A H R O K H C . B AG H ER I

CC Eyes. Bilateral pupils are equal, round, and reactive to light

(5–2 mm; direct and consensual light reflexes intact bilaterally).
You are called by the trauma team to evaluate a 25-year-old male There is bilateral subconjunctival hemorrhage and no evidence of
status post-high-speed motor vehicle collision and to manage his hyphema (blood in the anterior chamber of the eye, which may
facial trauma. be difficult to detect in a supine patient). Fundoscopic examina-
tion shows mild papilledema in the right eye (optic disc edema
HPI secondary to increased intracranial pressure). The bilateral intra-
ocular pressures measured with a portable tonometer are normal
The patient was the unrestrained driver in a high-speed, head-on at 16 mm Hg.
collision with another vehicle. No air bag was deployed, and there
was subsequent significant steering wheel and windshield damage. Imaging
The patient was found unconscious and was not arousable. He
was intubated at the scene because of a Glasgow Coma Scale The imaging modality of choice for evaluation of frontal sinus
(GCS) score of 7 (high index of suspicion for a severe intracranial injuries is a noncontrast axial computed tomography (CT) scan
injury) and was brought to your Level I trauma center by air with 1 mm or less slice thickness. However, CT is not a reliable
medical transport for evaluation and treatment. predictor of nasofrontal duct injury.
In the current patient, head and facial helical CT scans were
PMHX/PDHX/Medications/Allergies/SH/FH obtained after the primary and secondary surveys. The head CT
scan revealed a 3-cm 3 1-cm left subarachnoid hemorrhage with
All history is unknown. (When possible, the history should be no midline shift and two 1-cm 3 1-cm areas of hyperdensity in
obtained from available family members.) the left frontal lobe. (Frontal sinus fractures are commonly associ-
ated with intracranial injury.) Axial views of the facial CT scan
revealed a displaced, comminuted frontal bone fracture involving
Examination both the anterior and posterior tables of the bilateral frontal si-
nuses (Fig. 54.1A). There were also fractures of the nasal bones,
Primary Survey bilateral supraorbital rims, and left infraorbital rim. Three-dimen-
The primary survey is accomplished via the Advanced Trauma sional reconstruction allows assessment of the overall fracture
Life Support protocol. The patient is sedated and intubated with patterns and orientation of fracture segments (Fig. 54.1B). A
spontaneous respirations. A transport cervical collar is in place plain radiographic trauma series also was obtained, including
(correctly sized and positioned), and his pupils are equal and reac- cervical spine, anteroposterior chest, and anteroposterior pelvis
tive. His GCS score is 10T on arrival. He is otherwise hemody- views, which were all negative. (The incidence of facial fractures
namically stable. accompanied by spinal injuries is a significant concern for cranio-
maxillofacial surgeons.)
Secondary Survey
Labs
Vital signs. Blood pressure is 115/64 mm Hg, heart rate is
115 bpm (tachycardia), respirations are 12 breaths per minute, Standard laboratory tests for the evaluation of multisystem trauma
and temperature is 37.6°C. patients include a complete blood cell count, complete metabolic
Maxillofacial. There is a 10-cm stellate laceration through the panel, arterial blood gas analysis, urinalysis, and coagulation stud-
frontalis muscle in the left forehead and supraorbital region. Bony ies (prothrombin time, partial thromboplastin time, and interna-
crepitus and step deformities are noted on palpation of the supra- tional normalized ratio). A urine drug screen and blood alcohol
orbital rims, nasal bones, and frontal bone (indicative of commi- level are indicated in patients with decreased mental status.
nuted fractures). There is a flow of clear, blood-tinged fluid from For the current patient, laboratory values were within normal
the left naris (possible cerebrospinal fluid [CSF] rhinorrhea). The limits except for a slightly low hemoglobin and hematocrit (sec-
maxilla is stable. The dental occlusion is difficult to assess secondary ondary to blood loss from the scalp laceration and fluid resuscita-
to oral endotracheal intubation. tion). One milliliter of the blood-tinged transudate from the

265
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266 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

posterior sinus wall, and nasofrontal outflow tract (NFOT). In

general, fractures of the anterior or posterior table are considered
significantly displaced when bony segments are found to be dis-
placed greater than one table thickness. Indications for surgical
management are given in the following sections. However, these
indications are not absolute, and each case needs treatment plan-
ning on an individual basis.

Displaced Anterior Sinus Wall Fractures Without

Nasofrontal Outflow Tract Involvement
The goal of treatment in this clinical situation is to prevent cos-
metic deformity. After reduction, internal fixation is completed
with titanium or resorbable microplates. Surgical access may be
accomplished through a coronal or local approach (existing lac-
erations, open sky incision). Endoscopic repair through a transna-
sal or transcutaneous approach (brow or coronal incisions) may be
A used for minimally displaced anterior table fractures. Bone graft-
ing should be considered for avulsed fragments or extensive com-
minution. Isolated, nondisplaced anterior table fractures do not
require surgical reduction and may be managed conservatively.

Nasofrontal Outflow Tract Injury Without

Significantly Displaced Posterior Table Fracture
The outflow tract is often uninjured with minimally displaced
anterior table fractures; it more commonly presents with signifi-
cantly displaced frontal sinus fractures or concomitant naso-
orbito-ethmoid and Le Fort fractures. An untreated obstructed
NFOT injury prevents evacuation of mucin from the frontal
sinus and may lead to mucocele or mucopyocele formation, os-
teomyelitis, sinusitis, meningitis, or brain abscess. Treatment
goals are complete debridement of sinus mucosa from the sinus
B and upper outflow tract, using a curette or high-speed burr, and
obliteration of the frontal sinus and nasofrontal duct with vari-
• Fig. 54.1 A, Preoperative axial computed tomography (CT) scan dem- ous materials, including bone, temporalis muscle, fat, fascia,
onstrating comminuted displaced anterior and posterior sinus wall frac- Gelfoam (Pfizer), and hydroxyapatite cement. The anterior table
tures. B, Three-dimensional reconstruction of the preoperative CT scan segments are replaced and stabilized with rigid fixation. For an
demonstrating a comminuted frontal bone fracture with a step deformity isolated, mild NFOT injury, some authors advocate observa-
at the supraorbital rims bilaterally. There is also evidence of fractures at the
tion, NFOT reconstruction, or stenting; however, reobstruction
inferior orbital rims bilaterally.
has been reported in up to 30% of patients. Endoscopic frontal
sinusotomy or a modified endoscopic Lothrop procedure may
patient’s left naris was collected and sent for laboratory analysis. also be considered for a mild NFOT injury or persistent ob-
The sample tested positive for b2 transferrin (diagnostic of CSF). struction after conservative management. Less commonly used
surgical techniques include trephination, a frontoethmoidec-
Assessment tomy (Lynch or Knapp procedure), and a frontal sinus collapse
(Reidel) procedure.
Subarachnoid hemorrhage with left frontal lobe intracerebral contu-
sion; bilateral comminuted frontal sinus fracture with significant Displaced Posterior Table Fractures
displacement of the anterior and posterior tables; bilateral nasal bone,
left infraorbital rim, and bilateral supraorbital rim fractures; left These fractures can present with intracranial injury or dural tear
frontal stellate skin laceration, evidence of CSF rhinorrhea, possible and CSF leakage. The goals of treatment are acute management of
nasofrontal duct injury or obstruction, possible elevated ICP; Facial intracranial injury (often with a craniotomy), dural repair, and
Injury Severity Scale score of 10 (displaced frontal sinus fracture [5], cranialization in open approaches (removal of the posterior table,
bilateral supraorbital rim fractures [2], left infraorbital rim fracture allowing the brain parenchyma to occupy the frontal sinus).
[1], nasal bone fracture [1], and forehead laceration .10 cm [1]). Increasing support and evidence can be found for transnasal en-
doscopic approaches in patients with displaced posterior table
Treatment fractures who do not require simultaneous neurosurgical interven-
tion. Injuries of the posterior table with CSF leaks can now main-
Three components of frontal sinus fractures must be considered tain the frontal sinus drainage pathway with Draf IIb or Draf III
when determining the proper treatment: the anterior sinus wall, techniques.

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 CHAPTER 54 Frontal Sinus Fracture 267

Nasofrontal outflow tract obliteration before cranialization is

achieved with a variety of materials, including temporal fascia,
temporal muscle, bone, and tissue sealants. A pedicled pericranial
flap placed after cranialization facilitates separation of the brain
from the nasal environment. Open reduction and internal fixation
of the anterior table segments and reconstruction of the craniot-
omy defect with rigid fixation plates or mesh is completed. Man-
agement of isolated and minimally displaced fractures of the inner
table without an obvious dural tear is more controversial, and
conservative management or sinus obliteration may be considered.
The ability of the surgeon to evaluate the patency and function
of the NFOT is critical. For fractures treated nonsurgically and
those in which the nasofrontal ducts are not obliterated, interval
CT imaging must be performed to assess duct function over time.
Intraoperatively, patency may be assessed by injecting dye into the
duct and observing its emergence in the nasal cavity. However, the
accuracy of this test is questionable. A
In the current patient, the presence of a displaced posterior
table fracture, dural tears, and CSF leak warranted cranialization
through a coronal flap in coordination with the neurosurgical
team. A craniotomy was performed, the subarachnoid hematoma
was evacuated, and an external ventriculostomy drain (EVD) was
placed. The supraorbital rims and nasal bone were reconstructed
and rigidly fixated with titanium plates (Fig. 54.2A). The poste-
rior table was removed, and the dural tears were repaired by
primary closure. (A fascial graft and fibrin glue may be used if
primary closure is not possible.) The sinus mucosa was removed
from the sinus and upper outflow tract using a pear-shaped burr.
The remaining NFOT mucosa was inverted into the nose, and the
outflow tracts were occluded with a small amount of free tempo-
ralis fascia. An anteriorly based pericranial flap (based on deep
branches of the supratrochlear and supraorbital vessels) was
placed into the frontal sinus (Fig. 54.2B). The anterior table was
reduced and stabilized with titanium microplates (Fig. 54.2C).
The patient did well postoperatively. A postoperative CT scan B
demonstrated excellent restoration of frontal region contour and
projection (Fig. 54.3). The neurologic examination results im-
proved, the EVD was removed 5 days postoperatively, and the
patient was discharged home 11 days after surgery.

Complications
The reported overall complication rates for frontal sinus fracture
repair range from 4% to 18%. Early complications often present
within the first 6 weeks after surgical intervention. They include
CSF leakage, wound infection, meningitis, brain abscess, iatrogenic
brain injury (cerebral contusion), NFOT obstruction, supraorbital
nerve paresthesia, diplopia, headache, and chronic forehead pain.
Meningitis is the most worrisome early postoperative compli-
cation and has an incidence as high as 6%. Prompt diagnosis and
treatment are essential to minimize morbidity and mortality. Al-
teration in mental status, fever, or neck rigidity should prompt the C
clinician to obtain a head CT scan, which is followed by lumbar
puncture. Diagnosis may be delayed in trauma patients with im- • Fig. 54.2 A, Intraoperative photograph demonstrating cranialization
paired neurologic status. If meningitis is suspected, the patient (posterior table has been removed, and supraorbital bar has been recon-
should be stabilized medically and should receive empirically ad- structed). B, Anterior-based pericranial flap: anteriorly pedicled pericranial
ministered, broad-spectrum antibiotics with high CSF penetrance flap (based on the supratrochlear and supraorbital vessels) before inset-
ting. C, Intraoperative photograph demonstrating inset anterior-based
(e.g., nafcillin). The choice of antibiotic should be guided by
pericranial flap and restoration of superior frontal region contour.
Gram stain and culture results, when available.
Late frontal sinus fracture complications occur after 6 weeks
and may present more than 10 years after the surgical repair. They

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268 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

pneumatization into the frontal bone begins between the ages of

6 months to 2 years. The frontal sinus is radiographically detect-
able by age 7 years and reaches complete development in adoles-
cence. The sinus may be a single or paired structure, with one or
several vertical septa. The adult sinus is rarely symmetric and
varies in size, averaging 24.3 mm in height, 29 mm in width, and
20.5 mm in depth. A frontal sinus may be absent in 4% of the
population and may be rudimentary or completely lack pneuma-
tization on one side in approximately 12%.
The NFOT is often erroneously referred to as the nasofrontal
duct. This is a misnomer because the NFOT is a passive space
with walls formed by surrounding structures and thus is not a true
duct. The 1995 International Conference on Sinus Disease estab-
lished the current preferred nomenclature and a clear description
of the functional units of the outflow tract, which, from superior
• Fig. 54.3 Postoperative axial computed tomography scan demonstrat- to inferior, include the frontal sinus infundibulum (found pos-
ing removal of the posterior sinus wall and cranialization of the frontal lobe teromedially in the sinus), frontal sinus ostium, and frontal recess
into the previous sinus space, with good reduction of the anterior sinus (in the middle meatus). Drainage of the frontal sinus in the nasal
wall and restoration of proper contour. cavity is highly variable. In most cases, it drains superior and me-
dial to the ethmoid infundibulum; in some cases, it drains directly
into the ethmoid infundibulum; and in a few cases, it drains into
include cosmetic defects (which are common and result from in- the suprabulbar recess (superior and medial to the ethmoid bulla).
adequate reduction or stabilization of the anterior table), muco- The chief blood supply to the frontal sinus is by the anterior
cele or mucopyocele formation, pneumocephalus, osteomyelitis, ethmoidal branch and, less commonly, the supraorbital branch of
and intracerebral abscess. Mucocele formation can result from the ophthalmic artery. The supraorbital and supratrochlear arter-
retained sinus mucosa or compromised sinus ventilation (even ies may also penetrate the frontal sinus. Venous drainage occurs
partial obstruction of the duct from traumatic disruption can re- by the diploic veins of Breschet, which coalesce anteriorly to drain
sult in stasis of secretions). Mucopyoceles develop upon bacterial into the facial and superior ophthalmic veins. Posteriorly, the
contamination and can cause the infection to spread to the orbit diploic veins communicate directly with the dural sinuses and
and brain. Treatment goals are complete surgical removal of the marrow cavity of the frontal bone via the foramen of Breschet
mucocele or mucopyocele and reconstruction to isolate the (intracranial infection may occur by this route).
splanchnocranium (the part of the skull derived from the bran- Detection of a CSF leak is critical in determining the manage-
chial [or pharyngeal] arches that comprises the bones of the face) ment of a frontal sinus fracture. Measurement of electrolyte levels
from the orbit and nasal cavity. Endoscopic marsupialization of has been proposed in the past because CSF has a higher glucose
mucoceles has been reported, with limited success rates. level and lower levels of protein, sodium, and potassium than do
nasal secretions. (Compared with serum, CSF has a lower glucose
Discussion level and a higher chloride level.) However, these levels are vari-
able and are not reliable for identifying CSF. The “halo” test is
Frontal sinus fractures comprise 5% to 12% of all facial fractures performed by placing a drop of the fluid onto a clean bed sheet or
and are most commonly found in adults. These injuries usually filter paper. A positive test result is the formation of a clear halo
result from blunt trauma to the anterior skull at the glabella. The around the central stain.
most common mechanism is automobile accidents, and the next The best test for identifying CSF in serum or secretions is the
most common is assault. The force necessary to fracture the ante- b2 transferrin test using immunofixation electrophoresis. How-
rior wall of the frontal sinus (800–1600 N) is two to three times ever, b2 transferrin is also present in aqueous humor and peri-
greater than that required to fracture the zygoma, mandible, or lymph fluid, and false-positive test results may occur in patients
maxilla. Significant intracranial injury occurs more often with with inborn errors of glycoprotein metabolism, chronic liver dis-
frontal sinus injuries than with injury to the maxilla or mandible ease, or genetic variants of transferrin. Still, the reported sensitiv-
secondary to the proximity to the brain and the force necessary to ity for this test is 94% to 100%, and the specificity is 98% to
fracture the frontal bone. 100%; therefore, the b2 transferrin test is currently the gold
Primary pneumatization of the frontal sinus occurs around the standard for detection of CSF in otorrhea or rhinorrhea.
16th week of gestation. The frontal sinus develops as a smooth
mucosal pocket from single or multiple extensions of the frontal ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
recess or ethmoid infundibulum in the middle meatus. Secondary complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 268.e1

Bibliography Lee D, Brody R, Har-El G: Frontal sinus outflow anatomy, Am J Rhinol

11:283, 1997.
Manolidis S: Frontal sinus injuries: associated injuries and surgical man-
Bagheri SC, Dierks EJ, Kademani D, et al: Application of a Facial Injury agement of 93 patients, J Oral Maxillofac Surg 62:882-891, 2004.
Severity Scale (FISS) in cranio-maxillofacial trauma, J Oral Maxillofac Marshall AH, Jones NS, Robertson JA: CSF rhinorrhea: the place of
Surg 64:408-414, 2006. endoscopic sinus surgery, Br J Neurosurg 15(1):8-12, 2001.
Bell RB, Dierks EJ, Brar P, et al: A protocol for the management of fron- McLaughlin RB Jr, Rehl RM, Lanza DC: Clinically relevant frontal sinus
tal sinus fractures emphasizing sinus preservation, J Oral Maxillofac anatomy and physiology, Otolaryngol Clin North Am 34(1):1-22, 2001.
Surg 65(5):825-839, 2007. Metzinger SE, Metzinger RC: Complications of frontal sinus fractures,
Bell RB, Dierks EJ, Homer L, et al: Management of cerebrospinal fluid Craniomaxillofac Trauma Reconstr 2(1):27-34, 2009.
leak associated with craniomaxillofacial trauma, J Oral Maxillofac Surg Nahum AM: The biomechanics of maxillofacial trauma, Clin Plast Surg
62(6):676-684, 2004. 2:59-64, 1975.
Gerbino G, Roccia F, Benech A, et al: Analysis of 158 frontal sinus frac- Rice DH: Management of frontal sinus fractures, Curr Opin Otolaryngol
tures: current surgical management and complications, J Craniomaxil- Head Neck Surg 12:46-48, 2004.
lofac Surg 28:133, 2000. Roelandse FW, van der Zwart N, Didden JH, et al: Detection of CSF leak-
Gonty AA, Marciani RD, Adornato DC: Management of frontal sinus age by isoelectric focusing on polyacrylamide gel, direct immunofixation
fractures: a review of 33 cases, J Oral Maxillofac Surg 57(4):372-379, of transferrins, and silver staining, Clin Chem 44(2):351-353, 1998.
1999. Schultz RC: Frontal sinus and supraorbital fractures from vehicle acci-
Gossman DG, Archer SM, Arosarena O: Management of frontal sinus dents, Clin Plast Surg 2:93-106, 1975.
fractures: a review of 96 cases, Laryngoscope 116(8):1357-1362, 2006. Smith TL, Han JK, Loehrl TA, et al: Endoscopic management of the
Grayson JW, Jeyarajan H, Illing EA, et al: Changing the surgical dogma frontal recess in frontal sinus fractures: a shift in the paradigm? Laryn-
in frontal sinus trauma: transnasal endoscopic repair, Int Forum Al- goscope 112(5):784-790, 2002.
lergy Rhinol 7(5):441-449, 2017. Stammberger HR, Kennedy DW: Paranasal sinuses: anatomic terminol-
Helmy ES, Koh ML, Bays RA: Management of frontal sinus fractures, ogy and nomenclature: the Anatomic Terminology Group, Ann Otol
Oral Surg Oral Med Oral Pathol 69:137-148, 1990. Rhinol Laryngol Suppl 167:7-16, 1995.
Holt GR: Ethmoid and frontal sinus fractures, Ear Nose Throat J 62:33- Strong EB, Pahlavan N, Saito D: Frontal sinus fractures: a 28-year retro-
42, 1983. spective review, Otolaryngol Head Neck Surg 135(5):774-779, 2006.
Koudstaal MJ, van der Wal KG, Bijvoet HW, et al: Post-trauma mucocele Van Alyea OE: Frontal sinus drainage, Ann Otol Rhinol Laryngol 55:267-
formation in the frontal sinus; a rationale of follow-up, Int J Oral 277, 1946.
Maxillofac Surg 33(8):751-754, 2004. Wallis A, Donald PJ: Frontal sinus fractures: a review of 72 cases, Laryn-
Lang J: Clinical Anatomy of the Nose, Nasal Cavity and Paranasal Sinuses, goscope 98(6 Part 1):593-598, 1988.
New York, 1989, Thieme.

t.me/Dr_Mouayyad_AlbtousH
55
Naso-Orbital-Ethmoid Fracture
M A RT I N B. S TE E D a n d SH A H R O K H C . B AG H ER I

CC Primary Survey
A 21-year-old male arrives via emergency medical services (EMS) The patient’s primary survey is intact, and he has a Glasgow Coma
responders to the emergency department (ED) after a high-speed Scale score of 15. The patient is alert and oriented to person,
motor vehicle collision. place, time, and event and has been able to easily maintain his
airway. (Severe posterior nasal hemorrhage can compromise the
HPI airway and be a significant source of blood loss.)

The EMS personnel report that the patient was an unrestrained Secondary Survey
driver traveling at 60 mph through a red light at an intersection
when he hit an oncoming vehicle. The driver’s side airbag did not General. The patient is a well-developed and well-nourished male
deploy, resulting in the direct collision of the patient’s upper in moderate distress, requesting pain medications and supporting
midface with the steering wheel, causing a positive “steering a partially soaked 4 3 4 dressing held over the bridge of his nose
wheel deformity.” (The incidence of naso-orbital-ethmoid [NOE] and right eye.
fractures has decreased since the advent of airbags. However, the Vital signs. His blood pressure is 150/84 mm Hg (hyperten-
impact of the midface with the steering wheel continues to be a sive), heart rate is 125 bpm (tachycardia), respirations are 16 breaths
common cause of NOE fractures). The patient had a transient per minute, and temperature is 37.6°C.
loss of consciousness but remained coherent, alert, and oriented Maxillofacial. There is significant bilateral midfacial and peri-
during transport to the ED. He complains of a severe headache, orbital edema with a 10-cm horseshoe (U)-shaped laceration to the
poor vision, and pain in the midface. (A history of severe head- frontal region down to bone. A second 8-cm horizontal laceration
ache, loss of consciousness, or declining mental status should extends across the nasal bridge (nasion) and through both the right
raise suspicion of intracranial injury or hemorrhage.) The trauma and left upper eyelids with no orbital fat herniation (open globe
team has requested a consultation for management of the pa- injury should be suspected with exposure of orbital fat) (Fig. 55.1).
tient’s midfacial soft tissue lacerations and evaluation for facial
fractures.

PMHX/PDHX/Medications/Allergies/SH/FH
The patient has a prior history of substance abuse (cocaine) ac-
cording to the patient and telephone contact with a family
member.
A history of cocaine abuse is important to reconstructive
maxillofacial surgeons because it may imply previous nasal sep-
tal perforation or compromised local vasculature of the nasal
structures caused by repeated episodes of vasoconstriction from
nasal cocaine abuse. In addition, a chronic or recent history of
cocaine abuse has cardiovascular implications, putting the pa-
tient at increased risk for coronary vasospasm and cardiac
arrhythmias. Illicit drugs are commonly implicated in motor
vehicle accidents.

Examination
• Fig. 55.1 Preoperative photograph showing frontal and orbital and nasal
The initial evaluation of a trauma patient should follow the Ad- bridge lacerations, increased intercanthal distance, severe depression of
vanced Trauma Life Support protocol. the nasal bridge unit, bilateral midfacial edema, and periorbital ecchymosis.

269
t.me/Dr_Mouayyad_AlbtousH
270 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

There are several small arterial bleeders within each laceration. plain films fail to demonstrate the degree and location of bony dis-
Facial abrasions extend over the left malar (zygoma) region. The ruption. Thin cuts (1–1.5 mm) are usually required to determine the
patient exhibits a positive result on the bowstring test on the left extent of the NOE injury. Of surgical importance is the determina-
(movement of bone fragment at insertion of medial canthal ten- tion of the position and status of the frontal process of the maxilla
don upon lateral pull on the upper eyelid). The intercanthal dis- because this region bears the insertion of the medial canthal tendon.
tance is 42 mm (the distance between the left and right medial In the current patient, a facial helical CT scan without contrast
canthus may be increased in NOE fractures), and the interpupil- was obtained. Axial bony windows showed bilateral fractures at
lary distance is 62 mm. (Normal intercanthal distance is race de- the NOE region with avulsion of several bony segments and bi-
pendent and ranges from 28.6 to 33 mm for adult females and lateral medial orbital wall fractures (Fig. 55.2A). The orbital floors
28.9 to 34.5 mm for adult males.) appear intact bilaterally. There is evidence of a 1-cm punctuate
Nose. There is crepitus and tenderness of the nasal complex subarachnoid hemorrhage in the left temporal lobe, with no mid-
upon palpation (nasal bones are displaced and unstable), and line deviation. A three-dimensional reconstruction view permits
movement with digital pressure over bilateral medial canthi (NOE visualization of the lines of fracture (Fig. 55.2B and C).
complex instability requiring reduction and stabilization). There is
a widened nasal bridge, upturned nasal tip, and depressed radix. Labs
Nasal speculum examination reveals bright red blood in the bilat-
eral nares (epistaxis) and deviation of the nasal septum to the right In the current patient, a complete trauma panel was obtained. The
with no evidence of a septal hematoma. (This requires urgent results were remarkable for an elevated white blood cell count of
decompression.) Clear fluid was obtained from the right naris 15,100 cells/m L (may be secondary to demargination of leuko-
(rhinorrhea) and has been sent for laboratory evaluation for cere- cytes in the setting of acute trauma) and a urine toxicology screen
brospinal fluid (CSF). (The b 2 transferrin test and occasionally that was positive for cocaine metabolites.
glucose and chloride levels are used to confirm CSF rhinorrhea.) The b 2 transferrin test performed on the nasal fluid was negative
Maxilla. Bilateral hypoesthesia of the infraorbital nerve distribu- (low likelihood of dural tear, which could cause CSF rhinorrhea).
tions (cranial nerve V2) is present. The maxilla is nonmobile, and the
patient’s occlusion is intact. The patient has a full complement of teeth, Assessment
with no grossly carious teeth and no mobile dentoalveolar segments.
Eyes. There is severe bilateral chemosis and subconjunctival hem- • Type I NOE fracture of the right side (right medial canthal tendon
orrhage. The patient is unable to open either eye, and examination attached to one large segment of bone)
requires careful eyelid elevation. (A Desmarres retractor or disin- • Type III NOE fracture of the left side (significant comminution
fected paperclip retractor allows for gentle eyelid elevation.) There is and complete avulsion of left medial canthal tendon)
blunting of the bilateral medial palpebral fissures. There is no obvi- • 11-cm U-shaped frontal region laceration through frontalis muscle
ous epiphora (excessive tearing from the eye), but no attempts are to frontal bone, with no evidence of frontal sinus fracture
made at primary probing of any of the canaliculi. (The lacrimal • 10-cm linear horizontal laceration through both upper eyelids and
drainage system is commonly injured with NOE fractures.) probable left nasolacrimal duct injury
Right eye (OD) examination reveals a reactive pupil with hy- • OD grade I traumatic hyphema (less than one fourth of the height
phema (blood in the anterior chamber of the eye). The OD pupil of the anterior chamber of the right eye is filled with blood)
appears round, and visual acuity is limited to light perception. Left • Punctate left temporal lobe subarachnoid hemorrhage
eye visual acuity is 20/200 with a round and reactive pupil and no • Facial Injury Severity Scale score of 5 (NOE 5 3, facial laceration
hyphema. (Visual acuity should be tested with the patient’s correc- over 10 cm 5 1 1 1)
tive lenses whenever present.) Extraocular movements are intact bi-
laterally, and there is no enophthalmos. (Medial orbital wall fractures Treatment
can cause enophthalmos in the setting of NOE fractures.)
The physical examination of suspected NOE fractures should The goals of surgical correction of NOE fractures are to restore
be detailed and directed toward assessing the degree of telecanthus the patient to the preinjury levels of function and cosmesis. This
and early identification of concurrent ocular and neurologic inju- becomes extremely challenging in the treatment of complex and
ries. Soft tissue intercanthal distances greater than 35 mm are comminuted NOE fractures with concomitant injuries.
suggestive of a displaced NOE fracture, and distances greater than Adequate exposure is essential for the precise reduction and
40 mm are diagnostic. Crepitus or movement upon palpation of fixation required for correction of NOE fractures. Most com-
the medial orbital rim indicates instability and the presence of a monly, the combination of a coronal flap and lower eyelid inci-
fracture; clinical bowstring examinations can demonstrate whether sions (or simply a coronal flap alone) is adequate. Placement of
the canthal-bearing bone fragment is displaced and mobile. Other incisions in areas over the radix or lateral aspect of the nasal bridge
tests include the Furness test (the degree of displacement is as- should be avoided because of unfavorable scarring. Most often,
sessed by grasping the skin over the medial canthus with tissue the fractured segments can be fixated to a curved titanium plate
forceps) and the bimanual examination (with an intranasally that extends vertically from the nasofrontal junction along the
placed instrument applying lateral pressure to the NOE complex, frontal process of the maxilla onto the medial portion of the infe-
the medial canthal tendon is digitally palpated for movement). rior orbital rim. The canthal tendon is rarely avulsed from bone
and is usually attached to a sizable bony fragment that can be re-
Imaging duced to a correctly adapted plate. When the medial canthal
tendon is avulsed, a canthopexy must be performed, primarily
The imaging modality of choice in the diagnosis and evaluation of through transnasal wiring or by securing a permanent suture to a
midface fractures is a noncontrast maxillofacial computed tomogra- transnasal wire that is directed superiorly and posteriorly, as de-
phy (CT) scan of the face. Because of overlapping bony architecture, scribed by Herford and colleagues.

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 CHAPTER 55 Naso-Orbital-Ethmoid Fracture 271

B C
• Fig. 55.2 A, Preoperative axial bony computed tomography (CT) window showing fracture of the nasal
bones with severe displacement of the bilateral nasal bones and comminution of the frontal process of
the maxilla. This view also shows the fracture of the lamina papyracea and bilateral medial orbital walls.
B, Three-dimensional reconstruction CT of a different patient showing a naso-orbital-ethmoid (NOE) frac-
ture with intact frontal bone. C, Three-dimensional reconstruction of a different patient showing a com-
bined NOE fracture with frontal bone fracture.

The current patient was evaluated by the neurosurgical team comminuted NOE fractures benefit from immediate bone graft-
and the ophthalmology service after the primary and secondary ing. Each of these requirements is met through the use of a coro-
surveys and diagnostic imaging. The patient required no surgical nal incision, which provides large amounts of access and allows
intervention for the small subarachnoid hemorrhage and no intra- the concurrent harvest of cranial bone grafts for immediate graft-
cranial pressure monitoring considering consistently normal serial ing of the nasal dorsum or medial orbital walls.
neurologic examinations. The ophthalmologic team concurred Careful intraoperative examination revealed a 1-cm 3 1-cm
with the diagnosis of a grade I traumatic hyphema, which re- fiberglass foreign body within the right upper eyelid. A Jones type
quired no surgical intervention, and the high likelihood of a na- I test (fluorescein dye into eye) or Jones type II test (dye into the
solacrimal apparatus injury, which would be formally evaluated puncta or canaliculi) can be performed intraoperatively to assess
under general anesthesia at the time of NOE repair. The patient the lacrimal function. The nasolacrimal apparatus may be injured
was found to have no evidence of a ruptured globe or traumatic in 20% of patients with NOE fractures. It is especially susceptible
optic neuropathy. He was taken to the operating room and orally when telecanthus is present secondary to a loss of the protective
intubated. A coronal flap was not used because of the excellent influence provided by the anterior limb of the medial canthal
exposure through the existing lacerations (Fig. 55.3A). It must be ligament. Open reduction and anatomic fixation of the fracture
stressed that this is usually not the case. Access is paramount in segments usually result in reestablishment of the lacrimal drain-
the proper reduction and fixation of NOE fractures, and many age. Intraoperative repair may be completed through the use of a

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272 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

stent (e.g., a Crawford tube), which acts to bridge the two severed of migration, relapse, and telecanthus. Intranasal splints (i.e.,
ends of the canaliculi, and careful closure of the pericanalicular Doyle splints) were placed and sutured in place anteriorly through
tissues. Delayed assessment may be done with fluorescein dye, the membranous septum. The lacerations were closed in layers,
instrument probing, or dacryocystography. Refractory or uncor- with special attention to the upper eyelid regions, where the
rected epiphora often necessitates correction through a dacryocys- levator muscle and its insertion were evaluated and maintained.
torhinostomy at a later date. In this procedure, the tear drainage An external nasal splint (e.g., Denver or Aquaplast splint) was
pathways are reconnected to the inside of the nose. A small inci- placed for protection and to minimize edema. Postoperatively, the
sion is usually placed approximately midway between the corner patient underwent serial neurologic checks. A second CT head
of the eye and the bridge of the nose. The lacrimal sac is located, scan, obtained on postoperative day 1, showed no change in the
incised, and then connected to the nasal mucosa, creating a new punctate subarachnoid hemorrhage. The external and intranasal
tear drainage pathway. A stent is then placed in the newly created splints were removed, and the patient was discharged on the third
tear drainage pathway for a few months to prevent scarring of postoperative day.
the tear drainage ducts, which might otherwise result in failure of
the surgery. The tubes can usually be removed in the office with Complications
little if any discomfort or need for anesthesia.
In the current patient, the lacerations were meticulously Intraoperative
washed out with pulse irrigation. The NOE fractures were con-
firmed to be a type I on the right side, with the medial canthus Intraoperative complications are often best prevented by a thor-
attached to a large segment of bone, and a type III on the left side, ough preoperative evaluation and examination. Concomitant
with complete avulsion of the medial canthal ligament attach- ocular injuries must be identified and evaluated before general
ment. A 2.0 X-shaped plate was applied to secure the nasal bones anesthetic induction and surgical manipulation of the globe and
to the frontal bone (Fig. 55.3B). The medial orbital rims were also adnexal structures. Neurosurgical consultation must be obtained
reconstructed using rigid minifixation plates. Twenty-six–gauge in case of neurologic changes or radiographic evidence of intracra-
wires were used to directly secure the left and right medial canthal nial injury. In the case of severe epistaxis from midfacial injuries,
tendons to stable bone posterior and slightly superior to the inser- the use of bilateral posterior nasal packs can be lifesaving.
tion of the preinjured tendon. This is done to overcome the forces
Early
Nasolacrimal injury may present as epiphora secondary to inade-
quate tear drainage. Most cases of epiphora resolve within a few
weeks after NOE reduction or lacrimal duct repair (or both).
However, persistent epiphora may require secondary correction
with a dacryocystorhinostomy procedure.

Late
The majority of complications resulting from NOE fractures are
cosmetic in nature and are the result of untreated or inadequately
treated NOE fractures. Perhaps the most common is a residual
“saddle defect,” or shortened and deprojected nose. This is sec-
ondary to the loss of dorsal nasal support in the upper bony and
lower cartilaginous dorsum. The importance of immediate pri-
mary dorsal bone grafting has been emphasized in the literature.
It is important when placing the graft as a strut to position it in-
A feriorly underneath the lower lateral cartilage to provide support
for the inferior portion of the nose and prevent palpation of the
graft after healing is complete. The graft is secured with screws or
plate fixation. The plate may be placed inferiorly beneath the
bone graft to prevent cosmetic visualization of the plate beneath
the skin. Attention should be given to fixation of the graft superi-
orly to avoid overprojection at the nasofrontal region or at the
nasal tip. Primary graft failure (infection) and long-term graft re-
sorption can also occur.
Telecanthus is best managed at the time of initial surgery
through correct reduction of the bone fragments that carry the
medial canthal tendon insertions or, in the case of type III frac-
tures, meticulous reduction of the insertions themselves with
B overcorrection. Septal deviation may require immediate correction
or a septoplasty at a later date. Enophthalmos most often results
• Fig. 55.3 A, Intraoperative photograph showing access through facial from an increase in the orbital volume caused by untreated medial
lacerations. B, Intraoperative photograph after open reduction with inter- orbital wall or orbital floor fractures. These injuries should be ad-
nal fixation of the naso-orbital-ethmoid complex. dressed concurrently or secondarily with NOE reconstruction.

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 CHAPTER 55 Naso-Orbital-Ethmoid Fracture 273

Discussion tendon and the fragment of bone upon which it inserts. Three
distinct patterns have been identified. A type I injury is the sim-
Fractures of the NOE region are among the most complex maxil- plest form of NOE fracture and involves only one portion of the
lofacial injuries in both diagnosis and treatment. The superior medial orbital rim with its attached medial canthal tendon. Type
limits of this region are defined medially by the cribriform plate II fractures have a comminuted central fragment with the fracture
and laterally by the roof of the ethmoid sinuses. The anterior lines remaining external to the medial canthal tendon insertion.
cranial fossa and contents lie above. The lateral limits comprise Type III fractures have comminution involving the central frag-
the medial orbital walls and are made up primarily of the lacrimal ment of bone where the medial canthal tendon inserts. Variants
bone and the orbital plate of the ethmoid. The anterior limits of type I, II, and III fractures may occur in bilateral fractures.
consist of the frontal bone and, more laterally, the frontal process In a 1985 study by Holt and Holt, 67% of 727 patients with
of the maxilla. Posteriorly lie the sphenoid bone and its sinus. The facial fractures sustained some degree of ocular injury, although
inferior limit is the lower border of the ethmoid sinuses. An NOE most series report the incidence to be in the range of 20% to
fracture involves the central midface—the nasal bones, frontal 25%. A high degree of suspicion is warranted with significant
process of the maxilla, and ethmoid bones. In 1973, Epker coined NOE fractures, and a full fundoscopic examination should be
the term “naso-orbito-ethmoid” to describe this midfacial injury. performed. Slit-lamp examinations, when possible, allow evalua-
Before 1960, most textbooks offered little guidance in the treat- tion of adnexal structures. The nasolacrimal apparatus may also be
ment of these injuries, and early investigations focused on closed injured in about 20% of patients with NOE fractures.
treatment using external nasal dressings after nasal manipulation. Naso-orbital-ethmoid fractures are an uncommon but aes-
Open reduction with internal fixation has proved to be an impor- thetically challenging maxillofacial injury. The importance of
tant advance in the management of these fractures, and combined precise reduction and primary bone grafting in the setting of in-
with proper reduction of the medial canthal tendon and primary adequate dorsal nasal support and comminution cannot be over-
nasal dorsum bone grafting, it has improved the cosmetic result emphasized.
even in severe injuries.
A detailed classification scheme by Markowitz and colleagues ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
defined the injury pattern with respect to the medial canthal complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 273.e1

Bibliography Holt GR, Holt JE: Nasoethmoid complex injuries, Otolaryngol Clin
North Am 18:87-98, 1985.
Leipziger LS, Manson PN: Nasoethmoid orbital fractures: current con-
Ellis E III: Sequencing treatment for naso-orbito-ethmoid fractures, cepts and management principles, Clin Plast Surg 19:167-193, 1992.
J Oral Maxillofac Surg 51:543-558, 1993. Markowitz BI, Manson PN, Sargent L, et al: Management of the medial
Epker BN: Open surgical management of naso-orbital-ethmoid facial canthal tendon in nasoethmoid orbital fractures: the importance of
fractures, Trans Int Conf Oral Surg 4:323-329, 1973. the central fragment in classification and treatment, Plast Reconstr
Fedok FG: Comprehensive management of nasoethmoid-orbital injuries, Surg 87:843-853, 1991.
J Craniomaxillofac Trauma 1:36-48, 1995. Sargent LA, Rogers GF: Nasoethmoid orbital fractures: diagnosis and
Gruss JS: Naso-ethmoid-orbital fractures: classification and role of pri- management, J Craniofac Trauma 5:19-27, 1999.
mary bone grafting, Plast Reconstr Surg 75:303-317, 1985.
Herford AS, Ying T, Brown B: Outcomes of severely comminuted (type
III) nasoorbitoethmoid fractures, J Oral Maxillofac Surg 63:1266-
1277, 2005.

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56
Le Fort I Fracture
M A RT I N B. S TE E D a n d SH A H R O K H C . B AG H ER I

CC 37.6°C. (Mild tachycardia can be caused by a compensatory re-

sponse to volume loss from prolonged oropharyngeal bleeding or
A 26-year-old male presents to the emergency department (ED) from the sympathetic response associated with pain and anxiety.)
with the chief complaint of, “They hit my face with a brick and Eyes. Pupillary response, visual acuity, visual fields, and extra-
got my wallet. My face hurts. . . . I was bleeding from my nose, ocular movements are all within normal limits. (A complete eye
but it has stopped.” examination is mandatory in all patients with midface fractures.)
There is no evidence of subconjunctival hemorrhage or hyphema
HPI (blood in the anterior chamber of the eye).
Maxillofacial. The patient has moderate bilateral midface
You are called by the ED team to evaluate the patient. He reports edema with left facial abrasions extending over the lip region.
being struck in the face at the level of his upper lip and teeth just There is mild hypoesthesia of the bilateral infraorbital nerve dis-
below the nose by an unknown male who was walking the op- tributions (cranial nerve V2). The maxilla is mobile, with no si-
posite way on the sidewalk. (The vast majority of Le Fort I injuries multaneous movement of the nasal bones on palpation (as would
are from blunt, as opposed to penetrating, trauma.) He explains be seen in Le Fort II and III injuries). Examination of the teeth
that he was hit once in the face with a brick and subsequently fell reveals premature posterior occlusal contacts and a 5-mm anterior
to his knees, without any loss of consciousness (lower likelihood open bite (Fig. 56.1). There is no evidence of mobile dentoalveo-
for intracranial injury in the absence of loss of consciousness). lar segments. The remaining facial skeleton, including the nasal
bones, is intact and stable on palpation. Nasal speculum examina-
PMHX/PDHX/Medications/Allergies/SH/FH tion reveals a deviated nasal septum to the right, with no evidence
of a septal hematoma. (A septal hematoma needs to be drained to
The patient smokes one pack of cigarettes daily and drinks alcohol prevent subsequent necrosis of the quadrangular cartilage and
regularly. (Both of these factors contribute to an increased relative possible saddle-nose deformity.)
risk of postoperative infections. A history of alcohol abuse is more
frequently encountered in the trauma population.) The remainder Imaging
of his medical history is noncontributory.
The imaging modality of choice for the diagnosis and evaluation
Examination of suspected maxillary Le Fort I fractures is a noncontrast maxil-
lofacial computed tomography (CT) scan with thin cuts (axial
The initial evaluation of a trauma patient should follow the Ad-
vanced Trauma Life Support protocol.

Primary Survey
The patient’s primary survey is intact. (Control of the airway and
hemorrhage are both part of the primary survey. Compromised airway
and life-threatening hemorrhage are unlikely with isolated Le Fort I
injuries; however, they can be seen with more complex facial fractures;
that is, those with higher Facial Injury Severity Scale [FISS] scores).

Secondary Survey
General. The patient is a well-developed and well-nourished male
in no apparent distress who is holding a blood-soaked cloth under
his nose.
Vital signs. His blood pressure is 115/64 mm Hg, heart rate is
115 bpm, respirations are 12 breaths per minute, and temperature is • Fig. 56.1 Posttraumatic anterior open bite and malocclusion.

274
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 CHAPTER 56 Le Fort I Fracture 275

views with coronal reconstructions). Direct coronal imaging or

coronal reconstructions are helpful (patients with suspected cervi-
cal spine injuries should not hyperextend the neck for direct coro-
nal imaging). Three-dimensional reconstructed CT can be useful
to demonstrate the fracture anatomy (Fig. 56.2).
For the current patient, a facial helical CT scan without contrast
was obtained after the primary and secondary surveys were com-
pleted. Axial bony window cuts showed bilateral pterygoid plate,
anterior and lateral maxillary wall, and posterior nasal septal fractures,
with opacification of the maxillary antrum (Fig. 56.3A). A moderate
amount of soft tissue edema and subcutaneous emphysema was
noted. Coronal reconstruction views showed bilateral fractures
through the lateral walls of the maxillary sinuses (Fig. 56.3B). A
three-dimensional reconstruction view allowed clear visualization of
the lines of fracture at the Le Fort I level (Fig. 56.3C).
A
Labs
For the current patient, a complete trauma panel was obtained.
The results were remarkable for an elevated white blood cell
(WBC) count of 16,900 cells/mL. (Increased WBCs or leukocyto-
sis in the acute setting is most likely secondary to physiologic stress
because of catecholamine-induced demargination of WBCs.)

Assessment
Isolated Le Fort I maxillary fracture; FISS score of 2.

Treatment
The goal of treatment of Le Fort I injuries is to reduce the displaced
maxillary bone with its dentition to allow for uneventful healing, re-
establishment of the patient’s preexisting occlusal function, and es-
thetics. Treatment of a particular fracture needs to be individualized
B

C
• Fig. 56.3 A, Preoperative axial bony computed tomography (CT) win-
dow showing fractures of the pterygoid plates, anterior maxillary walls,
and subcutaneous emphysema and opacification of the maxillary sinuses.
B, Preoperative coronal bony CT window through the anterior maxilla and
nasal vault showing fracture at the Le Fort I level. C, Preoperative anterior
• Fig. 56.2 Preoperative three-dimensional lateral view of a different patient three-dimensional reconstruction showing a horizontal fracture of the
showing maxillary impaction anteriorly with resultant anterior open bite. maxilla at the Le Fort I level.

t.me/Dr_Mouayyad_AlbtousH
276 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

and includes several options, mainly either open reduction with in- superior alveolar, nasopalatine, and descending palatine arter-
ternal fixation (ORIF) or closed reduction with maxillomandibular ies and, uncommonly, the internal maxillary artery. Packing,
fixation (MMF). The use of surgical splints should be considered, cauterization, and ligation are usually sufficient in controlling
especially with segmental maxillary fractures. The degree of commi- most situations. When hemorrhage cannot be controlled, ex-
nution at the anterior and lateral maxillary walls needs to be assessed ternal carotid artery ligation can be performed. Arterial angi-
for possible reconstructive measures. ography with embolization should also be considered.
Currently, most surgeons consider ORIF the gold standard. As • Maxillary hypoperfusion is uncommon but can occur, espe-
a general principle, early reduction and fixation is preferable. After cially when the maxilla is fractured in multiple pieces or when
a 7- to 10-day period, some difficulty may be encountered in mo- surgical splints are used. Early reduction and stabilization with
bilizing the maxilla to achieve appropriate reduction, especially if rigid internal fixation may help improve the outcome. In addi-
the fracture is associated with significant impaction. Consideration tion, consideration should be given to positioning the maxilla
should also be given to completing osteotomy of the maxilla at back into the preoperative position (in trauma situations).
the Le Fort I level (as in an orthognathic Le Fort osteotomy) if the Postoperative use of hyperbaric oxygen has been suggested, but
fracture is incomplete or significant time has elapsed since the its benefits remain unclear. If prefabricated occlusal splints are
original insult. Attempting to mobilize the incompletely fractured used, they should be checked to prevent impingement on the
maxilla can result in unfavorable fractures, often distant from the soft tissues (and possibly the blood supply) of the palate.
site of injury. After MMF has been established, it is critical to es- • Malpositioning of the maxilla can occur when the bony inter-
tablish passive reduction of the maxilla (maxillomandibular com- ferences are not appropriately evaluated and the maxilloman-
plex) with the condyles seated in a correct position; otherwise, an dibular complex is not seated passively with the condyles in the
anterior open bite will reemerge after rigid fixation has been ap- correct position; this results in a postoperative anterior open
plied and the intermaxillary fixation is released. If adequate bone bite. Palatal fractures that are not reduced also result in im-
contact is available, a plating system applied bilaterally at the piri- proper maxillary segment positioning.
form rims and zygomatic buttress areas is usually sufficient for
stabilization. However, if more comminution is present and less Early
bone contact is available, immediate bone grafting or secondary
bone grafting reconstructive procedures should be considered. • Control of nasal bleeding can be obtained in the immediate
The presence of palatal fractures complicates the treatment of postoperative period using a variety of techniques for nasal pack-
Le Fort I fractures and deserves special attention. If there is a ing. A speculum and a good light source are essential for detect-
palatal fracture but no concurrent mandibular fractures, the man- ing an anterior versus a posterior origin. If adequate control is
dibular arch is used to guide the width of the maxilla with arch not achieved, exploration in the operating room or interven-
bars and MMF. With concurrent mandibular fractures, two op- tional radiology for angiographic evaluation may be necessary.
tions exist: (1) the mandible can be reconstructed first anatomi- • Malocclusion can result from improper intraoperative maxil-
cally, followed by the maxilla, or (2) alginate impressions can be lary positioning, early hardware failure, or undiagnosed man-
obtained and model surgery carried out with the use of an intra- dibular or maxillary segmental fractures. Careful examination
operative maxillary splint to reestablish the occlusion. and appropriate imaging modalities help discern the etiology
In the current patient, maxillomandibular arch bars were of malocclusion for surgical repositioning and refixation.
placed. An intraoral circumvestibular maxillary incision was made • Infraorbital nerve paresthesia can be the result of nerve injury
to gain access to the fractured segments. After appropriate mobi- at the initial trauma, especially when fracture patterns extend
lization of the maxilla, the patient was placed in MMF. The max- through the infraorbital foramen, or from intraoperative trac-
illomandibular complex was guided passively, using the arc of tion or manipulation for adequate reduction. Nasal septal de-
rotation of the condyle, into proper anatomic reduction while the viation can result from improper repositioning of the nasal
patient was paralyzed to ensure that the condyles were appropri- septum onto the nasal crest of the maxilla, undiagnosed nasal
ately positioned. (Failure to seat the condyles may result in post- septal injuries, or preoperative septal deformities. This can re-
operative anterior open bite.) The deviated septum was reduced sult in increased airway resistance, nasolacrimal obstruction,
onto the nasal crest of the maxilla and sutured to a hole drilled and aesthetic complaints by the patient.
through the anterior nasal spine. Subsequently, the maxilla was • Loss of vision can result from an unfavorable fracture pattern
stabilized with fixation at the piriform rim and zygomaticomaxil- of the maxilla or from the initial trauma, compounded by
lary buttress regions bilaterally (four plates). MMF was then re- surgical manipulation of the segment during repositioning.
leased, and the occlusion was found to be intact and reproducible. The orbital process of the palatine bone makes up a portion of
the bony orbit and has been hypothesized as a possible cause.
Complications (This is very rare for Le Fort I fractures but more common with
Le Fort III injuries.)
Complications of Le Fort I injuries are related to the severity of • Early postoperative infection can result from foreign bodies, ne-
the initial injury and to host-related factors but can be categorized crotic teeth, or bony segments but is also related to host factors
into intraoperative, early, and late complications. (malnutrition, immunocompromised state, chronic alcohol use).
Management should be directed at appropriate antibiotic selec-
Intraoperative tion, incision and drainage, and removal of any possible source.

• Bleeding can occur as a result of damage to any number of the Late

vessels in the vicinity, especially when significant disimpaction
or an osteotomy is required for reduction of the segment. Po- • Malocclusion, if not addressed early, typically presents with an
tential sources of bleeding include the anterior and posterior anterior open bite, posterior premature contacts, and an overall

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 CHAPTER 56 Le Fort I Fracture 277

Class III skeletal appearance. After union has developed, small The blood supply to the maxilla is from the descending pala-
discrepancies can be treated with orthodontics; larger ones need tine artery, which contributes to the greater and lesser palatine
to be addressed through orthognathic surgery. arteries and the terminal branch of the nasopalatine artery, and
• Late postoperative bleeding (especially with an intermittent from the anterior, middle, and posterior superior alveolar arteries.
pattern) should be taken seriously. Pseudoaneurysm formation Extensive research has been done with regard to the blood supply
should be high on the differential diagnosis list and can be of the fractured maxilla, mostly in association with orthognathic
evaluated by angiography. maxillary procedures. In experiments done by Bell and later by
• Epiphora (excessive tearing) can result from damage or obstruc- Bays and by Dodson and colleagues, it has been shown that the
tion of the nasolacrimal duct. (The nasolacrimal duct drains maxilla (along with its associated dentition and periodontium)
beneath the inferior turbinate 11–17 mm above the nasal floor maintains an adequate blood supply even after complete down-
and 11–14 mm posterior to the piriform aperture.) Epiphora fracture and ligation of the descending palatine artery. The max-
can be managed by a dacryocystorhinostomy procedure. illa remains pedicled to the palate, receiving contributions from
• Nonunion or fibrous union causes the maxilla to demonstrate the ascending pharyngeal artery (a branch of the external carotid
mobility, which can often be subtle. Management should be artery) and the ascending palatine artery (a branch of the facial
directed at refixation of the maxilla with rigid internal fixation, artery), which in turn anastomose with the greater and lesser
bone grafting, extraskeletal fixation, or MMF. palatine arteries.
Patients suspected of having maxillary fractures should be
Discussion evaluated according to the ATLS protocol. Because other bodily
injuries may be present, the initial evaluation and stabilization of
Maxillary fractures most frequently occur as a result of blunt the patient are best performed by a trauma team experienced in
trauma from assault, sporting injuries, and motor vehicle acci- the management of the multisystem trauma. Proper diagnosis
dents. They are frequently seen in conjunction with other facial should begin with a careful history and physical examination.
and systemic injuries. The Le Fort classification is frequently used The mechanism of injury should be considered. Symptoms
to describe midface fracture patterns. In 1901, Rene Le Fort pub- associated with a Le Fort I fracture may include facial pain, in-
lished the results of his experiments based on 35 cadavers whose fraorbital hypoesthesia, malocclusion, or epistaxis. Clinical signs
heads were subjected to different forms of force. Based on these suggestive of a Le Fort I fracture include facial edema, ecchymo-
findings, he concluded that the midface commonly fractures in sis, abrasions, lacerations, active epistaxis, palpable crepitus,
three predictable patterns. A Le Fort level I fracture involves the mobile maxilla, and step deformities. Intraoral examination
anterior and lateral walls of the maxillary sinus, lateral nasal walls, could identify fractured teeth, vestibular ecchymosis, mucosal
pterygoid plates, and nasal septum (see Fig. 56.3). It should be lacerations, palatal edema or ecchymosis (especially with frac-
noted that isolated Le Fort fractures are relatively uncommon and tures associated with midpalatal suture), and malocclusion (typi-
that fractures occur in a variety of combinations of Le Fort I, II, cally, an anterior open bite with posterior occlusal premature
or III types, with unilateral (hemi–Le Fort) and bilateral fractures. contacts secondary to the vector of impact and the pull of lateral
The “pure” Le Fort I fracture is typically bilateral and is composed and medial pterygoid muscles).
of the maxilla with associated alveolar bone and part of the pala-
tine bone posteriorly. Unilateral fractures are seen with an addi- ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
tional fracture between the midpalatal suture. complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 277.e1

Bibliography Ellis E III: Passive repositioning of maxillary fractures, J Oral Maxillofac

Surg 62:1477-1485, 2004.
Gruss JS, Mackinson SE: Complex maxillary fractures: role of buttress
Bagheri SC, Dierks EJ, Kademani D, et al: Application of a Facial Injury reconstruction and immediate bone grafts, Plast Reconstr Surg 78:9,
Severity Scale in craniomaxillofacial trauma, J Oral Maxillofac Surg 1986.
64:404-414, 2006. Gruss JS, Philips JH: Complex facial trauma: the evolving role of rigid
Bagheri SC, Dierks EJ, Kademani D, et al: Comparison of the severity of fixation and immediate bone graft reconstruction, Clin Plast Surg
bilateral Le Fort injuries in isolated midface trauma, J Oral Maxillofac 16:93-104, 1989.
Surg 63:1123-1129, 2005. Haug RH, Adams JM, Jordan RB: Comparison of the morbidity with
Bays RA, Reinkingh MR, Maron G: Descending palatine artery ligation maxillary fractures treated by maxillomandibular and rigid internal
in Le Fort osteotomies, J Oral Maxillofac Surg 51(Suppl):142, 1993. fixation, Oral Surg 80:629, 1995.
Bays RA: Complications of orthognathic surgery. In Kaban LB, Pogrel Iida S, Kogo M, Sugiura T, et al: Retrospective analysis of 1502 patients
MA, Perrott DH, et al. (eds): Complications in Oral and Maxillofacial with facial fractures, Int J Oral Maxillofac Surg 30:286-290, 2001.
Surgery, Philadelphia, 1997, Saunders, pp 193-221. Morris CD, Tiwana PS: Diagnosis and treatment of midface fractures. In
Bell WH, Fonseca RJ, Kennedy JW, et al: Bone healing and revasculariza- Fonseca RJ (ed): Oral and Maxillofacial Trauma, ed 4, St. Louis, 2013,
tion after total maxillary osteotomy, J Oral Surg 33:253, 1975. Saunders, pp 416-450.
Bell WH, Levy BM: Revascularization and bone healing after posterior Perciaccante VJ, Bays RA: Maxillary orthognathic surgery. In Miloro M,
maxillary osteotomy, J Oral Surg 29:313, 1971. Ghali GE, Larsen PE, et al. (eds): Peterson’s Principles of Oral and
Bell WH: Revascularization and bone healing after anterior maxillary Maxillofacial Surgery, ed 2, Hamilton, Ontario, 2004, BC Decker, pp
osteotomy, J Oral Surg 27:249, 1969. 1179-1204.
Cunningham LL Jr, Haug RH: Management of maxillary fractures. In Plaiser BR, Punjabi AP, Super DM, et al: The relationship between facial
Miloro M, Ghali GE, Larsen PE, et al. (eds): Peterson’s Principles of fractures and death from neurologic injury, J Oral Maxillofac Surg
Oral and Maxillofacial Surgery, ed 2, Hamilton, Ontario, 2004, BC 58:708-712, 2000.
Decker, pp 435-443. Top H, Aygit C, Sarikay A, et al: Evaluation of maxillary sinus after treat-
Dodson TB, Bays RA, Biederman GA: In-vivo measurement of gingival ment of midfacial fractures, J Oral Maxillofac Surg 62:1229-1236,
blood flow following Le Fort I osteotomy, J Dent Res 71:603, 1992. 2004.
Dodson TB, Bays RA, Neuenshwander MC: Maxillary perfusion during Vaughan ED, Obeid G, Banks P: The irreducible middle third fracture:
Le Fort I osteotomy after ligation of the descending palatine artery, a problem in management, Br J Oral Surg 21:124, 1983.
J Oral Maxillofac Surg 55:51-55, 1997. You ZH, Bell WH, Finn RA: Location of the nasolacrimal canal in rela-
Dodson TB, Neuenschwander MC, Bays RA: Intraoperative assessment tion to the high Le Fort I osteotomy, J Oral Maxillofac Surg 50:1075-
of maxillary perfusion during Le Fort I osteotomy, J Oral Maxillofac 1080, 1992.
Surg 54:827, 1994.
Dodson TB, Neuenschwander MC, Bays RA: Intraoperative measure-
ment of maxillary gingival blood flow during Le Fort I osteotomy,
J Oral Maxillofacial Surg 51(Suppl 3):138, 1993.

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57
Le Fort II and III Fractures
JU S T I N E M O E a n d M A RT I N B. S TE E D

CC unstable midfacial fractures because of altered anatomy, soft tissue

edema, expanding hematoma, and hemorrhage from the nasophar-
A 41-year-old male is transported to the emergency department (ED) ynx. An emergency surgical airway, including cricothyroidotomy,
by emergency medical services (EMS) personnel status after a motor may be necessary if intubation fails.)
vehicle accident (the most common etiology of Le Fort II and III in- Breathing and oxygenation. An oral endotracheal tube is in
juries). You are called to the trauma bay to evaluate his facial injuries. place, with mechanical ventilation on Fio2 of 100%. The patient
has bilateral chest rise, clear breath sounds bilaterally, and an oxy-
HPI gen saturation of 99%. Respirations are spontaneous and regular
at 12 breaths per minute.
The patient was an unrestrained driver (higher risk for more severe Circulation and hemorrhage control. Blood pressure is
facial injuries) involved in a high-speed, head-on collision with 107/90 mm Hg, and heart rate is 115 bpm. Peripheral pulses are
another vehicle. There was no rollover or ejection (lower risk of regular and thready. Extremities are pale and mildly diaphoretic,
cervical, thoracic, and lumbar spine injury), but significant dam- with delayed capillary refill. (Class II hypovolemic shock occurs
age was done to the front side of the car, with 6-inch intrusion with 15%–30% blood volume loss and is characterized by normal
and a steering wheel deformity (evidence of significant energy mean arterial blood pressure, increased diastolic blood pressure,
transfer to the head and neck). Upon arrival of EMS personnel, decreased pulse pressure, tachycardia, decreased urine output
the patient was hunched over the steering wheel; he had a [20–30 mL/hr], peripheral vasoconstriction, and anxiety.) Slow,
Glasgow Coma Scale (GCS) score of 13. active hemorrhage is observed in the nasopharynx with blood
Fifteen minutes later, at the ED (rapid transport time has re- pooling in the oral cavity. (Uncontrolled nasal bleeding can be a
duced prehospital morbidity), the repeat GCS score was 11 (mod- source of significant blood loss and commonly arises from Wood-
erate head injury), vital signs were consistent with mild volume ruff’s plexus posteriorly or Kiesselbach’s plexus anteriorly.) For
loss (tachycardia and hypotension), and there was active bleeding posterior nasal packing, a Foley catheter (a nasal balloon catheter
from both nares. The patient could not recall events surrounding or cuffed endotracheal tube may also be used) is inserted into the
the accident and admitted to loss of consciousness for an un- nares and passed beyond the nasopharynx; the balloons are in-
known period after striking the steering wheel with his face (in- flated, and the catheter or tube is advanced until the balloons oc-
dicative of intracranial injury, which can occur with up to 50% of clude the posterior nasal aperture. Anteriorly, Merocel packing
midfacial fractures). Deteriorating mental status and uncontrolled (Medtronic) is coated with bacitracin, inserted along the floor of
nasopharyngeal hemorrhage necessitated a definitive airway, so the nasal cavity, and expanded with a saline solution. (Many other
the patient was orally intubated in the ED. (Approximately 40% forms of nasal packing are available, including ribbon gauze,
of patients with Le Fort III injuries require advanced airway inter- sponges [Rhino Rocket, Shippert Medical Technologies Corp.],
ventions.) A cervical collar was placed for in-line cervical spine biodegradable foam [NasoPore, Polyganics], and balloon catheters
stabilization. (The reported incidence of cervical spine fracture in [Rapid Rhino, ArthroCare]). The anteroposterior nasal packs ef-
patients with maxillofacial injuries is 2%.) fectively control the acute hemorrhage. The patient responds well
to a 2-L bolus of lactated Ringer’s solution. The control of hemor-
rhage and adequacy of fluid resuscitation are frequently reassessed.
PMHX/PDHX/Medications/Allergies/SH/FH Disability and dysfunction. On the AVPU (A, awake; V, re-
The patient’s histories are unknown. (When possible, information sponds to voice; P, responds to pain; U, unresponsive) scale, the
may be obtained from family members.) patient is responsive to pain. His GCS score is E2 1 M5 1 V1T
5 8T. The right pupil is 4 mm and reactive, and the left pupil is
8 mm and nonreactive. (A fixed, dilated pupil may be a sign of
Examination increased intracranial pressure [ICP] or globe injury.) There are no
lateralizing signs.
Advanced Trauma Life Support Primary Survey Exposure and environmental control. The patient’s clothing
Airway and cervical spine control. The patient is orally intubated is removed, and a warm blanket or other warming devices are used
with a transport cervical collar in place. (Intubation is difficult with to prevent hypothermia.

278
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 CHAPTER 57 Le Fort II and III Fractures 279

Advanced Trauma Life Support Secondary Intraoral. Occlusion is difficult to assess secondary to orotra-
Survey cheal intubation. Ecchymosis is present along the posterior soft
palate bilaterally (Guerin’s sign, indicative of pterygoid plate dis-
History. The AMPLE history (allergy, medications, past medical junction or fracture). The mandible is stable, without any signs of
history, last meal, events leading to presentation) is taken from fracture (e.g., ecchymosis, step deformity, bony crepitus, mobility,
available sources. or deviation). The dentition is in good repair.
General. The patient is a well-developed and well-nourished
male who is intubated and sedated. He has a GCS score of 8T. A Imaging
transport cervical collar is in place.
Neurologic. Sequential neurologic examination is more chal- For trauma patients, the protocol for plain film radiographs in-
lenging in an intubated patient than in a conscious patient. Seda- cludes cervical spine, anteroposterior chest, and anteroposterior
tion should be discontinued for an accurate assessment of mental pelvis radiographs. Other studies are completed if indicated, in-
status. The use of propofol as the sedative drug allows for rapid cluding a cervical spine series (suspected cervical spine injury),
emergence and facilitates hourly neurologic evaluations. AVPU thoracic and lumbar spine series (motor vehicle accident with
and GCS scores, pupil size and responsiveness, and motor ejection or rollover or in symptomatic patients), and extremity
strength and responsiveness are assessed. (Weakness, hyporeflexia radiographs (suspected fracture or dislocation).
or hyperreflexia, and posturing can be indicative of intracranial or To evaluate midfacial fractures, noncontrast, axial cut CT with
spinal derangement.) cuts of 1 mm or less is the gold standard imaging modality. Direct
In an intubated patient, a high index of suspicion for intracra- coronal CT should be avoided in patients with suspected cervical
nial hemorrhage and edema should be maintained. Any acute de- spine injury because it requires hyperextended head positioning.
terioration in neurologic status warrants a STAT head computed In the current patient, a maxillofacial CT scan reveals fracture
tomography (CT) scan. An ICP monitoring device is indicated lines extending from the nasofrontal suture through the medial
in cases involving an initial low-yield neurologic examination wall of the orbit. On the right side, the fracture extends through
(unconscious and unresponsive), deep sedation, paralysis, or severe the superior orbital fissure, lateral orbital wall along the zygomati-
head injury with evidence of elevated ICP. cofrontal (ZF) suture, and along the zygomaticosphenoid suture.
Eyes. There is significant bilateral periorbital ecchymosis (rac- There is a fracture of the right zygomatic arch near the zygomati-
coon eyes are indicative of anterior basilar skull fracture) and peri- cotemporal (ZT) suture. On the left side, a pyramidal fracture
orbital edema, with OS (left) greater than OD (right). There is extends from the nasofrontal suture along the orbital floor, inferior
chemosis (conjunctival edema) and subconjunctival hemorrhage orbital rim, and anterior and lateral maxillary walls. Sagittal and
bilaterally. The OD pupil is round, reactive, and sluggish (4 to coronal views demonstrate a minimally displaced, left orbital floor
2 mm). The OS pupil is large, irregular (the apex of a tear-shaped defect. There is separation of the pterygomaxillary junction bilater-
pupil points toward the site of rupture), and nonreactive. The globe ally (pterygoid plates). (This is a classic description of a pure right
is flaccid (indicating possible ruptured globe) with a grade II hy- Le Fort III and a pure left Le Fort II fracture pattern.)
phema (blood in the anterior chamber of the eye). No orbital pres- The anterior maxilla is grossly comminuted bilaterally. (Le Fort
sure measurements are obtained. Visual acuity cannot be assessed. fractures most commonly present in combination with other fa-
Maxillofacial. Examination shows significant facial edema cial fractures.) There are air-fluid levels in the bilateral maxillary
and ecchymosis. Step deformities are palpated at the right lateral sinuses (consistent with blood in the sinuses). A moderate amount
orbital rim, the left infraorbital rim, and at the nasofrontal junc- of soft tissue edema and emphysema are also noted. A three-di-
tion. The intercanthal distance is 32 mm, with a negative bow- mensional reconstruction provides the most graphic representa-
string test. (A normal intercanthal distance is 30–34 mm and tion of the fractures, degree of displacement, and orientation of
varies by race and gender [increased for those of African and fragments.
Asian descent and for males].) There is no vertical or horizontal Because of the patient’s decrease in mental status (risk of intra-
dystopia (disturbance in globe position). There is mild left en- cranial injury), an initial head CT scan was obtained. It demon-
ophthalmos (loss of anteroposterior projection of the globe; strated bilateral frontal lobe contusions, with no evidence of skull
however, enophthalmos and dystopia are difficult to assess in the fracture, epidural or subdural hematoma, or increased ICP. A re-
presence of significant edema). Bimanual palpation yields gross peat head CT scan after 24 hours showed no evolution of the
mobility of the maxilla with associated mobility and crepitus at intracranial injury. (An initially negative head CT scan may also
the nasofrontal junction, left lateral orbital rim, and right infra- require a repeat scan at 12–24 hours because closed head injuries
orbital rim (indicative of maxillary or midfacial disjunction at may produce CT findings only after 24 hours.)
the Le Fort II and III levels).
On otoscopic examination, tympanic membranes are clear and Labs
intact, and there is no evidence of cerebrospinal fluid (CSF) otor-
rhea. There is no Battle’s sign (ecchymosis in the mastoid region, Standard laboratory tests for the evaluation of multisystem trauma
indicative of posterior basilar skull fracture). An 8-cm laceration patients included a complete blood count, complete metabolic
of the lower face involving the full thickness of the lip and mul- panel, arterial blood gas, urinalysis, and coagulation studies (pro-
tiple other abrasions are present. Hypoesthesia along the infraor- thrombin time, partial thromboplastin time, and international
bital nerve distribution is present bilaterally (commonly seen after normalized ratio). A urine drug screen and blood alcohol level are
fractures of the anterior maxillary wall, inferior orbital rim, and indicated in patients with decreased mental status.
orbital floor). The current patient demonstrates decreased hemoglobin
Intranasal. There is bright red blood in the bilateral nasal cavi- (11.2 g/dL) and hematocrit (32.6%) (true and relative anemia
ties. The nasal septum is deviated to the right, with no evidence of secondary to hypovolemia and hemodilution from fluid resuscita-
a septal hematoma. There is no evidence of CSF rhinorrhea. tion). Arterial blood gas analysis shows a mild base deficit of

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280 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

23.5. (Base deficit is a reliable indicator of adequacy of resuscita-

tion and mortality in trauma patients and is a better marker of
blood loss than are the hemoglobin and hematocrit.) There is also
a mild elevation in blood urea nitrogen (BUN) and creatinine
(Cr), with a BUN:Cr ratio of 15 (prerenal azotemia secondary to
hypovolemia) and a positive blood alcohol level (common in
trauma patients). The remainder of the patient’s laboratory values
are within normal limits.

Assessment
Comminuted midfacial fractures consistent with a right Le Fort III
and left Le Fort II pattern, with a concomitant left orbital floor frac-
ture and displaced nasal septal fracture, complicated by significant
nasopharyngeal hemorrhage, bilateral frontal lobe contusions, rup-
tured left globe, and laceration of the lower face and lip. Facial Injury
Severity Scale score is 6.

Treatment
A variety of treatment modalities have been advocated for the
treatment of Le Fort II and III fractures. Techniques are generally
categorized as open or closed reduction or a combination of the • Fig. 57.1 Patient with a Le Fort III fracture with multiple nasal and oral
two. Commonly, Le Fort fractures are sustained at more than one packing used to control posterior nasal and pharyngeal hemorrhage. The
level, and all combinations of Le Fort I, II, and III fractures are airway has been secured with a tracheostomy.
possible. Moreover, Le Fort fractures are usually comminuted and
occur in conjunction with other facial fractures, including naso-
orbito-ethmoid, orbital floor or rim, and zygomaticomaxillary For Le Fort II fractures, the inferior orbital rim and floor may
(ZM) complex fractures. As such, these fractures should be con- be accessed by various transcutaneous (lower lid, subtarsal, sub-
sidered by their individual components when developing a treat- ciliary) or transconjunctival (with or without lateral canthotomy)
ment plan. Medical comorbidities, associated systemic trauma, incisions. A transmucosal incision in the maxillary vestibule pro-
airway status, hemorrhage, and available resources further dictate vides access to the ZM buttress and inferior orbital rim for align-
the course of treatment in each case. ment and fixation. Existing lacerations may also be extended and
Intraoperative and perioperative airway management should used for access.
allow for safe anesthetic administration, optimal surgical care, It should be noted that it is not always necessary to visualize all
and decreased morbidity. Nasoendotracheal intubation facili- components of Le Fort II and III fractures. Isolated Le Fort II
tates intraoperative maxillomandibular fixation (MMF) and is fractures may sometimes be reduced with disimpaction forceps
considered if extubation is expected on completion of the pro- and MMF for 4 weeks, although they usually require open reduc-
cedure. Care must be taken in placing nasoendotracheal tubes in tion and internal fixation. Reduction should be achieved at the
patients with midfacial fractures that may have basilar skull nasofrontal region, inferior orbital rim, and ZM buttress in Le
components because there have been isolated reports of intracra- Fort II fractures and at the nasofrontal region, lateral orbital rim
nial placement of the endotracheal tube. However, there is insuf- (ZF suture area), and zygomatic arch (ZT suture area) in Le Fort
ficient evidence to exclude this technique in the hands of skilled III fractures. A key and often challenging step in the surgical cor-
personnel. Nasotracheal intubation may interfere with nasal rection of Le Fort fractures is disimpaction of the maxillofacial
septal correction. unit to allow passive positioning of the segment. This can be
Oral intubation is considered if the endotracheal tube may achieved by different techniques, such as using a Rowe disimpac-
pass through an edentulous space, to allow for MMF, or for sub- tion forceps or a wire passed through the anterior nasal spine.
mental intubation, in which the endotracheal tube is passed If disimpaction cannot be achieved with these techniques, a Le
through the anterior floor of the mouth and through a submental Fort I osteotomy can be made unilaterally or bilaterally to mobilize
transcutaneous incision. Early tracheostomy is considered for se- and reduce the maxilla and dentate segment. Osteotomy should be
vere midfacial fractures in which intubation is difficult and if considered only for noncomminuted maxillary fractures in which
prolonged postoperative intubation is expected (Fig. 57.1). rigid fixation with adequate bone buttressing is possible.
Multiple surgical approaches are possible to access Le Fort II Internal rigid fixation with miniplate systems is the current
and III fractures. For Le Fort III fractures, the coronal incision standard of care for Le Fort fractures. Comminuted Le Fort pat-
provides complete access to the nasofrontal region, lateral orbital terns often require fixation of the fragmented segments in a “sta-
rim, and zygomatic arch for reduction and fixation. A coronal ble to unstable” fashion. In particular, LeFort III fractures usually
incision provides optimal visualization, which is essential for com- present as a component of panfacial fractures rather than as iso-
minuted Le Fort III fractures. Releasing incisions in the coronal lated fractures. Several sequencing methods have been advocated
flap may be made to avoid intracranial monitoring devices, such for panfacial fracture management, including “bottom up” and
as a Camino bolt or an external ventriculostomy drain. Lateral “outside in.”
brow and upper blepharoplasty (supratarsal fold) incisions allow The location, amount, and size of rigid fixation also vary
access to the lateral orbital rim but not to the zygomatic arch. among surgeons and depend on the severity of displacement.

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 CHAPTER 57 Le Fort II and III Fractures 281

Severe comminution or avulsed bony segments at the anterior essential to determine the anterior or posterior origin. If ade-
and lateral maxillary walls may complicate reduction at the ZM quate control is not achieved by local means, exploration in the
buttress; infrequently, immediate or secondary bone grafting operating room or angiographic evaluation with interventional
may be indicated. In addition, Le Fort fractures complicated by radiology may be necessary.
a palatal fracture may benefit from the use of surgical splints to • Malocclusion can result from poor intraoperative maxillary reduc-
achieve an optimal postoperative occlusion. tion, early hardware failure, or undiagnosed mandibular or maxil-
It is not always necessary to fixate all reduced components of lary segmental fractures. Thorough examination and appropriate
Le Fort II and III fractures for proper alignment of the segments. imaging modalities help discern the etiology of the malocclusion.
For example, adequate fixation at the bilateral ZM or orbital rim Surgical repositioning and refixation should be considered.
areas may alleviate the need for fixation at the nasofrontal suture, • Nasal septal deviation can result from improper repositioning
thereby avoiding a coronal or other unsightly incision. If the of the nasal septum onto the septal crest of the maxilla, undi-
nasofrontal segment is unstable despite fixation at these areas, agnosed nasal septal injuries, or preoperative septal deformi-
exposure of the nasofrontal area may then be necessary using a ties. By definition, the nasal septum is fractured in Le Fort II
variety of approaches (coronal, upper blepharoplasty, Lynch, or injuries; thus, special care must be taken to identify and reduce
open sky incisions). deviations.
A stable mandible and intact dentition greatly facilitate the • Loss of vision is rarely reported as a direct or an indirect optic
treatment of midfacial fractures involving the dentate segment, nerve injury. Insult may result from bony compression, lacera-
particularly in the absence of direct visualization of fracture seg- tion, hematoma, or edema of the optic nerve and sheath after the
ments. After the maxillary segment has been mobilized, the patient initial trauma or after surgical manipulation of bony segments.
is placed in MMF, and the intact mandibular arc of rotation is used Ideal management is controversial and may include conservative
to determine the correct reduction of facial and cranial units. In treatment with steroids or surgical decompression. Other orbital
the presence of a fractured mandible, treatment of midfacial frac- injuries include iatrogenic corneal or penetrating injuries.
tures is dictated by anatomic reduction at stable segments. • Local wound infection can result from retained foreign bodies,
necrotic teeth, or avulsed bony segments and may be related to
Complications host factors. Management should be directed at appropriate
antibiotic selection; incision and drainage; and, when possible,
Complications of Le Fort II and III injuries are related to the se- removal of the source.
verity of the initial injury and host-related factors; they can be
categorized as intraoperative, early, and late complications. Late
Intraoperative • Malunion causes malocclusion, facial asymmetry, enophthal-
mos, and ocular dystopia. Malocclusion, if not addressed early,
• Bleeding can occur as a result of damage to any number of the typically presents with midfacial retrusion, decreased midfacial
vessels, particularly when significant disimpaction or an oste- height, anterior open bite, and mandibular overclosure. Sec-
otomy is required for reduction of the midfacial segment. Po- ondary repair is difficult; small discrepancies may be treated
tential sources of arterial bleeding include the anterior and with orthodontics, whereas larger deformities require orthog-
posterior superior alveolar, sphenopalatine, descending pala- nathic surgery.
tine, and internal maxillary arteries. Injury to the pterygoid • Nonunion or fibrous union causes the maxilla to demonstrate
venous plexus presents as a steady flow of dark blood. In most mobility, which may be subtle. Management should be di-
cases, packing, cauterization, and ligation are sufficient for rected at reduction and refixation with rigid internal fixation,
achieving hemostasis. If hemorrhage cannot be controlled lo- with or without MMF.
cally, external carotid artery ligation or transcatheter arterial • Late postoperative bleeding (especially with an intermittent
embolization should be strongly considered. pattern) is often serious and may suggest pseudoaneurysm
• Maxillary hypoperfusion is uncommon but may occur in com- formation. Future rupture of a false aneurysm presents as mas-
minuted maxillary fractures or with impingement of the pala- sive hemorrhage. A high index of suspicion should be main-
tal mucosa by surgical splints. Early reduction and stabilization tained, and angiography should be considered for evaluation.
with rigid internal fixation may help improve the outcome. • Epiphora (excessive tearing) can result from ectropion or from
Postoperative use of hyperbaric oxygen has been suggested, but nasolacrimal duct injury. (The duct drains beneath the inferior
its benefits remain unclear. Prefabricated occlusal splints turbinate, 11–17 mm above the nasal floor and 11–14 mm
should be checked to avoid impingement on the soft tissues of posterior to the piriform aperture.) Ectropion is managed by
the palate. an eyelid-tightening procedure; lacrimal injury requires lacri-
• Improper reduction and malpositioning of the maxilla can oc- mal stents or a dacryocystorhinostomy procedure.
cur when the bony interferences are not appropriately evalu- • Unrecognized CSF leakage is most commonly caused by frac-
ated and the maxillomandibular complex is not seated pas- tures through the cribriform or fovea ethmoidalis. Meningitis,
sively with the condyles in correct position. This results in a cerebral abscess, and epidural empyema have been reported up
postoperative anterior open bite. Infrequently, osteotomies are to several years after injury.
required to completely disimpact and reduce the midface. • Other complications include cosmetic deformity, unsightly
scars, hair loss (secondary to coronal incision), facial nerve
Early palsy (injury to temporal branch of facial nerve secondary to
coronal incision), and trigeminal nerve injury (hypoesthesia,
• Postoperative nasal bleeding can usually be controlled locally dysesthesia, or anesthesia of V1 secondary to coronal incisions
with nasal packs. A nasal speculum and a good light source are or V2 secondary to Le Fort II injury and treatment).

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282 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

Discussion unilateral, comminuted, and found in combination with other

Le Fort fractures and other facial fractures.
The Le Fort classification system was originally described by Initial management of patients with suspected maxillofacial
Rene Le Fort in a 1901 human cadaver study. It continues to be fractures should follow Advanced Trauma Life Support protocol.
used today to identify classic fracture patterns along three weak Airway management in patients sustaining Le Fort II or III inju-
lines in the facial bony structure (Fig. 57.2). The Le Fort II ries is paramount because altered mental status, changes in anat-
fracture results from blunt trauma at the level of the infraorbital omy, airway edema, and active hemorrhage can compromise a
rim and nasofrontal junction. It is a pyramidal fracture in which patient’s airway patency. The incidence of uncontrolled hemor-
the central midface and maxilla are mobilized independently rhage is greater in Le Fort II and III fractures than in all facial
from the facial skeleton and cranial base. The Le Fort III fracture injuries (incidences of 5.5% vs. 1.2% are reported by Bynoe and
results from blunt trauma at the level of the nasofrontal junction colleagues), and establishment of an emergent airway is often
and upper lateral orbital rims. It is termed craniofacial disjunc- necessary. Clinicians treating patients with midfacial trauma
tion because it causes disarticulation of the facial skeleton from should be prepared to establish a surgical airway both acutely and
the cranial base. in more controlled settings.
Knowledge of these fracture lines has been paramount in de- Ideally, surgical management of midfacial fractures should be
veloping reconstructive strategies in trauma, craniofacial, and completed as soon as the patient’s status allows. The goals of treat-
orthognathic surgery. In clinical practice, however, Le Fort II and ment include reestablishing premorbid occlusion and facial width,
III fractures rarely follow ideal fracture patterns and are often projection, and height. Early reconstruction allows for better resto-
ration of the preinjury appearance, as determined by the relation-
ship of bone and soft tissue. Delayed reconstruction at 7 to 14 days
after injury results in a second insult to the contused soft tissue and
may increase subcutaneous fibrosis, rigidity, and hyperpigmenta-
tion. The introduction of rigid miniplate fixation has obviated the
need for external fixation and interfragment wiring and has allowed
for greater flexibility in the sequence of repair. In general, the man-
agement of Le Fort fractures follows the principles of wide exposure
and direct viewing of fracture segments, the use of vertical and
Le Fort III horizontal buttresses of the face for alignment and fixation, and
level
immediate bone grafting to reconstruct comminuted or avulsed
bony structures.

Le Fort II
,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
level complete set of bibliography.

Acknowledgments
Le Fort I
level The authors and publisher wish to acknowledge Dr. Chris Jo and
Dr. Shahrokh C. Bagheri for their contributions on these topics
• Fig. 57.2 Fracture levels for Le Fort I, II, and III fractures. in the previous editions.

t.me/Dr_Mouayyad_AlbtousH
 282.e1

Bibliography Kelly KJ, Manson PN, Vander Kolk CA, et al: Sequencing Le Fort frac-
ture treatment: organization of treatment for a panfacial fracture,
J Craniofac Surg 1(4):168-178, 1990.
Bagheri SC, Dierks EJ, Kademani D, et al: Application of a Facial Injury Khanna S, Dagum AB: A critical review of the literature and an evidence-
Severity Scale (FISS) in cranio-maxillofacial trauma, J Oral Maxillofac based approach for life-threatening hemorrhage in maxillofacial sur-
Surg 64:408-414, 2006. gery, Ann Plast Surg 69(4):474-478, 2012.
Bagheri SC, Dierks EJ, Kademani D, et al: Comparison of the severity of Kreiner B, Stevens MR, Bankston S, et al: Management of panfacial
bilateral Le Fort injuries in isolated midface trauma, J Oral Maxillofac fractures, Oral Maxillofac Surg Knowl Update 3:63-81, 2001.
Surg 63:1123-1129, 2005. Le Fort R: Experimental study of fractures of the upper jaw. I, II, and II,
Bähr W, Stoll P: Nasal intubation in the presence of frontobasal fractures: Rev Chir De Paris 23:208-227, 360-379, 479-507, 1901; translated
a retrospective study, J Oral Maxillofac Surg 50:445-447, 1992. by Tessier P: Plast Reconstr Surg 50:497-506, 600-607, 1972.
Bell RB, Dierks EJ, Homer L, et al: Management of cerebrospinal fluid Manson PN, Clark N, Robertson B, et al: Comprehensive management
leak associated with craniomaxillofacial trauma, J Oral Maxillofac Surg of pan-facial fractures, J Craniomaxillofac Trauma 1(1):43-56, 1995.
62(6):676-684, 2004. Manson PN, Hoopes JE, Su CT: Structural pillars of the facial skeleton:
Bynoe RP, Kerwin AJ, Parker HH III, et al: Maxillofacial injuries and an approach to the management of Le Fort fractures, Plast Reconstr
life-threatening hemorrhage: treatment with transcatheter arterial Surg 66:53-61, 1980.
embolization, J Trauma 55(1):74-79, 2003. Marlow TJ, Goltra DD, Schabel SI: Intracranial placement of a nasotra-
Girotto JA, Gamble WB, Robertson B, et al: Blindness after reduction of cheal tube after facial fracture: a rare complication, J Emerg Med
facial fractures, Plast Reconstr Surg 102(6):1821-1834, 1998. 15:187-191, 1997.
Haug RH, Savage JD, Likavek MJ, et al: A review of 100 closed head Ng M, Saadat D, Sinha UK: Managing the emergency airway in Le Fort
injuries associated with facial fractures, J Oral Maxillofac Surg 50:218, fractures, J Craniomaxillofac Trauma 4:38, 1998.
1992. Roccia F, Cassarino E, Boccaletti R, et al: Cervical spine fractures associ-
Haug RH, Wible RT, Likavek MJ, et al: Cervical spine fractures and ated with maxillofacial trauma: an 11-year review, J Craniofac Surg
maxillofacial trauma, J Oral Maxillofac Surg 49:725, 1991. 18(6):1259-1263, 2007.
Horellou MF, Mathe D, Feisse P: A hazard of naso-tracheal intubation,
Anaesthesia 33:73-74, 1978.
Imola MJ, Ducic Y, Adelson RT: The secondary correction of post-trau-
matic craniofacial deformities, Otolaryngol Head Neck Surg 139(5):
654-660, 2008.

t.me/Dr_Mouayyad_AlbtousH
58
Orbital Trauma: Fracture of the Orbital
Floor
M A RT I N B. S TE E D, R O B E R T S . AT T I A , a n d S H A H R O K H C . B AG H ER I

CC Vital signs. Blood pressure is 135/84 mm Hg, heart rate is

108 bpm (tachycardia), respirations are 16 breaths per minute,
A 36-year-old male is seen in the emergency department after an and temperature is 37.6°C.
assault. He explains that he was “jumped, robbed, beaten, and Maxillofacial. There is moderate left midface edema with left
punched in the left eye.” You are asked to evaluate the patient for V2 hypoesthesia. There is no loss of malar projection (seen with
maxillofacial injuries. displaced ZMC fractures). The intercanthal distance is main-
tained at 32 mm with a negative bowstring test result. (A positive
HPI bowstring test result is seen with naso-orbito-ethmoid [NOE]
fractures.)
The patient was returning from work when he was assaulted. He Eyes. Examination of the left eye reveals subconjunctival hem-
received a right-handed blow with a fist to the left upper face (a orrhage (ruptured blood vessel that leaks into the space between
common pattern of injury). He reports no loss of consciousness the conjunctiva and sclera), chemosis (inflammation and edema
but has difficulty seeing out of his left eye, and his cheek is numb of the conjunctiva), and mild periorbital edema (Fig. 58.1).
(hypoesthesia of the V2 cutaneous distribution is suggestive of an Vision, pupil, and pressure are the “vital signs” of the eye. After
orbital floor, zygomaticomaxillary complex [ZMC], or isolated a thorough medical history and adnexal examination, it is impor-
anterior maxillary wall fracture). tant to check these measurements before dilating the eye. (Vital
signs may change with dilation.) The vision assessment that is
PMHX/PDHX/Medications/Allergies/SH/FH most important is the “best corrected vision.”
The current patient’s visual acuity was 20/20 in the right eye
Noncontributory. The patient has no previous history of maxil- and 20/40 in the left eye, determined using a 14-inch near card.
lofacial trauma. The pupils were equal, round, and reactive to light (5 mm to
Patients with a previous history of orbital floor reconstruction 3 mm) with accommodation. Assessment of direct and consensual
are at a higher risk of globe rupture with subsequent trauma to the visual reflexes revealed no abnormalities. (The “swinging flashlight
globe because the reconstructed orbital floor is less likely to frac- test” is based on the consensual light reflex and is the best method
ture. The energy delivered to the eye is absorbed by the globe (as for diagnosing a relative afferent pupillary defect [RAPD], also
opposed to being dispersed by fracture of the floor), causing more called a Marcus-Gunn pupil. Illumination of one eye that results in
devastating injuries (blindness). failure to constrict in the pupils of both eyes suggests an RAPD of

Examination
The initial evaluation of a trauma patient should follow the Ad-
vanced Trauma Life Support protocol.

Primary Survey
The patient’s primary survey is intact; he has a Glasgow Coma
Scale score of 15.

Secondary Survey
• Fig. 58.1 Preoperative view showing left subconjunctival hemorrhage
General. The patient is a well-developed and well-nourished male and an incidental finding, arcus senilis (a cloudy, opaque arc or circle
in no acute distress. around the edge of the eye, often seen in the eyes of older adults).

283
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284 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

the illuminated eye or a defect of the afferent visual pathway of the

illuminated eye.)
A tonometer pen revealed a globe tension pressure of
12 mm Hg. (Tonometry measures the intraocular pressure [IOP],
which, when high, may raise suspicion for a retrobulbar hemor-
rhage. An extremely low value is suggestive of globe rupture.
Normal IOP ranges from 11 to 20 mm Hg. Gentle digital palpa-
tion of the closed upper eyelid is a crude assessment of IOP; al-
though slight increases in IOP cannot be detected, a rock-hard
eye should raise concern about a marked increase in IOP.)
An additional useful test is the red color saturation test, which
is the most sensitive and best measure of optic nerve function. The
two eyes are evaluated separately. A red object is held in front of
the patient, who is asked whether the object seems to have the
same color (hue) and brightness (intensity) in each eye. If the
optic nerve has been damaged (e.g., by optic neuritis or increased
IOP), the red object appears duller and more brown or grayish to
A
the affected eye compared with the contralateral eye.
In the current patient, evaluation of the extraocular muscles of
the left eye revealed restriction of upward gaze (suggestive of infe-
rior rectus entrapment). There was no evidence of monocular dip-
lopia within 30 degrees of primary gaze. (Monocular diplopia
should be investigated for retinal detachment or lens dislocation.)
The patient reported binocular diplopia within 20 degrees of pri-
mary gaze. (This is commonly seen secondary to edema, neuromus-
cular paralysis, or extraocular muscle entrapment. To determine
what muscle groups and nerves are involved, the clinician should
determine what gaze directions improve and worsen the doubling.)
After administration of a topical mydriatic agent and fluorescein
dye to the eye, a slit-lamp examination was performed with a cobalt
blue light in an anterior-to-posterior sequence. This revealed no ab-
normalities of the bilateral adnexa (eyelids and lacrimal system) and
no corneal abrasions, opacities, or foreign bodies. There was no evi-
dence of blood within the anterior chamber (hyphema) and no evi- B
dence of injury to the iris (traumatic iridialysis) or lens (dislocation
or subluxation). (Traumatic iridodialysis occurs when the iris is torn • Fig. 58.2 A, Preoperative computed tomography (CT) scan (coronal cut,
bony window) showing a left orbital floor fracture. B, Preoperative CT scan
from its root. A red reflex can be seen through the tear. Surgical re-
(sagittal cut) showing a left orbital floor fracture with evidence of an intact
pair is indicated only if decreased visual acuity or diplopia persists. orbital rim.
The use of mydriatic agents to dilate the pupil of the eye is relatively
contraindicated in patients who have sustained head injuries because
of the need for multiple-interval neurologic examinations.)
Fundoscopic examination of the posterior segment (vitreous, and secondary surveys were completed. Coronal views (best view
retina, and optic nerve) revealed no vitreous or retinal hemorrhage. of the internal orbit) reveal a fracture of the left orbital floor with
There were no apparent tears or foreign bodies. A forced duction complete opacification of the maxillary sinus (Fig. 58.2A). Sagittal
test was performed after administration of a topical anesthetic and views showed the location of the fracture in an anterior-posterior
revealed true incarceration of infraorbital contents. (For this test, dimension (Fig. 58.2B). (Three-dimensional reconstruction views
one or two fine forceps are used to carefully move the eye in the add little information for the preoperative planning of orbital floor
directions of gaze while feeling for mechanical restriction. Further fractures, except for teaching purposes.)
measurements of globe position include those based on the
surrounding bone [e.g., Hertel exophthalmometer using the zygo- Labs
maticofrontal region or Naugel exophthalmometer using the fron-
tal bone]. If these bony landmarks are displaced or significant soft For the management of isolated orbital floor injuries, no routine
tissue edema is present, reliable readings are difficult to obtain.) laboratory testing is indicated unless dictated by the medical his-
The remainder of the current patient’s maxillofacial examina- tory. When evaluated as part of the treatment of a multisystem
tion revealed hypoesthesia of the left V2 distribution. No palpable trauma patient, routine laboratory tests include a complete blood
bony step deformities of the left orbital rim were noted. count, complete metabolic panel, liver function tests, and coagu-
lation studies.
Imaging
Assessment
Computed tomography (CT) is the gold standard for assessing the
status of the bony orbit. For the current patient, a facial helical CT Isolated fracture of the left orbital floor with entrapment of the infe-
scan (1-mm cuts) without contrast was obtained after the primary rior rectus muscle; Facial Injury Severity Scale score of 1.

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 CHAPTER 58 Orbital Trauma: Fracture of the Orbital Floor 285

Treatment Complications
A much-disputed topic is which orbital floor fractures require Orbital floor fractures may be seen in isolation or in association
treatment. Surgical intervention may be required in two clinical with other facial injuries. Complications can be related to the
situations: globe malposition and diplopia. Several factors can be impact or the initial injury, concomitant injuries, the surgical re-
helpful in determining whether a pure blowout fracture requires pair, or a combination of these elements and can be categorized as
internal orbital surgery; these factors can be broken down into early or late complications.
absolute indications, relative indications, and contraindications to
immediate repair. Early
Absolute Indications • Corneal abrasion. Clinical suspicion should be raised by a
patient’s complaint of ocular pain, photophobia, and a foreign
• Globe malposition with acute enophthalmos, hypoglobus, or body sensation. Corneal abrasions are diagnosed on clinical
both examination with fluorescent dye viewed under cobalt blue
• Immediate correction of diplopia in the setting of muscle (in- light. Treatment includes patching the eye (24 hours) and ad-
ferior rectus) incarceration and a positive forced duction test ministration of a topical cycloplegic (e.g., homatropine 5%)
result or unresolved diplopia with a positive forced duction test for ciliary body spasm.
result • Hyphema. This is defined as the presence of blood in the an-
• Immediate correction in the symptomatic pediatric patient terior chamber caused by damage to blood vessels in the ciliary
with an orbital floor “trapdoor” fracture that has elicited a ocu- body or rupture of blood vessels in the iris. Hyphema is graded
locardiac reflex (the oculocardiac reflex can be seen with true according to the extent to which it vertically fills the anterior
entrapment) chamber. Grade I is designated as less than one-third, grade II
is between one-third and half, grade III is one half to near to-
Relative Indications tal, and grade IV is total (eight ball) filling of the anterior
chamber. Treatment is directed toward controlling bleeding
• Prevention of a cosmetic deformity. Disruption of greater than and preventing rebleeding. This is especially important in pa-
50% of the orbital floor is likely to cause cosmetically apparent tients with sickle cell anemia or sickle cell trait because sickling
enophthalmos, especially with fractures in the critical area at (obstruction of blood flow in the microvasculature caused by
the junction of the floor and medial wall. the distorted red blood cells) leads to increased intraocular
• Correction of unresolved diplopia (7–11 days) in the setting of pressures and optic nerve damage.
soft tissue prolapse. • Superior orbital fissure syndrome. Compression of the con-
tents of the superior orbital fissure accounts for the manifesta-
Contraindications to Immediate Repair tions of this syndrome. Clinical findings include loss of forehead
sensation, loss of corneal reflex, ophthalmoplegia, upper lid pto-
• Any condition that puts the globe in jeopardy, such as ocular sis, edema (secondary to venous obstruction), and proptosis. This
injuries (e.g., hyphema, retinal tears, lens displacement). For syndrome must be differentiated from orbital apex syndrome,
example, a lacerated globe or hyphema may put the globe at which also involves the optic nerve, causing loss of vision.
increased risk because of the retraction necessary to perform • Lens dislocation. Subluxation of the lens may occur because
orbital surgery. of disruption of the lens zonule fibers. The lens margin is often
• The status of the noninjured eye as a possible contraindication. visible, but visual acuity may be compromised, and monocular
Diplopia (binocular) would not be possible in a patient with diplopia can be present. Zonular disruption can cause disloca-
one blind eye; therefore, the only reason to perform surgery, tion of the lens either posteriorly or anteriorly. Patients who
other than restriction of globe motion secondary to incarcera- are symptomatic with posterior dislocation can be treated with
tion of soft tissues, would be to prevent globe malposition. an aphetic contact lens or with intraocular lens implantation.
The current patient had binocular diplopia within 20 degrees of An anteriorly dislocated lens is an ophthalmic emergency be-
primary gaze, a positive forced duction test result with concurrent cause of possible blockage of the aqueous flow, resulting in
evidence of greater than 50% orbital floor disruption, and a high acute glaucoma. Attempts at repositioning the lens can be
likelihood of cosmetically significant postinjury enophthalmos. made by a skilled ophthalmologist; this involves maximally
The patient was taken to the operating room 4 days after the dilating the pupils, placing the patient in a supine position,
assault to allow for partial resolution of soft tissue edema. A pre- and indenting the cornea with a gonioprism.
septal (between the septum and the overlying orbicularis oculi • Retrobulbar hemorrhage. Retrobulbar hemorrhage is an ocu-
muscle) transconjunctival incision was made, without the need lar emergency, and prompt diagnosis and treatment are essen-
for a lateral canthotomy (Fig. 58.3A). After the bony defect was tial to prevent loss of vision. This emergent clinical entity can
isolated (Fig. 58.3B), a preformed orbital floor plate was fitted occur after a traumatic injury to the orbit or postoperatively
and then properly further contoured and fixated (Fig. 58.3C and after orbital or eyelid surgery. The orbit is a relatively closed
D). A forced duction test, which was confirmed with the contra- compartment, and orbital pressure can rise rapidly with hem-
lateral side, showed full mobility of the eye in all directions. The orrhage. If left untreated, orbital compartment syndrome may
incision was closed with 5-0 fast-absorbing gut suture, and a frost develop, causing ischemia of the optic nerve. Patients with
suture was placed. A postoperative CT scan (Fig. 58.4) revealed increased orbital pressure present with pain, decreased vision,
proper positioning and contour of the reconstruction plate. diplopia, ophthalmoplegia (restricted extraocular movements),
The patient did well postoperatively, with no apparent enoph- proptosis, ecchymosis around the eye, chemosis, resistance to
thalmos or diplopia on follow-up at 6 weeks. retropulsion, and an afferent pupillary defect. An emergent

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286 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

A B

C
• Fig. 58.3 A, Intraoperative photograph of a transconjunctival incision. Note the retraction suture place-
ment through the tarsal plate to minimize lower lid injury and the scleral shield to prevent inadvertent
corneal abrasion. B, Orbital floor defect seen through the transconjunctival incision. C, Titanium mesh
plate for reconstruction. D, Mesh implant in place, restoring the orbital floor contour.

lateral canthotomy with inferior cantholysis is indicated, al- • Ruptured globe. Globe rupture occurs when the integrity of
lowing the orbital contents to expand anteriorly. the outer membranes is disrupted by blunt or penetrating
• Traumatic optic neuropathy. Traumatic optic neuropathy trauma. A peaked, teardrop-shaped, or otherwise irregular
presents as a sudden loss of vision secondary to either blunt or pupil may indicate a ruptured globe. A full-thickness lacera-
penetrating trauma to the orbit that cannot be explained by tion to the cornea or sclera constitutes a globe perforation,
other ocular pathological changes. The damage to the nerve is requiring repair in the operating room. Prolapse of the iris
either direct (hemorrhage or compression), shearing (accelera- through a full-thickness corneal laceration may be seen as a
tion of the nerve at the optic canal where it is tethered to the dark discoloration at the site of injury. Scleral buckling is in-
dural sheath), or through transmission of a shock wave dicative of rupture with extrusion of ocular contents. IOP will
through the orbit along the course of the optic nerve. Many likely be low, but direct measurement is contraindicated to
treatment modalities have been advocated, including high- avoid pressure on the globe. Globe rupture is a major ophthal-
dose intravenous steroids, optic canal decompression, and op- mologic emergency that requires surgical intervention.
tic nerve sheath fenestration. The largest study looking at • Blindness. This is a known but uncommon complication of
traumatic optic neuropathy, the International Optic Nerve facial trauma, with a reported incidence of only 2% to 5%. In
Trauma Study, was conducted by Levin and colleagues in a review of the University of Maryland shock trauma experience
1999. They concluded that the use of corticosteroids in pa- of facial trauma over 11 years, the researchers discovered that
tients with traumatic optic neuropathy did not change the 2987 of the 29,474 admitted patients (10.1%) sustained facial
outcome (loss of visual acuity) compared with the control fractures and that 1338 of these fractures (44.8%) involved one
group that did not receive any steroid therapy. or both of the orbits. Operative repair of the facial fractures was

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 CHAPTER 58 Orbital Trauma: Fracture of the Orbital Floor 287

A B

C
• Fig. 58.4 A, Postoperative computed tomography (CT) scan (coronal view) demonstrating proper align-
ment and contour. B, Postoperative CT scan showing the length of the plate from the infraorbital rim.
C, Postoperative CT scan (three-dimensional reconstruction) showing the contour of the titanium mesh.

performed in 1240 of these patients. Three patients (0.24%) • Unresolved diplopia. Diplopia that has a neuromuscular ori-
experienced postoperative complications that resulted in blind- gin (e.g., cranial nerve III palsy) should be observed for spon-
ness. In 13 of 27 other patients (48%), blindness was attributed taneous recovery over 6 months. Elective strabismus surgery
to intraorbital hemorrhage. Another 5 patients experienced vi- can be considered if the diplopia is unresolved. Acute entrap-
sual loss with unspecified mechanisms related to increased in- ment of the extraocular muscles, causing diplopia, needs to be
traorbital pressure. Within the restricted confines of the optic addressed soon after the injury.
canal, even small changes in pressure may cause ischemic optic • Enophthalmos. Enophthalmos results from an increase in
neuropathy. orbital volume and persists if the orbital volume is not restored
adequately. This occurs in large unrepaired fractures, particu-
larly when multiple walls are involved. Defects at the junction
Late of the floor and medial wall of the orbit are most prone to
Late complications of orbital floor fractures and repair can be the causing enophthalmos. Studies have shown that an increase in
result of injuries sustained at the time of the traumatic event or orbital volume of anywhere from 0.5 to 1 cc creates approxi-
complications associated with the repair itself. mately 1 mm of enophthalmos.
• Lacrimal system injury. Epiphora (excessive tearing caused by • Ectropion. Ectropion is the outward eversion of the lid mar-
impaired drainage) can occur. Eyelid lacerations, particularly gin away from the globe. This can result in corneal irritation
those extending medially, should be thoroughly evaluated for and exposure and abnormalities of lacrimal outflow. Preven-
lacrimal drainage system injury, canthal tendon disruption, or tion of ectropion begins with minimizing vertical tension
injury to the tarsal plate and levator aponeurosis. Fractures when closing eyelid lacerations or periorbital skin incisions.
through the lacrimal apparatus (NOE) can also cause epiphora. Use of the transconjunctival incision, with resuspension of the

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288 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

suborbicularis oculi fat, and meticulous repair of eyelid lacera- human cadaver experiments during the mid-1970s, Fujino
tions reduce the incidence of this complication. Cicatricial convincingly demonstrated the occurrence of orbital floor frac-
ectropion results from scarring of the anterior lamella; involu- tures with direct blows to the orbital rim without fracture of the
tional ectropion results from horizontal lid laxity, usually be- orbital rim itself. Recent studies, such as that by Waterhouse
cause of age-related weakness of the canthal ligaments and and associates, have revealed that orbital fractures may occur by
pretarsal orbicularis. way of the “buckling” or “hydraulic” mechanism, with a com-
• Entropion. Entropion is malposition of the eyelid, resulting in bination of the two mechanisms being the most likely etiology,
inversion of the eyelid margin. Cicatricial entropion occurs as depending on the direction of the striking force.
a result of scarring of the palpebral conjunctiva, with conse- A recent study by Fan and colleagues demonstrated a high cor-
quent inward rotation of the eyelid margin. relation between the increment of orbital volume and the degree
• Unesthetic scar. Cutaneous placement of periorbital incisions of enophthalmos. An increase of 1 cm3 of the orbital volume
(e.g., an infraorbital incision) carries the risk of an unesthetic scar. elicited 0.89 mm of enophthalmos. The authors concluded that
the measurement of orbital volume in patients with orbital blow-
Discussion out fractures could be used to predict the degree of late enoph-
thalmos and that this may be accomplished through the use of
The management of orbital floor fractures remains controversial. computer-assisted volumetric measurements.
The indications for and timing of surgical intervention have proved The approaches to the orbit include the transconjunctival (often
difficult to study and evaluate. Isolated orbital wall fractures with a lateral canthotomy and inferior cantholysis), subciliary, lower
account for 4% to 16% of all facial fractures. If fractures that extend eyelid crease, and transcaruncular approaches. The transconjunctival
outside the orbit (ZMC, NOE) are included, the proportion is approach has been shown to result in fewer cases of postoperative
30% to 50% of all facial fractures. ectropion and may be used in conjunction with the transcaruncular
The optimal management of orbital fractures necessitates an approach to gain further access to the medial orbit. Attention to the
intimate knowledge of the complex anatomy of the region. The medial orbital wall is paramount in completely treating orbital frac-
orbit is a quadrilateral pyramid, with an average volume of 30 cm3 tures and preventing enophthalmos.
and a height and width at the rim averaging 40 mm and 35 mm, The literature provides support for notable clinical differences
respectively. The average length of the medial wall is 40 to 45 mm in orbital floor fracture patterns between pediatric patients and
(rim to optic canal). Seven bones make up the orbits: the sphenoid, adults. Jordan and associates coined the term “white-eyed blow-
maxillary, lacrimal, ethmoid, frontal, zygomatic, and palatine out fracture” for patients 16 years or younger with minimal soft
bones. The orbital process of the frontal bone and the lesser wing of tissue injury, severe diplopia, extraocular muscle limitation, and
the sphenoid make up its roof. The floor is made up of the orbital extremely small extrusion of tissue around the orbit seen on CT
plates of the maxilla, zygoma, and palatine bone. The zygoma and imaging. Diplopia, extraocular muscle limitation, and trapdoor
the greater and lesser wings of the sphenoid form the lateral wall. fractures are more frequent in children than in adult patients and
The medial wall is formed by the frontal process of the maxilla and can be accompanied by nausea and vomiting.
the lacrimal, sphenoid, and ethmoid (lamina papyracea) bones. The choices for reconstruction materials for repair of orbital
The distances to known orbital landmarks are crucial for pre- bony contour are numerous and remain controversial. Many
venting postoperative complications and aiding intraoperative autogenous (split calvarial bone, iliac crest, septal cartilage or
dissection. These measurements are averages and may be altered rib), alloplastic (titanium mesh, porous polyethylene [MED-
by posttraumatic changes in the orbital rim. The average distance POR], poly[glycolic acid] and poly[lactic acid], Gelfilm), and
from the orbital rim to the orbital apex is 40 to 45 mm. The sub- allogeneic (lyophilized cartilage or dura, banked bone) materials
periosteal dissection along the orbital walls can safely be extended have been used and advocated. The use of autogenous materials
up to 25 mm posteriorly along the inferior and lateral rims. is thought to decrease the risk of infection and extrusion; allo-
Three theories have been advocated with regard to the physi- plastic materials offer superior ease in intraoperative handling
ologic mechanism of orbital floor fractures. and contouring.
• The hydraulic theory, advocated by Smith and Regan in 1957, When the entire orbit has been disrupted and there are no
proposed that a generalized increased orbital content pressure posterior landmarks to guide the reconstruction, accurate position-
resulted in direct compression of the orbital floor, thereby ing of bone grafts or titanium mesh becomes exceedingly difficult.
fracturing the thin orbital bone. Especially in late repairs, there is a significant challenge to estab-
• The globe-to-wall contact theory, proposed by Raymond Pfei- lishing proper orbital contour, volume, and medial bulge projec-
ffer in 1943, stated that a force is delivered to the globe, push- tion. The risk of encroachment on the orbital apex and optic nerve
ing it backward into the orbit, causing it to strike and fracture also exists. Presurgical virtual planning, patient-specific implants,
the bony walls. This theory is based on common sense and ra- and the use of intraoperative navigation (Box 58.1) can aid recon-
diologic reasoning, but it is not evidence based. Erling and struction in such cases, improving the predictability of a complex
colleagues found that the size of the orbital wall defect exactly orbital reconstruction.
fit the size of the globe in many cases of blowout fractures ana- A multidisciplinary approach to complex orbital trauma is
lyzed with CT scans. They stated that it is the “displacement of highly recommended, and consultation with ophthalmology or
the globe” that directly causes many orbital wall fractures. oculoplastic services should be considered. Many posterior seg-
• In 1974, Fujino proposed that a direct compression force or ment injuries may be subtle and need to be identified before ex-
buckling force, transmitted via the orbital rim, was the caus- ploration and reconstruction of the bony orbital architecture.
ative factor in orbital floor fractures. This theory of a bone
conduction mechanism of injury was first proposed by Le Fort ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
and Lagrange at the turn of the 20th century. In a series of dried complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 58 Orbital Trauma: Fracture of the Orbital Floor 289

• BOX 58.1 Four Phases of Navigation-Assisted Computer-Aided Reconstruction

1. Data acquisition phase. Visualization, orientation, and diagnosis of the or- 3. Surgical phase. Surgery involves CAD/CAM-derived stereolithographic
bital deformity. Clinical and radiographic diagnoses are made, and a high- models or custom orbital implant insertion using intraoperative navigation
quality computed tomography (CT) scan of the orbits with 1-mm slices is (Fig. 58.5C and D).
obtained (Fig. 58.5A). 4. Assessment phase. Evaluation of the accuracy of the treatment plan
2. Manipulation (simulation) phase. Mirroring, segmentation, and virtual or- transfer using intraoperative or postoperative CT imaging (Fig. 58.5E and F).
bital implant insertion (Fig. 58.5B). CT data are imported into a proprietary
CAD/CAM, Computer-aided design and computer-aided manufacturing.
software program for virtual planning before surgery.

A B
• Fig. 58.5 A, Preoperative scan of large late repair right orbital floor and medial wall fracture. B, Postop-
erative scan after navigation-assisted computer-aided reconstruction with patient-specific implant.

t.me/Dr_Mouayyad_AlbtousH
 289.e1

Bibliography Lang GK: Ophthalmology: A Pocket Textbook Atlas, ed 2, New York,

2000, Thieme.
Le Fort R: Experimental study of fractures of the upper jaw. Parts I, II
Appling WD, Patrinely JR, Salzer TA: Transconjunctival approach vs and II, Rev Chir De Paris 23:208-227, 360-379, 479-507, 1901
subciliary skin-muscle flap approach for orbital fracture repair, Arch [translated by Tessier P: Plast Reconstr Surg 50:600-607, 497-506,
Otolaryngol Head Neck Surg 119:1000-1007, 1993. 1972].
Burnstine MA: Clinical recommendations for repair of orbital facial Levin LA, Beck RW, Joseph MP, et al: The treatment of traumatic optic
fractures, Curr Opin Ophthalmol 14:236-240, 2003. neuropathy: the International Optic Nerve Trauma Study, Ophthal-
Dulley B, Fells P: Long-term follow-up of orbital blowout fracture with mology 106:1268-1277, 1999.
or without surgery, Mod Probl Ophthalmol 14:467-470, 1975. Lorenz P, Longaker M, Kawamoto H: Primary and secondary orbit sur-
Erling BF, Iliff N, Robertson B, et al: Footprints of the globe: a practical gery: the transconjunctival approach, Plast Reconstr Surg 103:1124-
look at the mechanism of orbital blowout fractures, with a revisit to the 1128, 1999.
work of Raymond Pfeiffer, Plast Reconstr Surg 103:1313-1316, 1999. Markiewicz MR, Bell RB: The use of 3D imaging tools in facial plastic
Fan X, Li J, Zhu J, et al: Computer-assisted orbital volume measurement surgery, Facial Plast Surg Clin North Am 19(4):655-682, 2011.
in the surgical correction of late enophthalmos caused by blowout Pfeiffer RL: Traumatic enophthalmos, Arch Ophthalmol 30:718-726, 1943.
fractures, Ophthal Plast Reconstr Surg 9:207-211, 2003. Rhee JS, Kilde J, Yoganadan N, et al: Orbital blowout fractures: experi-
Feliciano DV, Mattox KL, Morre EE: Trauma, ed 6, New York, 2007, mental evidence for the pure hydraulic theory, Arch Facial Plast Surg
McGraw-Hill. 4:98-101, 2002.
Friedrich RE, Heiland M, Bartel-Friedrich S: Potentials of ultrasound in Shere JL, Boole JR, Holtel MR, et al: An analysis of 3,599 midfacial and
the diagnosis of midfacial fractures, Clin Oral Invest 7:226-229, 2003. 1,141 orbital blowout fractures among 4,426 United States Army
Fujino T: Experimental “blow-out” fracture of the orbit, Plast Reconstr soldiers, 1980-2000, Otolaryngol Head Neck Surg 130:164-170, 2004.
Surg 54:81-82, 1974. Shorr N, Baylis HI, Goldberg RA, et al: Transcaruncular approach to the
Girotto JA, Gamble W, Robertson B, et al: Blindness after reduction of medial orbit and orbital apex, Ophthalmology 107:1459-1463, 2000.
facial fractures, Plast Reconstr Surg 102(6):1821-1834, 1998. Smith B, Regan WF Jr: Blow-out fracture of the orbit: mechanism and
Goldenberg-Cohen N, Miller NR, Repka MX: Traumatic optic neuropa- correction of internal orbital fracture, Am J Ophthalmol 44(6):733-
thy in children and adolescents, J AAPOS 8:20-27, 2004. 739, 1957.
Hammer B: Orbital Fractures: Diagnosis, Operative Treatment, Secondary Soparkar CN, Patrinely JR: The eye examination in facial trauma for the
Corrections, Seattle, 1995, Hogrefe & Huber. plastic surgeon, Plast Reconstr Surg 120(7 Suppl 2):49s-56s, 2007.
He D, Li Z, Shi W, et al: Orbitozygomatic fractures with enophthalmos: Waterhouse N, Lyne J, Urdang M, et al: An investigation into the
analysis of 64 cases treated late, J Oral Maxillofac Surg 70(3):562-576, mechanism of orbital blowout fractures, Br J Plast Surg 52(8):607-
2012. 612, 1999.
Holt JE, Holt GR, Blodgett JM: Ocular injuries sustained during blunt Westfall CT, Shore JW, Nunery WR, et al: Operative complications of
facial trauma, Ophthalmology 90:14-18, 1983. the transconjunctival inferior fornix approach, Ophthalmology
Holtmann B, Wray RC, Little AG: A randomized comparison of four 98(10):1525-1528, 1991.
incisions for orbital fractures, Plast Reconstr Surg 67:731-737, 1981. Wray RC, Holtmann B, Ribaudo JM, et al: A comparison of conjunctival
Jordan DR, Allen LH, White J, et al: Intervention within days for some and subciliary incisions for orbital fractures, Br J Plast Surg 30:142-
orbital floor fractures: the white-eyed blowout, Ophthal Plast Reconstr 145, 1977.
Surg 14:379-390, 1998.

t.me/Dr_Mouayyad_AlbtousH
59
Panfacial Fracture
C H R I S J O, M A RT I N B. S T EE D, a n d S H A H R O K H C . B AG H ER I

CC Breathing and oxygenation. The oral endotracheal tube is in

good position (confirmed by portable chest radiograph) on me-
A 49-year-old male is transported to the emergency department chanical ventilation. The right hemithorax shows no chest rise or
(ED) by emergency medical service (EMS) personnel status after a breath sounds and is hypertympanic to percussion (indicative of a
pedestrian-versus-automobile accident. You are called by the trauma pneumothorax, also confirmed by portable chest radiograph). A
team for the evaluation and management of his facial injuries. chest tube is placed to reexpand the right lung. Oxygen saturation
is 90% on 100% inspired oxygen (suggestive of a ventilation-
HPI perfusion mismatch).
Circulation and hemorrhage control. Blood pressure is
The patient arrives at the ED intubated. The driver of the auto- 90/70 mm Hg, and heart rate is 125 bpm (moderate hypotension
mobile and another eyewitness report that the patient was walk- and tachycardia consistent with class III shock). (Class III hypo-
ing alongside a busy intersection and suddenly jumped into the volemic shock is indicative of a 30%–40% loss of blood volume,
path of a vehicle traveling at approximately 35 mph. The front which is characterized by a heart rate .120 bpm; decreases in
end of the car struck his thighs, and then his face hit the hood and systolic blood pressure, mean arterial blood pressure, pulse pres-
windshield, causing significant damage to the automobile. He was sure, and urine output [5–15 mL/hr]; and altered mental status).
launched several feet into the air and landed in a prone position A small amount of bleeding is observed from the nasopharynx
on the pavement. He had a Glasgow Coma Scale (GCS) score of and is easily controlled with bilateral nasal packs. The magnitude
3 at the scene and was orally intubated by EMS personnel for of bleeding does not clinically correlate with the estimated blood
airway protection. (Airway intubation is warranted for a GCS loss and volume depletion (raising suspicion for other sources of
score of 8 or lower, which is indicative of a severe head injury.) bleeding). The abdomen is soft and nondistended, and the fo-
When you arrive in the ED, the patient is being actively resusci- cused abdominal sonography for trauma (FAST) is negative
tated by the trauma team according to the Advanced Trauma Life (FAST examination is used in the hypotensive blunt trauma pa-
Support (ATLS) protocol, and the orthopedic team is evaluating tient and evaluates the perihepatic, pericardiac, perisplenic, and
multiple extremity fractures. pelvic windows for the presence of free intraperitoneal fluid or
cardiac tamponade); this rules out intraabdominal hemorrhage
PMHX/PDHX/Medications/Allergies/SH/FH (hypovolemic) and cardiac tamponade (obstructive) as the source
of shock. Bilateral femoral deformities (each femur fracture can be
The patient’s histories are unknown. (Information may be ob- a source of 1.5–2 L of blood loss) and other open extremity frac-
tained from family members, when present.) tures can be a source of significant blood loss and hypovolemic
shock. Fractures should be reduced and stabilized to reduce the
Examination amount of hemorrhage in the initial resuscitation phases. Fluid
resuscitation should begin with crystalloid intravenous (IV) fluid
The initial evaluation of a trauma patient should be dictated by boluses to maintain organ perfusion. Transfusion of packed red
the ATLS protocol. blood cells should be considered in class III hemorrhagic shock.
Disability and dysfunction. On the AVPU (A, awake; V, re-
Primary Survey sponds to voice; P, responds to pain; U, unresponsive) scale, the
patient is unresponsive (off sedation) and has a GCS score of E1
Airway and cervical spine control. The patient has been orally 1 M1 1 V1T 5 3T. Pupils are equal, 7 mm, with a sluggish
intubated, and a transport cervical collar is in place. (In a review reaction to light. (Large pupils with a sluggish reaction to light
of 563 patients with maxillofacial injuries, Haug and associates reflex may indicate a closed head injury and elevated intracranial
found that concomitant cervical spine fractures occurred in 2% of pressure [ICP].) Sedation should be discontinued for an accurate
patients. Of those with cervical spine fractures, 91% had man- assessment of mental status as needed. Initial head computed to-
dibular fractures. Bagheri and colleagues found a 1.5% incidence mography (CT) scan reveals moderate contusions in the frontal
of cervical spine fractures in a series of 67 patients with isolated and occipital lobes (coup, countercoup injury, indicative of a
midfacial fractures.) rapid acceleration-deceleration mechanism). A Camino bolt is

290
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 59 Panfacial Fracture 291

placed to monitor the ICP, which reveals a mildly elevated open- incisors (teeth #23 and #24), with gross mobility of the mandibular
ing pressure at 22 mm Hg (normal ICP is #15 mm Hg). segments. The patient has an anterior open bite with no distinct
Exposure and environmental control. The patient’s clothing mandibular posterior stop and bilateral posterior prematurities
has been removed, and a warm blanket and other warming de- (indicative of bilateral condylar fractures or Le Fort level fracture),
vices are used to prevent hypothermia. with the oral endotracheal tube exiting between the edentulous
spaces. There is ecchymosis at the posterior soft palate bilaterally
Secondary Survey (Guerin’s sign, indicative of pterygoid plate disjunction or fracture).

The AMPLE history (allergy, medications, past medical history, Imaging

last meal, events leading to presentation) is taken from available
sources. A plain film radiograph series in the acute setting includes cross-
General. The patient is a well-developed male who is intu- table cervical spine, portable anteroposterior (AP) chest radiogra-
bated and sedated and has a cervical collar in place. phy, and an AP pelvis radiograph. Other studies are added as
Neurologic. The GCS score is 3T (off sedation). Pupils are needed, including cervical spine series (in suspected cervical spine
7 mm, equal, and sluggish. (This parameter was covered during injury), thoracic and lumbar spine series, and extremity radio-
the primary survey but should be repetitively monitored for graphs (depending on the mechanism of injury).
changes.) The ICP-monitoring device (e.g., intraparenchymal Axial cut bony window CT scans (with coronal reconstruc-
Camino bolt or external ventriculostomy drain) gives a precise, tions) are the gold standard radiographic examination for midfa-
moment-by-moment assessment of ICPs. A sustained ICP greater cial fractures. Direct coronal views are useful but should be
than 25 mm Hg warrants intervention to reduce the pressure (IV avoided in patients with suspected cervical spine injury. (The pa-
mannitol, hyperosmolar therapy with 3% NaCl, elevation of head tient’s head needs to be hyperextended for a direct coronal CT
of bed, hyperventilation to reduce the Paco2 to the low range of scan.) Three-dimensional (3D) reconstructions are helpful ad-
normal). Therapy is aimed at not only reducing ICP (,20 mm Hg) juncts because they provide the most graphic representation of the
but also at maintaining cerebral perfusion pressures (cerebral per- fractures, degree of displacement, and orientation of fragments. A
fusion pressure 5 mean arterial pressure 2 ICP), which should panoramic radiograph is always helpful; however, in the unstable
be maintained greater than 70 mm Hg (35% reduction in mor- patient with cervical–thoracic–lumbar spine precautions, this is
tality rate) to prevent secondary brain injury. Invasive hemody- not likely to be possible.
namic monitoring is indicated when hyperosmolar therapy is In the current patient, head and facial helical CT scans with-
initiated to maintain an acceptable blood pressure and cerebral out contrast were obtained after the primary and secondary sur-
perfusion pressure (mortality rate increases 20% for each 10–mm veys were completed. The head CT scan revealed moderate frontal
Hg loss of cerebral perfusion pressure). lobe and occipital lobe contusions without evidence of intracere-
Maxillofacial. There is significant upper and lower facial edema. bral hemorrhage or midline shift. (These scans should be repeated
A 2-cm full-thickness laceration extends over the bridge of the nose in 12–24 hours to monitor for any changes.) The fine cut axial
(indicating blunt trauma to the upper midface), and there is a 5-cm face CT scan revealed bilateral nasal bone fractures, fractures of
full-thickness stellate laceration over the lower lip and chin. the lateral orbital rims and walls, and bilateral zygomatic arch
Eyes. There is significant periorbital edema. Visual acuity can- fractures (Fig. 59.1A and B). Fractures at the pterygoid plates and
not be assessed. The patient has bilateral periorbital ecchymosis along the anterior and posterior maxillary sinus and lateral nasal
(raccoon eyes, indicative of anterior basilar skull fracture) and bi- walls also were seen (Fig. 59.1C). Coronal reconstruction views
lateral subconjunctival hemorrhage and chemosis. Intercanthal anteriorly demonstrated fractures at the nasofrontal junction, a Le
distance is 36 mm without blunting of the medial canthus. (An Fort I fracture, and a midpalatal split (Fig. 59.1D). Coronal views
increased intercanthal distance is indicative of a naso-orbital-eth- of the midface demonstrated severe comminution of the midface,
moid [NOE] fracture or avulsion of the medial canthal tendon. including at the NOE, orbital floors, and zygomaticofrontal junc-
Normal intercanthal distance is 30–34 mm and varies among races tion (Fig. 59.1E). Scans of the mandible demonstrated bilateral
and genders.) The bowstring test result (a clinical test for evalua- condylar neck fractures (Fig. 59.1F; also see Fig. 59.1C) and a
tion of the medial canthal attachment) is negative. Bilateral step midline mandibular symphysis fracture. Fig. 59.1G shows the 3D
deformities are present at the lateral and inferior orbital rims (step reconstructed view, which also demonstrated fracture of the ante-
deformity and bony crepitus indicate the presence of fractures). rior table of the frontal sinus, confirmed on the axial views.
Nose. The nasal bridge demonstrates crepitus with gross mo- The results of the CT scan of the cervical spine were negative.
bility. The endonasal examination reveals an edematous nasal The AP chest radiograph showed evolving bilateral pulmonary
mucosa with mild bleeding. The anterior nasal septum is midline contusions and a chest tube in good position without any residual
with no septal hematoma. (Septal hematoma requires immediate pneumothorax.
incision and drainage to prevent necrosis of the septal cartilage
and potential perforation and saddle-nose deformity.) No cere- Labs
brospinal fluid (CSF) rhinorrhea or otorrhea is noted. The maxilla
is grossly mobile with bony crepitus at the anterior maxillary walls Standard laboratory tests for the evaluation of multisystem trauma
and the zygomaticomaxillary (ZM) buttresses. No step deformity patients include a complete blood count, complete metabolic
or crepitus is appreciable at the zygomatic arches bilaterally. (This panel, arterial blood gas values, urinalysis, and coagulation studies
does not exclude the possibility of fractures.) (prothrombin time, partial thromboplastin time, and interna-
Intraoral. There is bilateral maxillary vestibular ecchymosis tional normalized ratio). A urine drug screen and blood alcohol
(indicative of fractures of the ZM buttresses). There are multiple level are indicated in patients with decreased mental status.
missing maxillary teeth and a step deformity with an associated The current patient demonstrated decreased hemoglobin
gingival laceration between the left mandibular lateral and central (9.2 g/dL) and hematocrit (26.6%) (suggestive of blood loss;

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292 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

• Fig. 59.1 A, Axial cut bony window computed tomography (CT) scan showing displaced
bilateral lateral orbital wall fractures. B, Axial cut bony window CT scan showing the inferior
component of the bilateral naso-orbital-ethmoid (NOE) type I fracture (inferior orbital rim frac-
tures) and bilateral zygomaticomaxillary complex) fractures. C, Axial cut bony window CT
scan showing a right subcondylar fracture, a palatal split of the maxilla, pterygoid plate frac-
tures or disjunction, and maxillary sinus wall comminution. D, Coronal reconstruction CT scan
showing Le Fort I fracture with a palatal split and bilateral NOE type I fracture. E, Coronal
reconstruction CT scan showing bilateral lateral orbital rim fractures, a comminuted Le Fort I
fracture, nasal septal comminution, and nondisplaced orbital floor fractures. F, Axial cut bony
window CT scan showing a left subcondylar fracture. G, Three-dimensional CT reconstruction
demonstrating the spatial relationship of the fractures. The symphysis and anterior frontal si-
G
nus fractures are seen clearly in this view.

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 CHAPTER 59 Panfacial Fracture 293

however, acutely, hemoglobin or hematocrit may not be an accu-

rate measure because of a delay in volume redistribution). Arterial
blood gas analysis showed a moderate base deficit of 25.5 mEq.
(Base deficit is one of the parameters monitored for adequacy of
resuscitation in hypovolemic shock and is a better indicator of
acute blood loss than hemoglobin or hematocrit.) The complete
metabolic panel demonstrated a mild elevation in blood urea ni-
trogen (30 mg/dL) and creatinine (1.9 mg/dL) (indicative of
prerenal azotemia secondary to blood loss) and a negative blood
alcohol level and urine drug screen. (Alcohol and drug intoxica-
tion must be considered and ruled out as the source for altered
mental status.) The remainder of the patient’s laboratory test re-
sults were within normal limits.

Assessment
Panfacial fracture involving the frontal bone, midface, and mandi-
ble—Facial Injury Severity Scale score of 17; complicated by class III
hemorrhagic shock, closed head injury, multiple extremity fractures,
and right pneumothorax with bilateral pulmonary contusions.
Maxillofacial injures are classified as shown in Table 59.1.

Treatment
Treatment begins with initiation of the ATLS protocol and stabi-
lization of the patient. Maxillofacial injuries compromising the
airway should be promptly evaluated. Tracheotomy should be
readily considered for panfacial fractures. Submental intubation is
also a viable alternative. A cricothyrotomy is usually reserved for
an acute airway emergency. The control of hemorrhage from the
maxillofacial region is part of the ATLS protocol. Nasal packing
and pressure dressings should be applied as needed. Severe or life-
threatening posterior nasal bleeding can be managed emergently
with posterior balloon nasal packing or with Foley catheters
placed bilaterally through the nares into the oropharynx and then
inflated and pulled tight to the soft palate (Fig. 59.2). If local
packing measures are unsuccessful, interventional management is
needed.
Treatment of panfacial fractures can be challenging and should
begin, after completion of the ATLS protocol, with a thorough
maxillofacial and radiographic examination. Often the patient
requires significant resuscitation before facial surgery. After the • Fig. 59.2 Clinical photograph demonstrating emergent bilateral place-
maxillofacial diagnosis has been made, a treatment plan must be ment of Foley catheters through the nose. The catheters were insufflated
developed to expose the necessary fractures for alignment and after they had been passed over the soft palate, then pulled back and tied
fixation. Selective exposure of necessary fractures is used for stabi- together.
lization with rigid fixation. (Before the advent of rigid fixation, it
was common for all fracture sites to be exposed.) The surgeon

must develop a preoperative plan to expose, examine, align, fixate,

TABLE and reconstruct the facial skeleton in an orderly fashion. This may
59.1 Classification of Maxillofacial Injuriesa include immediate bony reconstruction with bone grafting tech-
niques. If necessary, the entire facial skeleton can be visualized by
Upper face Fracture of the anterior wall of the frontal sinus and combining multiple approaches.
frontal bar (5) After the fracture sites have been exposed, the principle of us-
Midface Bilateral ZMC fractures (2 3 1) ing the buttresses of the facial skeleton to help align the fractures
Bilateral NOE fractures (type I) (3) from “stable to unstable” segments is followed. Different concepts
Le Fort I fracture (2), with a midpalatal split (1) and strategies regarding the order of stabilization have been advo-
Mandible Bilateral subcondylar (2 3 1) and symphysis (2) fractures
cated in the past; these include progression from top to bottom,
bottom to top, inside to out, and outside to in. With the advent
a
The Facial Injury Severity Scale designation is given in parentheses. of miniplates and rigid internal fixation, a broader range of recon-
NOE, Naso-orbital-ethmoid; ZMC, zygomaticomaxillary complex. structive possibilities allows new definitions of optimal sequenc-
ing in facial reconstruction. Goals for linking fragmented bones

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294 S E C TI O N V I I I Craniomaxillofacial Trauma Surgery

came into existence. Starting with stable bone, fractured and dis- extended medially, via a transcaruncular incision, for
placed segments are fixated to adjacent stable, nondisplaced bone greater exposure of the medial orbital wall. The transcon-
in a piecemeal fashion. junctival incision is preferred by most surgeons because it
In the current patient, the following treatment sequence was used. has the lowest incidence of transient and permanent post-
1. Management of the airway. Because of the severity of this operative lower eyelid malposition. If a coronal incision is
patient’s head injury and anticipation of prolonged mechanical not used, the lateral orbital rim can be exposed via an upper
ventilation, an open tracheotomy was initially performed. blepharoplasty incision or a lateral brow incision. Paranasal
2. Exposure of fractures. Maxillary and mandibular arch bars Lynch incisions can be used to access NOE fractures; how-
were applied but not tightened (leaving the arch bars slightly ever, this technique is associated with poor cosmesis.
loose on the least dentate segment of the fracture allows for 3. Alignment and fixation of fractures. After all necessary
adjustment at a later time, when the proper occlusion and fractures had been exposed, attention was turned to the dento-
horizontal facial width have been established). Subsequently, alveolar segments and occlusion. Fracture of the dentate seg-
all fractures necessary for alignment and fixation were exposed ment (parasymphysis, symphysis) of the mandible, along with
in a systematic fashion. a maxillary palatal split, can make it difficult to restore proper
a. Transoral exposure of the maxillary and mandibular frac- lower facial width and occlusion. In the current patient, the
tures was accomplished with a maxillary circumvestibular surgeons chose to rely on proper reduction of the symphysis
incision (from first molar to first molar) and a genioplasty- fracture (guided by direct visualization of the lingual cortex
type incision. (The midpalatal fracture can also be accessed reduction and correct position of the condylar heads in the
via a parasagittal palatal incision if it needs to be rigidly glenoid fossa) to define the lower facial third width and occlu-
fixated.) The midface was degloved to expose the body of sion. Proper horizontal width of the maxilla was obtained by
the zygomas, bilateral ZM buttress, pyriform rim (naso- placing the dentoalveolar segments into intermaxillary fixation
maxillary buttress), inferior portion of the NOE fracture, with a properly reduced mandible. Typically, fractures through
and inferior orbital rims (inferior orbital rims can be plated dentate segments are addressed first. However, when dealing
from this access) while skeletonizing and protecting the with a symphysis (parasymphysis) and bilateral (or unilateral)
infraorbital neurovascular bundles. The mandibular sym- subcondylar fractures, it may be wise to reduce and rigidly fix-
physis fracture was exposed by degloving the anterior man- ate the subcondylar fractures before addressing the symphysis
dible to the inferior border anterior to the mental foramina. fracture. This allows the surgeon to visualize and keep the
Both mental nerves (and associated three branches) were condylar heads in the glenoid fossa as the symphysis fracture is
identified and protected. (Some surgeons prefer an extra- reduced and fixated (assisted by gentle digital pressure at the
oral approach via a submental incision, which decreases mandibular angles). When subcondylar fractures are addressed
mental nerve injury and gives better visualization of the after fixation of the symphysis, there may be undetected splay-
lingual cortex reduction to prevent splaying.) If a fracture ing of the lingual cortex at the symphysis, causing subsequent
exists in the posterior mandible (body, angle, or ramus), condylar displacement and fixation lateral to the fossa. With
submandibular (Risdon), retromandibular (Hinds), or in- the occlusion set and the mandibular symphysis and condylar
traoral incisions can be used. neck fractures reduced and fixated, the mandible’s arc of rota-
b. A coronal incision (also referred to as the bicoronal incision tion is used to guide the proper reduction of the midfacial
in the literature) was made to access the frontal bone and fractures. (The vertical dimension of the maxilla cannot be
sinuses, superior and lateral orbital rims (supraorbital bar), established by the mandible.)
the NOE complex, and the zygomatic arches. This incision a. Following the “stable to unstable” principle, the most
also provides access for a cranial bone graft harvest, if cephalad fractures were addressed next using the anterior
needed. (The parietal area offers the thickest bicortical cranial vault as the stable point of fixation. The frontal bar
width, reducing the risk of entry into the cranium.) The and anterior table of the frontal sinus should be recon-
incision was extended into bilateral preauricular incisions structed first, starting at the lateral orbital rims (frontozy-
(some surgeons prefer an endaural approach) for access to gomatic suture area) and working medially toward the ra-
the mandibular condyle and better access to the zygomatic dix. (The frontal sinus should also be addressed according
arch and body. to the type of injury and should be addressed after recon-
c. The inferior orbital rims and inferior component of the structing the frontal bar.) Then the zygomatic arches are
NOE fractures were exposed via a transconjunctival ap- fixated bilaterally. (Accurate reduction of the zygomatic
proach. Various periorbital incisions can be used for access arches is important for restoring proper AP projection of
to the inferior orbital rims, orbital floor and medial orbital the midface.) The superior portion of the NOE fracture
walls, inferior components of the NOE, and lateral orbital (near the nasofrontal junction) is then reduced and fixated
rims. The lower eyelid incisions can be transcutaneous or to the stable frontal bar, and the inferior portion is ad-
transconjunctival. The transcutaneous approaches include dressed later via the periorbital and/or maxillary vestibular
the subciliary, subtarsal, and inferior orbital rim (unfavor- access. (Some surgeons prefer to use a long C-shaped plate
able scarring) incisions. The subciliary incision can be a to vertically span the entire NOE fracture and simultane-
skin-only flap, skin–muscle flap, or stepped flap. The ously fixate it to the inferior orbital rims and frontal bar.)
stepped flap is recommended when using this approach Otherwise, comminuted NOE fractures are typically ad-
because it has a lower incidence of postoperative lower dressed last after reduction and stabilization of the sur-
eyelid malposition (ectropion, entropion, and scleral show). rounding bony structures.
The transconjunctival incision can be done with or without b. The orbital rim fractures were reduced and fixated via the
a lateral canthotomy and inferior cantholysis, depending transconjunctival incisions. The orbital floor can be ex-
on the amount of access needed. This incision can be plored and reconstructed (cranial bone graft or alloplastic

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 CHAPTER 59 Panfacial Fracture 295

orbital floor plate or mesh) if indicated. In the current pa- wound abscess, meningitis, cerebral abscess, epidural empyema),
tient, the inferior component of the NOE fracture was facial nerve palsy, anosmia, and trigeminal nerve injury (hypoes-
coincident with the inferior orbital rim fracture, which was thesia, dysesthesia, anesthesia).
part of the zygomaticomaxillary complex (ZMC) fractures.
c. After the upper and midface had been reduced and stabi- Discussion
lized, the fractured maxilla at the Le Fort I level was reduced
and fixated to the now-reduced and stable midface using the The term panfacial fracture is frequently used incorrectly. Panfacial
buttresses (ZM and nasomaxillary) as a guide for reduction fractures involve the upper, middle, and lower thirds of the face.
and with the patient in maxillomandibular fixation. Mini- Traditionally, the facial skeleton is divided into thirds or upper
plates were placed at the ZM buttresses and pyriform rims and lower halves. More recently, Manson and others have de-
bilaterally. Further stabilization may be required for palatal scribed four anatomic areas of the face: the frontal area (including
split situations, such as this case. Palatal vault fixation, inter- the frontal bar), the upper midfacial area (including the ZMC and
maxillary fixation, or a palatal strap splint can be used to NOE), the lower midfacial area and occlusion (including the
prevent horizontal collapse of the maxilla. maxilla at the Le Fort I level and the maxillary and mandibular
4. Primary bone grafting. Primary bony reconstruction with dentoalveolar segments), and the basal mandibular area (includ-
immediate cranial bone grafts can be performed at this point. ing the condyle, ramus, body, and symphysis). Nonetheless, when
Areas that are highly comminuted or missing bony segments there is a fracture in each of these four anatomic areas, it is con-
require one-piece bone grafts to replace the defects in bone sidered a true panfacial fracture. Comminution is a common
volume and to support the overlying soft tissue. The need may feature of all midfacial fractures, especially at the anterior maxil-
arise to reconstruct the nasal dorsum, orbital rims, orbital lary sinus wall and in the ZM buttress area.
floors, maxillary sinus walls, ZM buttress area (usually com- It is of paramount importance to maintain the three dimen-
minuted in high-impact injuries), and any other area of sions of the facial skeleton: the height (from vertex to menton),
avulsed or severely comminuted bone. the width (bizygomatic width), and the AP projection. Recon-
5. Soft tissue repair and resuspension. Soft tissue injuries struction of the anatomy using alignment and fixation of the fa-
should be addressed last. Layered closure of incisions and lac- cial vertical and horizontal buttresses is crucial. The horizontal
erations and resuspension of stripped periosteum and suspen- buttresses, as described by Manson and associates, include the
sory ligaments of the face are important to provide a natural frontal bar, infraorbital rim, zygomatic arch, maxillary alveolar
soft tissue drape. bone, and mandibular buttresses. The vertical buttresses include
the orbital, frontonasomaxillary, frontozygomaticomaxillary, pter-
Complications ygomaxillary, and mandibular buttresses.
In the past, it has been advocated to wait until edema resolves
Major complications secondary to the surgical correction of panfa- before fixation of facial fractures. However, surgeons have found
cial fractures can be difficult to assess and depend on the severity of that waiting can make surgical efforts more difficult. Now,
the initial traumatic insult. Damage secondary to the initial trauma immediate repair, after the patient has been stabilized, is recom-
itself is usually the most devastating (e.g., death, loss of vision, in- mended. Staging of the fracture repair is beneficial in many in-
tracranial injury, cranial nerve deficits, cervical spine injury). For stances when the patient has multiple comorbidities that require
maxillofacial trauma surgeons, the most troubling complication is a critical care. Panfacial fractures frequently occur concomitantly
poor cosmetic or functional outcome. Wide exposure for proper with closed head injuries, mandating neurosurgical evaluation
alignment of facial substructures, rigid fixation, and immediate and possible treatment before any maxillofacial intervention. A
bone grafting reconstructive techniques have significantly reduced team approach, in conjunction with neurosurgeons, is important
the incidence of postoperative facial deformities. However, despite in cases requiring cranialization of the frontal sinus. It is impor-
accurate reduction of facial fractures, the soft tissue envelope can tant to reconstruct the frontal bar and superior aspect of the NOE
exert undesirable forces in the form of scar formation and wound fracture before placement of an anteriorly based pericranial flap to
contracture. This can lead to a progressive migration of the bony allow access to this region.
infrastructure of the face and to late postoperative deformities. It is The goal of modern panfacial fracture repair and reconstruc-
important for patients to realize that a full functional and cosmetic tion is achievement of the preinjury level of both function and
outcome may require multiple operations and revisions. cosmesis. The treatment of these complex fractures mandates a
Other complications of panfacial repair include CSF leaks, knowledge of facial bony anatomy and facial cosmetic surgery.
nonunion, malunion, cosmetic deformity (telecanthus, orbital
dystopia, loss of malar projection, increased midfacial or lower ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
facial width, nasal deformity), malocclusion, infection (local complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 295.e1

Bibliography Horellou MF, Mathe D, Feisse P: A hazard of nasotracheal intubation,

Anaesthesia 33:73-74, 1978.
Kreiner B, Stevens MR, Bankston S, et al: Management of panfacial
Bagheri SC, Dierks EJ, Kademani D, et al: Application of a Facial Injury fractures, Oral Maxillofac Surg Knowl Update 3:63-81, 2001.
Severity Scale in craniomaxillofacial trauma, J Oral Maxillofac Surg Le Fort R: Experimental study of fractures of the upper jaw. I, II, and II,
64:404-414, 2006. Rev Chir De Paris 23:208-227, 360-379, 479-507, 1901; translated
Bagheri SC, Dierks EJ, Kademani D, et al: Comparison of the severity of by Tessier P: Plast Reconstr Surg 50:497-506, 600-607, 1972.
bilateral Le Fort injuries in isolated midface trauma, J Oral Maxillofac Manson PN, Clark N, Robertson B, et al: Comprehensive management
Surg 63:1123-1129, 2005. of panfacial fractures, J Craniomaxillofac Trauma 1(1):43-56, 1995.
Bähr W, Stoll P: Nasal intubation in the presence of frontobasal fractures: Manson PN, Hoopes JE, Su CT: Structural pillars of the facial skeleton:
a retrospective study, J Oral Maxillofac Surg 50:445-447, 1992. an approach to the management of Le Fort fractures, Plast Reconstr
Bell RB, Dierks EJ, Homer L, et al: Management of cerebrospinal fluid Surg 66:53-61, 1980.
leak associated with craniomaxillofacial trauma, J Oral Maxillofac Surg Marion DW, Darby J, Yonas H: Acute regional cerebral blood flow
62(6):676-684, 2004. changes caused by severe head injuries, J Neurosurg 74:407-414,
Bouma GJ, Muizelaar JP, Bandoh K, et al: Blood pressure and intracra- 1991.
nial pressure-volume dynamics in severe head injury: relationship Marlow TJ, Goltra DD, Schabel SI: Intracranial placement of a nasotra-
with cerebral blood flow, J Neurosurg 77:15-19, 1992. cheal tube after facial fracture: a rare complication, J Emerg Med
Bouma GJ, Muizelaar JP: Relationship between cardiac output and cere- 15:187-191, 1997.
bral blood flow in patients with intact and with impaired autoregula- Marmarou A, Anderson RL, Ward JD, et al: Impact of intracranial pres-
tion, J Neurosurg 73:368-374, 1990. sure instability and hypotension on outcome in patients with severe
Buehler JA, Tannyhill RJ: Complications in the treatment of midfacial head trauma, J Neurosurg 75:S59-S66, 1991.
fractures, Oral Maxillofacial Surg Clin North Am 15:195-212, 2003. Ng M, Saadat D, Sinha UK: Managing the emergency airway in Le Fort
Changaris DG, McGraw CP, Richardson JD, et al: Correlation of cere- fractures, J Craniomaxillofac Trauma 4:38, 1998.
bral perfusion pressure and Glasgow Coma Scale to outcome, Rosner MJ, Daughton S: Cerebral perfusion pressure management in
J Trauma 27:1007-1013, 1987. head injury, J Trauma 30:933-941, 1990.
Haug RH, Wible RT, Likavek MJ, et al: Cervical spine fractures and
maxillofacial trauma, J Oral Maxillofac Surg 49:725, 1991.

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60
Mandibular Orthognathic Surgery
S U Z A N N E B AR N E S a n d J O N AT H A N G R I F F I N

CC into four components, TMJ, skeletal analysis, dental analysis, and

soft tissue analysis.
A 22-year-old female is referred by her orthodontist for evaluation 1. TMJ
and surgical treatment of an asymmetric class III skeletal maloc- a. Full range of motion
clusion. The patient reports “My lower jaw is crooked.” b. No significant deviation
c. No pain, clicking, popping, or crepitus
d. Maximal incisal opening of approximately 40 mm
HPI 2. Skeletal analysis
This patient previously underwent comprehensive orthodontics at a. Lower facial third with deviation to the left of midline
a younger age. However, as she aged, she noticed her occlusion b. Transverse
began to change. She was reevaluated by her orthodontist several i. Maxillary midline is coincident with the facial midline.
years later and subsequently referred to her oral surgeon for surgi- ii. The chin point is about 4 mm to the left of the facial
cal correction of her skeletal malocclusion. She denies any tem- midline.
poromandibular joint (TMJ) dysfunction symptoms. iii. There is no maxillary cant.
iv. The arch lengths of the maxilla and mandible are coor-
dinated (because of previous orthodontic therapy).
PMHX/PSHX/Medications/Allergies/SH/FH v. The mandibular midline is 4 mm to the left of midline.
c. Anteroposterior dimension
Noncontributory. i. Nasolabial angle: 97 degrees
ii. Labiomental angle: 127 degrees
Examination iii. Straight facial profile
3. Dental analysis
The patient’s preoperative clinical photos can be appreciated in a. Class III at both the first molars and canines
Fig. 60.1. Her examination, as outlined as follows, was divided b. Overjet is 0 mm; overbite is 0%; edge-to-edge occlusion

A B C
• Fig. 60.1 Frontal (A) and profile (B) views of the patient. The asymmetry is most clearly appreciated by
the frontal view. Additionally, from the frontal view of the dentition (C), the asymmetry and crossbite are
also appreciated. (Photos courtesy of Dr. Luis Vega.)

297
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298 S E C TI O N Orthognathic Surgery

c. Posterior crossbite on the left side Recent advances in digital imaging have improved the preop-
d. Level arch form, well aligned, and without crowding erative treatment planning for patients undergoing orthognathic
4. Soft tissue analysis surgery. Traditional and CBCT scans have been implemented to
a. Normal overlying soft tissue envelope improve surgical outcomes. CT imaging modalities allow virtual
b. Adequate thickness of the upper and lower lips three-dimensional reconstructions and enhanced soft tissue analy-
c. No labial incompetence or mentalis strain sis during preoperative planning. Although CBCT scans are more
widely available in most oral surgery offices, many still need to
Imaging provide adequate fields of view for the digital workflow of virtual
surgical planning. Although not necessary for all orthognathic
In mandibular orthognathic surgery, proper imaging remains cases, CT imaging is a valuable tool for navigating complex den-
crucial to achieving successful results. The panoramic radiograph tofacial deformities and asymmetries.
and lateral cephalogram continue to be the standard for treatment
planning orthognathic surgery. The advent of modern imaging Treatment
techniques, including traditional and cone-beam computed to-
mography (CBCT) scans, has expanded surgeons’ ability to plan Orthognathic surgery may treat various dentofacial conditions,
orthognathic surgeries virtually. including deficits in speech, difficulty swallowing, problems with
The panoramic radiograph allows the surgeon to critically mastication, TMJ disorders, or obstructive sleep apnea. Aesthetic
evaluate the patient’s dentition as well as the maxilla and mandi- concerns also drive orthognathic surgery. Mandibular orthogna-
ble in one image. Additionally, it displays the position and devel- thic surgery is mainly dependent on any coexisting maxillary de-
opment of the patient’s third molars if present. Removal of third formity. If none exists, one may proceed with mandibular surgery
molars before or at the time of mandibular orthognathic surgery alone. However, bimaxillary surgery may be indicated with coex-
is a debated topic among oral and maxillofacial surgeons. There is isting deformities because the maxillary occlusal position estab-
conflicting evidence in the literature regarding whether removing lishes the final position of the mandible.
third molars before mandibular orthognathic surgery is beneficial The sagittal split osteotomy (SSO) is the culmination of several
in reducing intra- and postoperative complications. However, the modifications, resulting in a safe and reliable way to treat multiple
patient’s age appears to be associated more with unfavorable splits deformities in the mandible. The procedure’s versatility allows it
than the presence of third molars. Fig. 60.2A demonstrates the to set back or advance the mandible or correct asymmetries within
patient’s preoperative panoramic radiograph. the dentofacial complex. Other mandibular osteotomies can be
A lateral cephalogram is an excellent tool for evaluating the used for mandibular orthognathic surgery, such as the intraoral
patient’s skeletal positioning in the anteroposterior dimension. vertical ramus osteotomy, inverted L osteotomy, or a combination
This image allows the practitioner to perform cephalometric of the various osteotomies. Various factors are considered when
analysis before surgery and is the standard in preoperative imaging deciding which osteotomy should be performed. Some things to
for mandibular orthognathic surgeries. Most important, this im- consider are the anticipated movement of the distal segment, the
age provides information on how the mandible relates to the patient’s preexisting TMJ disorder, concern for neurosensory defi-
maxilla and skull base, aiding in diagnosis and treatment plan- cits, ability to tolerate maxillomandibular fixation, and concern
ning. Fig. 60.2B demonstrates the patient’s preoperative lateral for a cervical incision. For the sake of the discussion, and the deci-
cephalogram. Currently, most cephalometric analyses are com- sion that was made for the patient described, we will continue
pleted via a digital workflow by manually selecting the necessary with describing the SSO.
landmarks within an analytical software. Recent advances in The patient is brought to the operating room and nasally intu-
software engineering have been made toward automatic tracing bated with a nasal RAE tube. Bilateral inferior alveolar nerve
and analysis via artificial intelligence with high degrees of sensitiv- blocks are given using a 50:50 mix of 1% lidocaine with
ity and specificity. However, this technology has yet to be widely 1:100,000 epinephrine and 0.5% Marcaine with 1:200,000 epi-
implemented, and further study is warranted. nephrine. An oropharyngeal screen and bite block were placed in

A B
• Fig. 60.2 A, Preoperative panoramic radiograph. B, Preoperative lateral cephalogram. (Courtesy of Dr.
Luis Vega.)

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 CHAPTER 60 Mandibular Orthognathic Surgery 299

the patient’s mouth. The external oblique ridge is palpated with a osteotomy, a large osteotome can be placed at the most anterior
Minnesota retractor, and an incision is made just over the ridge aspect and at the inferior border, and a Smith spreader is placed
using Bovie electrocautery, being careful to leave a 5-mm cuff of more posterior, to begin slowly propagating the split. Again, at-
attached gingiva. A #9 periosteal elevator is then used to dissect in tention is needed during this time to visualize the osteotomy
a subperiosteal plan on the medial and lateral aspect of the man- moves as anticipated. After the split is complete, the inferior al-
dible, as well as superiorly to the coronoid. It can be helpful to use veolar nerve is visualized and confirmed to be in the proximal
the Bovie electrocautery to remove some of the temporalis tendon segment. After completing both sides, the proximal segment may
while a V-notch retractor is placed on the coronoid and pulled be mobilized and placed into the proper occlusal position using a
superiorly. prefabricated splint, and maxillomandibular fixation is applied. A
When the dissection is performed on the medial aspect of the pickle fork is used to apply gentle pressure on the proximal seg-
mandible, it is best to start farther posterior than the anticipated ment to seat the condyle in the glenoid fossa. The osteotomy site
location of the lingula. After a subperiosteal dissection is estab- is checked for any interferences that need to be removed, and the
lished, a #9 periosteal elevator can be used to palpate the stop of inferior borders of the proximal and distal segments are aligned.
the lingula. This is then confirmed with placement of a nerve The surgical sites are then fixated with plates. Maxillomandibular
hook in the lingula. fixation is removed, and the occlusion is confirmed to be as
After the dissection is completed, it is important to evaluate planned.
the anatomy of the patient’s ramus. Although a gentle S curve is The patient remained for observation postoperatively and was
often pictured in diagrams for the SSO, if the patient has a narrow discharged on postoperative day 1. She continued to follow up in
ramus, there may not be adequate room for a curve from the the clinic. Postoperative clinical photos and imaging can be ap-
medial to sagittal components of the osteotomy. If the ramus preciated in Fig. 60.3.
proves to be narrow, it is likely the medial osteotomy will need to
be angled so that it directs straight into the sagittal osteotomy. Complications
The authors find it helpful when discussing the anticipated oste-
otomy with residents to mark the mandible with a sterile pencil Mandibular orthognathic surgery is widely used for correcting
because the marking is not easily removed by blood or irrigation. dentofacial abnormalities because of its safety and efficacy in
Before the medial osteotomy is made, a periosteal elevator is treating these conditions. As a result, procedures such as the bilat-
placed on the distal aspect of the lingula to protect the neurovas- eral SSO are routinely performed electively. However, a wide array
cular bundle. If desired, a lighted medial ramus retractor can be of complications are reported in the literature, and discussions
placed over the periosteal elevator, which is then removed to should be had with patients before their surgery. Some of the
allow for additional light, visualization, and protection of the most common complications include postoperative neurosensory
neurovascular bundle. It is the authors’ preference to use a recip- deficits, unfavorable fracture patterns of the mandible, bleeding,
rocating saw to perform the osteotomy. First, a medial osteotomy infection, hardware failure, and TMJ pain and dysfunction.
is made at the level just above the lingula, at a 45-degree angle, if
possible. It is important to ensure the osteotomy extends beyond Intraoperative
the lingula posteriorly.
Then the osteotomy is continued in the sagittal plane, taking An unfavorable fracture pattern or bad split is the most reported
care to ensure the saw is cutting through the outer cortex and just intraoperative complication for an SSO. Bad splits have been re-
into medullary bone. The sagittal component extends anteriorly ported since the conception of the SSO, and recent literature re-
to the area of the second molar. The reciprocating saw should ports an estimated 2.3% occurrence per SSO. Several factors may
parallel the orientation lateral ramus and mandibular body. Ad- influence the frequency of unfavorable fracture patterns, includ-
ditional thought needs to be considered when determining how ing the patient’s anatomy, the presence of third molars, and the
far anterior the sagittal osteotomy should extend. If there is a surgeon’s skill. Decreased width of bone between the inferior al-
significant advancement anticipated, it is useful to extend the os- veolar canal and the buccal cortex may increase the risk of a bad
teotomy further so there will be adequate bony contact after the split. The current evidence is inconclusive regarding the presence
advancement is complete. of third molars at the time of surgery. However, many surgeons
Before the lateral osteotomy is made, the bite block is re- advocate for removing these teeth 6 to 12 months before surgery
moved, and pressure is placed on the mandible to occlude the to allow for adequate bone fill in the third molar sites.
teeth, which allows for easier access for the lateral and inferior Vascular injury during mandibular orthognathic surgery is an-
border osteotomies. First, the lateral osteotomy is made at the other complication. The most common vessels are branches of the
anterior extent of the sagittal osteotomy. Attempts are made to external carotid artery, including the inferior alveolar and facial
make this a gentle curve connecting the sagittal and lateral oste- arteries. Retromandibular vein injuries may also occur. Most of
otomies. The lateral osteotomy should be at a 45-degree angle. these complications resolve with digital pressure and topical hemo-
Next, the inferior border is cut approximately 2 mm. static agents. Uncontrollable hemorrhage during an SSO is rare.
After the osteotomies have been completed on both sides, the
mandible is split using a mallet and small, straight osteotomes. Early
Beginning with the medial osteotomy, a small osteotome is
propagated to ensure the osteotomy extends past the lingula. In the early postoperative period, malocclusion is a common
Then, progressively moving anterior, an osteotome is tapped with complication in mandibular orthognathic surgery. If the condyle
the mallet the entire distance of the osteotomy. If movement of is improperly positioned after fixation of the bony segments, a
the segments is not appreciated, the surgeon should localize where malocclusion will result. Condylar positioning may also have
there may be a need to refine the osteotomy with the reciprocat- implications for postoperative skeletal changes such as condylar
ing saw. When slight movement is appreciated throughout the resorption. Intraoperative diagnosis of condylar malposition is

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300 S E C TI O N Orthognathic Surgery

A B C

D E
• Fig. 60.3 Frontal (A) and profile (B) views of the patient postoperatively. The correction of the asym-
metry is most clearly depicted in the frontal view and the view of the occlusion (C). A postoperative
panorex (D) and lateral cephalogram (E) are also demonstrated. (Courtesy of Dr. Luis Vega.)

paramount in preventing this complication. Immediate malocclu- Avascular necrosis is an uncommon but devastating complica-
sion after the release of intermaxillary fixation during surgery is a tion. It is even less common in the mandible than the maxilla. The
crucial indicator for improper position of the condyle during primary blood supply to the surgical site of the mandible in SSOs
fixation. Critical evaluation of this malocclusion may further comes centripetally from the periosteum. As a result, care must be
identify which condyle is mispositioned, and the issue may be taken when stripping the periosteum and muscular attachments
fixed intraoperatively. in the posterior mandible to remove only necessary tissue, ensur-
Surgical site infection is another reported early complication ing adequate blood flow to the surgical segments.
in mandibular orthognathic surgery. The mandible is more sus- Postoperative neurosensory deficits are a commonly reported
ceptible to postoperative infection than the maxilla for two sequela of mandibular orthognathic surgery. However, early par-
main reasons. First, the blood supply is less robust in the esthesia is not a complication because most patients experience
mandible, primarily because of the increased density of bone. temporary disturbances. Most often, early deficits improve to
Second, there is greater gravitational saliva pooling and food baseline within 1 year after surgery.
accumulation in the mandibular vestibules. Naturally, this in-
creases the risk of bacterial invasion at the surgical sites, leading Late
to an increased incidence of infection. Increased age has been
reported as a risk factor for postoperative infections, though Permanent injury to the inferior alveolar nerve is arguably the
conflicting evidence exists. Smoking and immunocompromised most critical complication of mandibular orthognathic surgery.
conditions continue to be risk factors. There is moderate evi- Permanent injury may be defined as a neurosensory deficit persist-
dence supporting more than 1 day of postoperative antibiotics ing longer than 1 year. The reported incidence of nerve injuries in
for prophylaxis against surgical site infections in mandibular mandibular orthognathic surgery is widely variable (12.8%–
orthognathic surgery. No specific antibiotic regimen has been 33.9%) and likely attributable to insufficient standardization in
proven most effective; there is ongoing debate regarding the the assessment of nerve injuries. Mandibular movement greater
length and type of antibiotics. than 7 mm and excessive manipulation of the inferior alveolar
Early hardware failure necessitating removal is another compli- nerve increases the risk of neurosensory deficits. Although objec-
cation seen in orthognathic surgery. Recent reports suggest that tive measurements of neurosensory deficits exist, they are often
nearly 11% of patients undergoing bilateral SSOs will need hard- expensive and challenging to obtain routinely. Many practitioners
ware removal in the future. Often, this is secondary to active evaluate these changes subjectively because it is quicker and easier.
infection at the surgical site, and smoking is the most significant The incidence of permanent nerve injury increases with the pa-
risk factor for hardware removal. The implantation of foreign tient’s age and should be discussed with the patient preoperatively.
material, such as titanium plates or screws, increases the risk of Modern mandibular orthognathic surgery is primarily com-
infection, especially in areas of the body with a high bacterial pleted with rigid internal fixation. Compared with more historical
load, such as the oral cavity. forms of fixation such as wire osseous fixation, rigid internal

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fixation aids in minimizing the skeletal relapse seen postopera- approach by positioning the lateral osteotomy in a vertical posi-
tively. However, the type and amount of movement should be tion. He also used a buccal osteotomy positioned anteriorly be-
considered. Generally, more extensive mandibular movements tween the first and second molars.
have a higher propensity for relapse toward preoperative occlu- Hunsuck later modified the technique by limiting the medial
sion. Bioresorbable rigid internal fixation has been a budding area osteotomy to extend only part of the way toward the posterior
of research over the past decade and remains controversial in or- border of the ascending ramus. Additionally, the vertical and lat-
thognathic surgery. Recent studies suggest excellent short- and eral osteotomy was posterior and distal to the second molar. In
long-term stability for various orthognathic procedures. However, 1977, Epker published the importance of limiting the soft tissue
rigid internal fixation with titanium screws shows superior stabil- dissection of the pterygomasseteric sling. The culmination of these
ity in mandibular setback procedures. modifications provided the foundation for today’s modern SSO.
The definitive etiology of relapse remains unclear because no The successful application of mandibular orthognathic surgery
specific technique has been identified to prevent this complica- relies on both the surgeon and the orthodontist. The two must
tion. Most consider postoperative skeletal changes (e.g., condylar work closely and with clear communication to produce excellent
resorption) and unfavorable muscular adaptation to the patient’s results. In preparation for surgery, orthodontic therapy is applied
new occlusion as significant inciting factors. Additionally, postop- differently for surgical cases than conventional treatment without
erative TMJ positioning is an area of concern regarding both operative intervention. The orthodontist must ensure proper
skeletal relapse after orthognathic surgery and TMJ symptoms alignment and dental decompensation to allow for optimal occlu-
after surgery. sion when the mandible is repositioned surgically. The incisors
Temporomandibular joint dysfunction (TMD) has been a re- must have the appropriate inclination, and the teeth must be sup-
ported complication of SSOs since their inception. Because of ported within an adequate alveolar bone. Additionally, sturdy
this, the importance of evaluating the TMJ before treatment is hooks must be applied via orthodontic brackets or molar bands to
paramount in managing this complication after surgery. In some allow for intraoperative maxillomandibular fixation.
instances, orthognathic surgery may improve symptoms in pa- During the clinical evaluation of patients who may need orthog-
tients with preexisting TMD. Recent literature suggests patients nathic surgery, it is helpful to create a problem list identifying the
more frequently see an improvement (40%–89.1%) versus an patients’ skeletal, dental, and soft tissue diagnoses. The bone, teeth,
aggravation (8%–11.5%) in TMJ symptoms after SSOs. How- and soft tissue must be evaluated in all planes. Additionally, the
ever, there is a conflicting information on whether SSOs improve mandibular plane angle may play a role in treatment planning be-
or worsen symptoms of TMD, and more research is needed. cause it directly affects patients’ function, esthetics, and dentition.
In a patient with mandibular deficiency and a low mandibular
Discussion plane angle, the face often appears short with a deep labiomental
crease and eversion of the lower lip. Upon dental evaluation, there
One of the earliest intraoral mandibular techniques described was may be an excessive curve of Spee and a deep bite. In contrast,
the step osteotomy by Schuchardt in 1942. This approach in- mandibular deficiency with a high mandibular plane angle may
volved an oblique osteotomy at the lingual mandibular surface have the opposite presentation (tall face, flat labiomental crease,
finishing approximately 1 cm inferior on the buccal aspect of the anterior open bite). These are factors to consider when making
mandible. Trauner and Obwegeser, in 1957, described the now- treatment plans to correct mandibular deformities and influence
popular SSO. This technique is a modification of the step oste- the extent of orthodontic therapy, surgical treatment, and the treat-
otomy described by Schuchardt. Obwegeser advocated for a ment sequence.
greater distance between the medial and lateral horizontal cuts Mandibular orthognathic surgery remains a viable treatment
and connecting them via an osteotomy in the oblique ridge. The option for various dentofacial conditions. It has proven safe and
cut is finished using a chisel along the lateral cortex, completing effective and is implemented frequently with successful outcomes.
the SSO. This technique gained popularity as it offered safe, reli-
able advancement or reduction of the mandible with improved ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
stability of the segments. Dal Pont subsequently modified this complete set of bibliography.

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 301.e1

Bibliography and meta-analysis, Int J Oral Maxillofac Surg 47(2):141-151, 2018.

doi:10.1016/j.ijom.2017.09.013.
Moriarty TF, Schlegel U, Perren S, et al: Infection in fracture fixation: Can
Agbaje JO, Salem AS, Lambrichts I, et al: Systematic review of the inci- we influence infection rates through implant design?, J Mater Sci Mater
dence of inferior alveolar nerve injury in bilateral sagittal split osteot- Med 21(3):1031-1035, 2010. doi:10.1007/s10856-009-3907-x.
omy and the assessment of neurosensory disturbances, Int J Oral Reyneke JP, Ferretti C: Intraoperative diagnosis of condylar sag after bi-
Maxillofac Surg 44(4):447-451, 2015. doi:10.1016/j.ijom.2014.11.010. lateral sagittal split ramus osteotomy, Br J Oral Maxillofac Surg
Brignardello-Petersen R, Carrasco-Labra A, Araya I, et al: Antibiotic 40(4):285-292, 2002. doi:10.1016/S0266-4356(02)00147-X.
prophylaxis for preventing infectious complications in orthognathic Steenen SA, van Wijk AJ, Becking AG: Bad splits in bilateral sagittal split
surgery, Cochrane Database Syst Rev 1(1):CD010266, 2015. osteotomy: systematic review and meta-analysis of reported risk fac-
doi:10.1002/14651858.CD010266.pub2. tors, Int J Oral Maxillofac Surg 45(8):971-979, 2016. doi:10.1016/j.
Cetira Filho EL, Sales PHH, Rebelo HL, et al: Do lower third molars ijom.2016.02.011.
increase the risk of complications during mandibular sagittal split Toh AQJ, Leung YY: The effect of orthognathic surgery on temporoman-
osteotomy? Systematic review and meta-analysis, Int J Oral Maxillofac dibular disorder, J Cranio-Maxillofac Surg 50(3):218-224, 2022.
Surg 51(7):906-921, 2022. doi:10.1016/j.ijom.2021.12.004. doi:10.1016/j.jcms.2021.11.012.
Dal Pont G: Retromolar osteotomy for the correction of prognathism, Trauner R, Obwegeser H: The surgical correction of mandibular progna-
J Oral Surg Anesth Hosp Dent Serv 19:42-47, 1961. thism and retrognathia with consideration of genioplasty. I. Surgical
Demirbas AE, Yilmaz G, Topan C, et al: Risk factors influencing recovery procedures to correct mandibular prognathism and reshaping of the
of neurosensory disturbances following sagittal split ramus osteotomy, chin, Oral Surg Oral Med Oral Pathol 10(7):677-689, 1957.
J Craniofac Surg 31(1):E35-E38, 2020. doi:10.1097/SCS.0000000 doi:10.1016/s0030-4220(57)80063-2.
000005839. Van Sickels JE, Richardson DA: Stability of orthognathic surgery: a re-
Epker BN: Modifications in the sagittal osteotomy of the mandible, view of rigid fixation, Br J Oral Maxillofac Surg 34(4):279-285, 1996.
J Oral Surg Am Dent Assoc 1965 35(2):157-159, 1977. doi:10.1016/S0266-4356(96)90002-9.
Hunsuck EE: A modified intraoral sagittal splitting technic for correction Verweij JP, Houppermans PNWJ, Gooris P, et al: Risk factors for com-
of mandibular prognathism, J Oral Surg Am Dent Assoc 1965 26(4): mon complications associated with bilateral sagittal split osteotomy: a
250-253, 1968. literature review and meta-analysis, J Cranio-Maxillofac Surg 44(9):
Jiang N, Wang M, Bi R, et al: Risk factors for bad splits during sagittal split 1170-1180, 2016. doi:10.1016/j.jcms.2016.04.023.
ramus osteotomy: a retrospective study of 964 cases, Br J Oral Maxil- Verweij JP, Mensink G, Fiocco M, et al: Presence of mandibular third
lofac Surg 59(6):678-682, 2021. doi:10.1016/j.bjoms.2020.08.107. molars during bilateral sagittal split osteotomy increases the possibil-
Kalmar CL, Humphries LS, Zimmerman CE, et al: Orthognathic hardware ity of bad split but not the risk of other postoperative complications,
complications in the era of patient-specific implants, Plast Reconstr Surg J Craniomaxillofac Surg 42(7):e359-e363, 2014. doi:10.1016/j.
146(5):609E-621E, 2020. doi:10.1097/PRS.0000000000007250. jcms.2014.03.019.
Lin SI, McKenna SJ, Ye F, et al: What are the effects of age and presence Yu HJ, Cho SR, Kim MJ, et al: Automated skeletal classification with
of third molars on the occurrence of unfavorable splits during sagittal lateral cephalometry based on artificial intelligence, J Dent Res
split osteotomy?, J Oral Maxillofac Surg Off J Am Assoc Oral Maxillofac 99(3):249-256, 2020. doi:10.1177/0022034520901715.
Surg 79(1):226.e1-226.e8, 2021. doi:10.1016/j.joms.2020. Zaroni FM, Cavalcante RC, da Costa DJ, et al: Complications associated
08.025. with orthognathic surgery: A retrospective study of 485 cases, J Cranio-
Luo M, Yang X, Wang Q, et al: Skeletal stability following bioresorbable Maxillofac Surg 47(12):1855-1860, 2019. doi:10.1016/j.jcms.2019.
versus titanium fixation in orthognathic surgery: a systematic review 11.012.

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61
Maxillary Orthognathic Surgery
A R A SH K HO J A S TEH , S A D R A M O H AG H E G H , a n d HE L IA S A DAT HAE R I BO RO O J E N I

CC had a maximum mouth opening of 45 mm with no deviation or

deflection.
A 24-year-old female was referred for combined surgical–
orthodontic management of her class III skeletal malocclusion and
maxillary hypoplasia. Her chief complaint was her “sunken face.”
Skeletal Component
No orbital dystopia was reported, and the intercanthal distance
HPI was normal. A slight nasal deviation was noted (Fig. 61.1).

The patient came in after 16 months of orthodontic treatment. Transverse Dimensions

The occlusion was aligned and prepared for corrective jaw surgery. • Maxillary dental midline was 2 mm deviated to the right.
No history of temporomandibular joint (TMJ) disorder was • The mandibular dental midline was on.
reported. • The chin point coincided with facial midline.
• The maxillary arch width was adequate.
P MHX/PSHX/Medications/Allergies/SH/FH Anteroposterior Dimension
The patient had no remarkable medical condition and required no • Overjet: –1.5 mm
systemic considerations. Elective orthognathic surgeries should be • Nasolabial angle: 95 degrees
performed with caution in patients with American Society of Anes- • Mentolabial fold: shallow
thesiologists grade III or higher. The risk of reoperation, relapse, • Leptoprosopic face
and postoperative respiratory complications is increased in medi-
cally compromised patients. More specifically, patients with rheu- Vertical Dimension
matic diseases must be in remission stage and receive antirheumatic • Normal facial height
therapy. A history of denosumab uptake necessitates a 6-month • Maxillary incisor length: 8 mm
drug holiday. Myotonic dystrophy and congenital myopathy hold • Upper incisor shows at rest (normal, 2–4 mm tooth show):
an increased risk of respiratory distress symptoms, delayed recovery, 0 mm
dysphagia, lower lip ptosis, and drooling. Moreover, patients with • Upper incisor shows in full smile (normal full crown 1 1 mm
numerous syndromic conditions, such as Ehlers-Danlos, osteogen- of gingival margin): 4 mm 1 interdental gingiva
esis imperfecta, neurofibromatosis, and Noonan syndrome, require
utmost pre- and postoperative special care.
Dental Component
Examination • Open bite
• Overjet (normal, 12.5 to 1 3.5): –1.5 mm
The surgeon should observe the lip–teeth relationship before sur- • Class III is present at the first molar and canine bilaterally
gery. The maxillary midline, nasal tip, and forehead relationship • Appropriately leveled curve of Spee
must be documented. Measuring the alar base and comparing it • Ideal maxillary and mandibular arch form
with the intercanthal distance is recommended. • Sufficient dental decompensation was obtained without the
Presurgical examination of patients occurs in four stages: TMJ, need for premolar extraction (a 0.8-mm space is required for
skeletal, dental, and soft tissue. General anesthesia requires special 1-degree incisor retraction; 1 mm of arch space will be ob-
assessments, such as airway, cardiopulmonary, and neurologic assess- tained after 1.25 degrees of incisor proclining)
ments. The examination results of the patient are described below. • Properly repaired dentition with no missing teeth or
extractions
Temporomandibular Joint Component
No tenderness was reported for the joint and masticatory mus-
Soft Tissue
cles. No signs of clicking or crepitus were detected. The patient • Adequate upper lip length and thickness

302
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 CHAPTER 61 Maxillary Orthognathic Surgery 303

A B C

D E
• Fig. 61.1 Preoperative photography: frontal (A), profile (B), and intraoral views (C–E).

• Paranasal deficiency Data Alignment, Fusion, and Synchronization

• Nasolabial angle: 95 degrees The next step is to record synchronization. The CBCT data are
imported as Digital Imaging and Communications in Medicine
Imaging (DICOM), and the orientation is set to natural head position in
axial, frontal, and sagittal planes. The algorithms and the 3D
Virtual Surgical Planning Workflow outcome must be clinically validated. If necessary, the 3D out-
come can be fine-tuned manually based on overlap of contours in
Data Acquisition CBCT images when moving or rotating the models.
The virtual surgical planning (VSP) workflow starts with acquir-
ing data regarding the patient’s dentition; occlusion, orofacial, Virtual Patient Model: Image Rendering and
and pharyngeal hard and soft tissues; and their dynamic relation. Segmentation
This is achieved through standardized cone-beam computed to- DICOM and stereolithography/standard triangle language (STL) files
mography (CBCT) and intraoral and facial three-dimensional are visualized through volume and surface rendering. Volume render-
(3D) scanning. Images must be taken while the patient is in natu- ing is obtained by assigning a color and opacity to voxels based on
ral head position and must include the patient’s profile and frontal their Hounsfield unit (i.e., radiodensity). Using surface rendering in-
view and 45-degree pictures on both sides. cludes identifying structure boundaries according to Hounsfield unit
Occlusal surface registration can be performed using one of the thresholds, allowing osteotomy simulation and movement of bony
following three approaches: segments. Sequential two-dimensional visualization of voxel layers or
1. Scan the patient’s impression using the CBCT. Using laser contours is obtained with slicing in sagittal, coronal, or axial planes.
scanners in this method is not recommended because of the The compromised CBCT resolution prevents defining condy-
high possibility of undercut missing. lar heads from glenoid fossae surfaces and upper and lower denti-
2. Scan the fabricated dental cast from the direct impression. It is tion. These structures can be separated in segmentation process.
feasible to use both CBCT and laser scanners. Besides, the Extraneous information can be eliminated from the volume, and
patient’s actual occlusion can be registered. a panoramic radiograph can be constructed from CBCT.
3. Use intraoral scanners to record the dental arches and occlusal
relationship with the accuracy of one micron. However, the Virtual Diagnosis
intraoral scanning speed is significantly lower than for extra- Using simulation imaging systems, 3D spatial positional changes can
oral scanning procedures. be visualized in real time (Fig. 61.2). Virtual diagnosis necessitates

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A B

C D
• Fig. 61.2 Preoperative computed tomography records: Measurements were performed for diagnosis
and treatment planning. (A) Midline, (B) Maxillary plane angle, (C) Occlusal cant, (D) Sagittal jaw relation
to skull.

providing the operation team with clinical photographs of the patient

to confirm natural head position, incisor show both in repose and
during animation, and the relation of soft tissue facial midline and
bony midline. The following sequence is recommended in the diag-
nosis phase: (1) dento-maxillo-facial deformity and bite, (2) individ-
ual anatomy and pathology (e.g., fenestration or dehiscence), (3)
airway, (4) TMJ, and (5) 3D cephalometric analyses on both hard
and soft tissue.
Certain established methods are used to detect bony discrep-
ancies, including (1) simulated cephalometric analysis, (2) virtual
mirroring and performing color distance mapping on the contra-
lateral side, and (3) volumetric analysis of the upper respiratory
tract and facial bones.
Surgical Planning and Simulation
Virtual maxillary osteotomies can be made, and bony segments
can be repositioned and adjusted with translational movements in
all three spatial planes and rotational movements as roll, pitch,
and yaw with up to six degrees of freedom (Figs. 61.3 and 61.4).
Three-dimensional VSP allows these adjustments while refer-
encing planes that are derived from the patient’s facial bones. For • Fig. 61.3 Three-dimensional simulation of the surgery and hard tissue
instance, when no orbital dystopia is present, the orbits can be prediction.

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 CHAPTER 61 Maxillary Orthognathic Surgery 305

Maxillary occlusal Overall evaluation of

cant Upper dental midline facial asymmetry after Evaluation and correction
evaluation and correction evaluation and correction virtual occlusal of flaring (“yaw”)
(“roll”) definition

Profile evaluation and

Upper vertical incisal Upper sagittal incisal 3D chin position
occlusal plane
position position evaluation and correction
correction (“pitch”)
evaluation and correction evaluation and correction (“roll,” “yaw,” and “pitch”)

Patient
Final adjustments of
communication of the
the individualized 3D
individualized 3D
virtual treatment plan
virtual treatment plan

• Fig. 61.4 Step-by-step approach to analyze every maxillofacial component related to the treatment
planning. 3D, Three-dimensional.

considered as reference to adjust the roll of the osteotomized choice. Complete blood count, platelet count, and coagulation
maxillary segment in patients with maxillary cant. Upper incisor studies (i.e., prothrombin time, partial thromboplastin time, in-
inclination can be corrected through adjusting the pitch of oste- ternational normalized ratio) are routinely warranted.
otomized maxillary segment based on the true vertical plane. Yaw
correction is performed to align maxillary and facial midlines. Assessment
Designing of Cutting and Positioning Guides and Hard Maxillary deficiency in the sagittal plane direction resulting in class
Tissue Prediction III skeletal deformity, anterior skeletal open bite, midline shift to the
Le Fort cutting guides and plates can be designed and modified. right side, and occlusal cant.
The locations of plate screw holes can be determined according to
the teeth roots, adjacent nerve branches, the antrum, and bone Treatment
quality. Thus, pilot hole locators and drilling vectors can be
aligned in ideal regions. Treatment involves both orthodontic and surgical phases. Presur-
Achieving maximum intercuspation and detection of potential gical orthodontic treatment is performed to align and level the
occlusal or bony collisions manually includes identification on occlusion, coordinate arches and decompensation, and provide
dental casts and virtual replication. Detection of collisions is sufficient space for osteotomies. The postoperative orthodontic
achieved through increasing the translucency of bony segments treatment is done to achieve a stable occlusion and close the pos-
and finding anatomic overlaps via volume rendering. Another terior open bite after surgery.
method is to scroll through axial, sagittal, and transverse slices in Le Fort I osteotomy is an optimal treatment for maxillary re-
search of possible contacts. A combination of embedded algo- positioning in all three directions. In this case, 4-mm maxillary
rithms for automation and manual handling is often used. During advancement was done to solve the maxillary deficient. Consider-
this step, the 3D skeletal prediction can be generated. ing the anterior open bite and absence of tooth show in rest posi-
tion, 3-mm posterior maxillary impaction and 2-mm anterior
Soft Tissue Prediction and Outcome Monitoring inferior disimpaction were performed. Moreover, 2-mm inferior
Virtual patient models can aid patient communication and provide repositioning of the left side and 1-mm superior repositioning of
predicted response to surgery. However, the nonlinear relationship the right side of the maxilla were considered to correct occlusal
between the soft tissue and bony movements complicates the soft cant. Last, to correct the midline, maxilla had to be rotated 2.2
tissue prediction after orthognathic surgery (Fig. 61.5). Although mm to the left side.
the accuracy of predictions remains questionable, implementation To treat vertical maxillary excess, Le Fort I is used in the case of
of finite element methods and artificial intelligence may solve prob- less than 6 mm of impaction. For higher levels, horseshoe osteot-
lems (Table 61.1). omy, a modification of Le Fort I, is recommended. This procedure
can accompany segmental osteotomies in the case of transverse
Labs deficiencies or dual occlusal plan. Surgically assisted rapid palatal
expansion is the treatment choice in the case of having pure trans-
Appropriate preoperative laboratory tests are selected based on verse issues.
each patient’s unique systemic health condition and associated The necessity of using hypotensive anesthesia should be dis-
risks depending on the procedure and anesthetic method of cussed with the anesthesiologist. Using hypotension induced by

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306 S E C TI O N Orthognathic Surgery

• Fig. 61.5 Soft tissue prediction results after maxillary advancement.

TABLE
61.1 Three-Dimensional Measurements beta-blockers is recommended because they are more effective and
more easily titrated than gases. In healthy patients, arterial blood
Measurements in Normal Parameters pressure can be reduced at most 30% below the baseline level with
Patient for White Patients Patient Notes a minimum amount of 50 mm Hg. In patients who underwent
Cranial base angle: SN to Frankfurt horizontal bimaxillary surgery without hypotension, blood transfusion was
normal angle: 6.6 degrees necessary in 13% to 48% of the cases. In case of hypotension, an
indwelling bladder catheter monitors the intraoperative output
SNA: 77.4 degrees 78–84 degrees Maxillary anteroposterior and renal perfusion. Next, nasotracheal intubation is performed.
deficiency relative to The tube should be placed below the vocal cords for proper stabil-
SNB: 78.3 degrees 75–80 degrees the cranial base
sagittal plane)
ity during premaxillary manipulations. A shoulder roll is placed to
ANB: 0.9 degrees Normal range: extend the neck.
1–5 degrees Mandibular progna-
Class I: 1 degree , ANB thism relative to the
,5 degrees cranial base Incision
Class II: ANB .5 degrees
Class III: ANB ,1 degree Anterior, lateral, and pterygomaxillary regions are exposed most
commonly via horizontal circumvestibular incision, extending
SN-Pog: 78–83 degrees contralaterally from one upper first molar to another. A full mu-
78.4 degrees
coperiosteal incision is placed above keratinized gingiva and over
Wits: 6.4 mm 11 mm the level of teeth apices using electrocautery or a scalpel. The pa-
Maxilla incisor to
rotid papilla of Stensen’s duct must be identified and protected.
mandible incisor: Keeping the incision perpendicular to its underlying bone curva-
1.9 mm ture averts buccal fat pad extrusion. An inverted V design is used
to release the frenulum. At the anterior region, the incision must
Maxilla right canine be kept below the anterior nasal spine (ANS) to prevent nasal
to mandible right mucosa perforation into the nasal cavity.
canine: 2.9 mm
Tissue reflection at a subperiosteal plane is initiated at piri-
Maxilla left canine form rims using a periosteal elevator. The subperiosteal dissec-
to mandible left tion is limited to the tissue above the incision line, and the
canine: 3.4 mm mucogingival tissue cuff remains untouched. Any vertical or
Open bite: 3.4 mm Maxillary counterclock- horizontal vestibular incision that leads to periosteal tearing
wise rotation can divulge the anterior lobe of buccal fat pad, and its subse-
Occlusal plane an- 8 6 4 degrees quent herniation in severe cases of tearing complicates the
gle: 13.7 degrees surgical approach and manipulation of posterior maxillary soft
Occlusal cant: Distances between in the and hard tissue.
2.2 degrees orbital point to occlu- Subperiosteal dissection on the labial portion of the maxilla
sal plane: 46.4 mm causes detachment of muscle insertions, which are responsible for
on the left and facial expressions. This can result in altered anatomic landmarks
43.2 mm on the right (e.g., lip line). The facial expression muscles are entrapped within
ANB, angle between point A-nasion and point B-nasion lines; SNA, Sella nasion, A point;
a superficial musculoaponeurotic system (SMAS) and function as
SNB, sella nasion, B point; SN-Pog, angle between Pogonion-nasion and sella-nasion lines. a connected gear because of their attachments either to one
another or to facial bones.

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Gentle dissection restricts manipulation to the subperiosteal injury to the maxillary artery. The distance between the inferior
plane, averting displacement of muscle insertions and tearing extent of the pterygomaxillary fissure to the posterior superior
periosteum and supraperiosteal tissue, leading to injured terminal alveolar artery, infraorbital artery, and descending palatine artery
branches of neurologic and vascular components. Exposed and are 15 mm, 32 mm, and 25 mm, respectively.
manipulated muscular structures depend on selected incision de- For maxillary impaction, two osteotomy lines are required.
sign and position and the dissection technique’s extension and Both of them should follow the rules mentioned earlier. Osteoto-
nature (i.e., submucosal, trans- or paramuscular). mies are parallel and are created downward from the piriform rim
to the zygomaticomaxillary (ZM) buttress. The distance between
Muscular Transections two cuts is defined in the treatment planning phase. Thereafter,
the bony segment between the osteotomies is removed.
Facial expression muscles of the nasolabial region are responsible Lateral wall osteotomy can be done using customized osteot-
for upper lip and nasal base movements. Their attachment to the omy guides fabricated based on the patient’s CT. Two screw holes
labial portion of the maxilla also determines the vestibular depth. are considered in each part of the guide for fixation. After the
Vestibular incisions, such as the horizontal circumvestibular inci- osteotomy, the bridging structure is segmented and replaced with
sion, can approach deep layers of SMAS, consisting of the incisi- a repositioning guide. The superior portion of the osteotomy
vus labi superiorirs (ILS), depressor septi nasalis, myrtiformis, guide acts as the retainer for the repositioning guides and remains
transverse nasalis, and dilator naris muscles. The transverse nasa- at the site. Commonly used guides consist of the following com-
lis, myrtiformis muscle, and levator anguli oris muscles are tran- ponents: occlusal splint, bone attachments, connecting arms, and
sected when performing horizontal circumvestibular incision for osteotomy line indicator. Splints can be eliminated from the de-
Le Fort I surgery. The incision can lead to loss of tension in the sign when creating definitive repositioning holes.
intact superior layer of midface musculature because of its inter-
twining with the deep layer. However, the majority of depressor Pterygoid Plate Separation
septi nasi remains intact. The pterygoid plate is separated using a curved osteotomy
The horizontal cirumvestibular incision can often transect with placed behind the tuberosity at the pterygomaxillary junction
the ILS when placed 5 to 10 mm superior to the mucogingival downward and inferiorly. The upper edge of the instrument
junction. If cut, muscular fiber ends can be visualized and ap- must be above the previously created horizontal osteotomy. A
proximated via double-layer suturing. finger is placed at the palatal side at the hamulus and tuberosity
Deep-layer SMAS muscles in the posterior maxilla that may be junction to feel the extent of the osteotomy and avoid soft tissue
transected by horizontal incision during Le Fort I are the levator perforation. The anterior edge of the osteotome must be angled
anguli oris (LAO) and buccinator. The LAO originates 1 cm be- inferiorly and medially. The created osteotomy should have a
low the infraorbital foramen at the maxillary canine fossa. Tran- width of 6 to 8 mm.
secting the LAO can impede the elevation of angles of the mouth
and the patient’s smiling profile. Lateral Nasal Wall and Septal Osteotomy
In-depth cognition of the precise location of these muscular At the anterior extension of the lateral maxillary osteotomy, the
attachments can improve incision design and minimize adverse lateral nasal wall is osteotomized using a safe-ended straight os-
postoperative changes in facial expression. teotome. The cut is made parallel to the nasal floor below the
inferior turbinate. Lateral walls are positioned divergently, and
Retraction the osteotomy should follow the direction. Caution must be
taken not to go deeper than 25 to 30 mm. A U-shaped cut is
A reverse-angled Obwegeser retractor is placed at the pterygomax- created to separate the nasal septum. The osteotomy line starts
illary junction for feasible exposure, careful enough to avert iatro- above the ANS and extends posterior and inferiorly parallel to
genic periosteal laceration. the nasal floor.
Tissue inferior to the incision is slightly or not at all elevated. The Le Fort I osteotomy usually affects the nasal and labial
If interdental osteotomies are to be performed, the keratinized esthetic, especially when advancement or impaction procedures
gingiva is subperiosteally elevated conservatively using a Wood- are performed. Several methods have been proposed to confine
son elevator. the adverse effects, such as the alar cinch technique with or with-
out a V-Y mucosal suturing, ANS reduction, nasal floor reduc-
Osteotomy tion, excision of the alar base, adjusting the caudal septum, or
different nasal tip corrections. In addition to the mentioned ap-
Lateral Wall Osteotomy proaches, subnasal maxillary osteotomy design can maintain the
Osteotomy cuts can be created with steps or in a sloping shape. perinasal musculature insertions and the ANS or septum position
The osteotomy must be below the infraorbital foramen and ptery- with excellent clinical outcomes. In this approach, instead of the
gomaxillary fissure and above root apices. Osteotomy starts from conventional circumferential incision, a V-shaped one is made in
a point 3 to 4 mm above the nasal floor and goes toward the first the anterior portion that saves the soft tissue adjacent to the piri-
molar region. In the anterior part, the osteotomy should be per- form apparatus. Thus, the attachment of the muscles is preserved.
formed below the level of the inferior turbinate to prevent harm- Without undermining the flap, an anterior subspinal osteotomy
ing the nasolacrimal complex. At this stage, a point 30 to 35 mm is performed. The rest of the procedure is performed the same as
above the first molar bracket is reached. the traditional approach.
A 5-mm space from the root apices and the osteotomy cut
must be preserved. To avoid infraorbital pedicle injury, the oste- Downfracture and Mobilization
otomy cut should not exceed 30 mm from the alveolar border.
Besides, the osteotomy cut should be performed less than 20 mm A bilateral inferior digital pressure at the canine fossa can readily
from the inferior border of the pterygomaxillary suture to avoid separate the osteotomized segment. Cautions must be taken to

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308 S E C TI O N Orthognathic Surgery

avoid nasal mucosa tearing. A Seldin elevator or tongue retractor scan rather than plaster model surgery (Fig. 61.6). Surgical splints
is placed at the posterior tuberosity to complete mobilization and can be either separated from the osteotomy or repositioning guides
push the posterior maxilla downward. If unexpected resistance is or be a part of them to increase their stability.
felt, osteotomies should be revised. Even with the advent of VSP, the position of the maxilla is sig-
nificantly related to the mandibular rotation when using surgical
Posterior Interference Removal splints. The instability of the mandibular condyle–fossa relationship
may reduce the accuracy, especially in the vertical positioning of the
During maxillary impaction, nasal septum deviation can be pre- jaw. Several bone-supported or bone- and dental-supported guides
vented by making a deep groove in the midline with a round bur or have been proposed to increase vertical positioning accuracy
trimming the inferior part of the septum. Bony interferences may (Fig. 61.7). Repositioning guides that define the position of the
also be seen at the tuberosity and lateral nasal walls and can be maxilla regardless of the mandibular rotation can be used instead.
trimmed with a rongeur. Besides, partial inferior turbinectomy is
necessary when more than 5 mm of impaction is indicated. Com- Repositioning, Fixation, Grafting, and Final
plete removal of the inferior turbinate may cause some complications.
The pyramidal processes of the palatine bone must also be re- Evaluation
duced. The greater palatine nerve and artery should be retracted Two miniplates are placed at the piriform and ZM buttress
to prevent any injuries. In addition, the posterior tuberosity, an- around the osteotomy line. With the aid of VSP, prototyping
terior pterygoid plate, and posterior lateral maxillary can also be models of the patients are fabricated before the surgery and the
reduced to allow facile displacement. plates are bent according to the new positions on the model.
In the VSP approach, a secondary guide is added to the re-
Surgical Splint Placement maining part of the osteotomy guide that had been screwed to the
lateral wall of the maxilla previously. The maxilla is positioned to
The surgical splint is ligated to the upper teeth using arch wire. fit the guide, and anterior plates are screwed for initial fixation.
Next, the upper and lower jaws are fixated together. The triangle Repositing guides obviate the need for occlusal wafers. When the
finger maneuver is performed to place the mandibular condyle at maxilla lengthening is the procedure’s aim, spacers fabricated
the optimal position. In detail, two fingers are placed at the gonial based on VSP are placed at this stage and removed after screwing
notch and thumbs at the chin. Two fingers apply upward pressure, the fixation plates. The repositioning guides can be used in com-
and the thumbs exert a downward force in the posterior direction. bination with occlusal splint regardless of using osteotomy guides
In the VSP method, splints are fabricated based on the occlusal (see Fig. 61.7).

A B
• Fig. 61.6 Design of the intermediate (A) and final (B) surgical splints.

A B
• Fig. 61.7 A, Design of a repositioning guide and occlusal splint. In this case, the osteotomy was created
based on the traditional approach, and guides are only used in the repositioning phase. B, Bone-sup-
ported repositioning guide to define the vertical position of the maxilla from the cranial base instead of
adjusting it with the mandibular position.

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 CHAPTER 61 Maxillary Orthognathic Surgery 309

Usually, two holes are created above and below the osteotomy Neurologic Dysfunction
line to fix the plates with four screws. The most inferior hole of
the anterior plate is screwed first bilaterally. Measurements and Temporary paresthesia of trigeminal branches can occur after
maxillary position are confirmed at this stage. Next, the posterior maxillary vestibular incision and dissection. Nasopalatine and
plates are screwed. Stricter fixation with more plates or screws is superior alveolar nerves inevitably intervene with Le Fort osteot-
required for thin bone or large bone gaps. omy fracture lines. Cranial nerve (CN) damage after Le Fort os-
teotomies is often associated with unfavorable fractures in skull
base or anatomic variations. The most common neurosensory
Closure deficit after maxillary surgery is associated with the infraorbital
Nasal Cinch Suture (Alar Base Suture) nerve. The infraorbital nerve may undergo compression, retrac-
To minimize the risk of postoperative nasal base widening, a nasal tion, or transection during subperiosteal dissection or disimpac-
cinch suture is placed after dissection and exposure of paranasal tion. Insensitivity alleviates spontaneously over 2 to 8 weeks after
musculature. A permanent or slowly resorbing suture material surgery. Neurosensory alternation are often immediately per-
(e.g., 2-0 polyglycolic acid) is placed onto the alar base bilaterally ceived after surgery and may be caused by infraorbital nerve trac-
through an intraoral approach. Recontouring and reduction of tion or trauma to descending palatal; nasopalatine; or anterior,
bony inferior piriform rims and ANS prevent alar base widening medial, and posterior alveolar nerves.
and overelevation of the nasal tip. The suture may or may not be Obscure neurosensory deficits with long-term sensory loss
secured to the ANS. Despite septal removal, securing the nasal hold a 15% to 2% prevalence. Maxillary osteotomies may cause
septum to the ANS in the midline averts septal deviation. This is long-term neurologic sequelae to the upper lip, teeth, palate, gin-
done by passing the suture through a drilled hole in the ANS and giva, and mucosa. Mucosal sensitivity often returns within 6 to
cartilaginous nasal septum. The nasal cinch can also prevent sep- 12 months after surgery. Permanent palate and buccal gingival
tum displacement during extubating. As the suture tightens, it numbness is rare. Yet to preserve sensation, greater palatine neu-
pulls alar bases toward one another and often results in an im- rovascular bundle preservation is indicated. A permanent loss of
mediate shorter alar base width, upturned nose, and protruded teeth response to pulpal stimulation is probable. Tooth vitality
upper lip appearance. These immediate changes will resolve after evaluations must only rely on presence of intact blood supply.
a few weeks. Upon recovery, the alar base may even widen com- However, decreased blood flow to maxillary teeth during and after
pared with its preoperative dimensions. It must be considered that Le Fort osteotomy and gradual return to normal state over post-
the nasal tube may distort the nose and mislead the surgeon about operative months are expected. Educating patients in preoperative
the midline position. visits and realistic neurosensory evaluations can enhance patient
anxiety and the postoperative course. Return of pulpal sensitivity
V-Y Closure is often expected over 1 year.
Because Le Fort I horizontal incision transects with midface mus- Prolonged dysfunction of CNs X, XI, and XII is reported con-
culature and attachments, placing double-layer correcting sutures sequent to substantial bleeding during Le Fort downfracture. This
to approximate the muscle fibers in apt anatomic orientation is may be caused by downfracture manipulation and pressure pack-
necessary for maintaining correct three-dimensional facial con- ing to control bleeding. Cerebrovascular accident and lifelong
tour and prevent impaired facial expression. Deep muscle closure hemiparesis upon excessive intraoperative bleeding after maxillary
via braided resorbable suture is followed by mucosal closure. downfracture are also described. Posterior displacement of sharp
Maxillary advancement and normal scarring after circumves- bony margins during pterygomaxillary disjunction was assumed
tibular incision can lead to a shortened and thinned upper lip to be responsible for the traumatic arteriovenous fistula inspected
appearance with a reduced vermillion show. A V-Y mucosal clo- in angiography. Sphenopalatine ganglion dysfunction caused by
sure involves converting the horizontal incision into a vertical proximal hematoma formation after Le Fort I osteotomy was de-
through grasping the midline vestibular incision and pulling it scribed with a postoperative secretomotor rhinopathy. Temporary
upward with a skin hook. Vertical closure of incision at 1 cm away impaired hearing consequent to edema in palatal tissues and the
from the midline on either side of the skin hook is performed Eustachian tube was observed in cleft patients who underwent Le
using a resorbable suture (e.g., 4-0 Vicryl). This aims to increase Fort I osteotomy, which resolved after 6 months. Force transmis-
median tubercle pucker and length. sion and propagation of indirect trauma to the labyrinth of the
internal ear during Le Fort osteotomy to temporal bone could
Vestibular Closure manifest as Eustachian tube dysfunction and tinnitus or dislodged
The remaining parts of incision are sutured posterior-anteriorly in otoliths and benign paroxysmal positional vertigo (BPPV). The
a simple running manner using a resorbable gut suture (e.g., 4-0 symptoms of BPPV may be relieved via the Epley maneuver.
Vicryl).
Ophthalmic Complications
Complications
Ophthalmic complication after maxillary orthognathic surgery is
Surgical complications after Le Fort I osteotomy hold a 8.5% associated with multiple nerve branches. CN II, III, and VI inju-
prevalence. Common postsurgical complications in descending ries are rare and caused by unfavorable ascending of fracture to-
order include neurosensory disturbance, hemorrhage, oroantral ward cranial bases. Amaurosis and hypoesthesia of homolateral
communication, soft tissue injury, tooth injury, infection, osteo- V1 nerve after surgery, leading to poor vision, was reported to be
necrosis, and permanent nerve injury. Using piezoelectric instead consequent to optic nerve ischemia; however, no evidence of
of the conventional can decrease the possibility of neurosensory nerve injury was found. Possible causes include high osteotomies
disturbance, hemorrhage, oroantral communication, tooth injury, in malformation syndromes; indirect trauma from bony lesions of
and permanent nerve injury. the optic nerve canal; osseous flexibility of the region, preventing

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310 S E C TI O N Orthognathic Surgery

fracture; and a combination of pterygomaxillary disjunction, that is exposed from the posterior part of the incision is remained
maxillary traction, and vascular predispositions that lead to nerve in the surgical site to stop bleeding. The pack should be removed
ischemia. CN III palsy on day 2 after surgery was an initial repre- the next day.
sentative of subarachnoid hemorrhage in a patient with carotid– Delayed hemorrhage can occur from several hours to 10 days
cavernous fistula and aneurysm in the internal carotid artery. CN after surgery and usually occurs in the form of epistaxis. This can
VI dysfunction and oculomotor palsy were present after 5 days be caused by trauma during the nasal intubation process or mu-
and resolved spontaneously within 10 weeks. The cause included cosa separation from the nasal floor or nasal septum. Otherwise,
hematoma formation because of pterygoid plate fracture during bleeding is mainly related to descending palatine artery, the inter-
disjunction, cavernous sinus thrombosis, and fractured sphenoid nal maxillary artery, and the pterygoid plexus. It must be consid-
sinuses. The vidian and greater petrosal nerves can be subjects of ered that severe epistaxis is usually caused by a pseudoaneurysm
sustained injury during Le Fort osteotomies. Interrupted para- and is seen 7 to 10 days after surgery. Proper angulation of the
sympathetic innervation to the lacrimal glands caused by neuro- osteotome in the pterygomaxillary junction (i.e., inferior from the
logic injury or hemolacria and imbalanced tearing subsequent to ZM crest toward the pterygoid plates) can help to prevent this
nasolacrimal duct damage were managed conservatively until they complication. Indeed, the osteotomy site is only 25 mm far from
resolved over 8 months. the internal maxillary artery, and considering the length of the
Low circumvestibular incision, gentle retraction, and elimina- osteotome (i.e., 15 mm), there is only remains a 10-mm safety
tion of compressive factors, such as bony elevations, fixation margin. Variations between patients should also be considered.
techniques, or factors that induce hematoma formation, can The descending palatine artery is near the pterygoid plates. Thus,
minimize injury to terminal nerve branches. Management of some recommend retracting it during the surgical procedure, es-
nerve injuries via meticulous releasing of nerve segments and pecially in the segmental maxillary osteotomy. However, it is im-
tension-free reapproximation with epineural sutures for passive possible to preserve this artery in severe maxillary advancements,
anastomosis during surgery can dominantly enhance patient re- and it is usually sacrificed and managed subsequently.
covery. As the first maneuver to manage delayed bleeding, intermaxil-
lary fixation, if used, should be released, and high blood pressure
Hemorrhage should be controlled. The bleeding source should be specified at
this stage through light and suction. If the bleeding does not allow
Life-threatening bleeding has been reported in 1% of cases after the surgeon to inspect the site precisely, local anesthesia injection
Le Fort I osteotomy. Severe nasal bleeding within the first 2 weeks can be performed in the nose and around the palatine foramen.
after surgery can signify arterial hemorrhage. Excessive intra- and Bed rest and nasal packing can help to manage minor postopera-
postoperative bleeding can be attributed to the descending pala- tive bleeding, which usually ceases within 3 to 5 days. In case of
tine arteries or pterygoid venous plexus. Nasal and maxillary sinus severe nasal bleeding or any atypical postoperative epistaxis, inter-
mucosa may be other sources of bleeding. ventional radiographies are required. Atypical means bleeding is
Intraoperatively, bleeding is usually caused by vessel injuries more frequent, recurrent, persistent, or larger than the typical
that can occur in two forms. The first is direct harm caused by postoperative course. Computed tomography angiography can
poor instrumentation (e.g., when an instrument is positioned help identify the injured vessel. Angiography enables direct embo-
high toward the pterygopalatine fossa). This usually affects lization. Based on the acquired data, the following procedures
branches of the internal maxillary artery. The second type of vessel may be necessary: packing of the maxillary sinus, reoperation with
injury is indirect injury caused by sharp, bony edges during the clipping or electrocoagulation of bleeding vessels, application of
pterygoid plate separation or maxillary downfracture and usually hemostatic agents in the pterygomaxillary region, and ligation of
involves the descending palatine arteries and pterygoid plexus. In the external carotid artery at the lingual or facial artery branch in
case of maxillary impaction and advancement, the bone sur- extreme cases. The hemorrhage should be controlled as close to
rounding descending palatine artery in the medial sinus wall the bleeding source as possible to decrease the possibility of bleed-
should be removed to eliminate any interferences. This might ing caused by contralateral circulation.
cause bleeding, which will be easily managed by arterial ligation
and cauterization. The bleeding severity can be different based on Avascular Necrosis
the extent of the injury and the harmed vessel. However, this issue
can be detected readily and managed during the operation. But it This complication occurs in fewer than 1% of the surgeries. Cau-
should be considered that hypotensive anesthesia may undermine tion must be taken because this issue can more commonly occur
the amount of hemorrhage and cause delayed bleeding. in patients with anatomic anomalies such as orofacial cleft, cra-
Severe intraoperative bleeding can be managed by the follow- niofacial dysplasia, or vascular irregularities. Radiation, smoking,
ing maneuver. First, the osteotomy and downfracture should be pregnancy, and trauma are the common factors associated with an
completed to let the surgeon inspect the surgical site for the bleed- increased possibility of necrosis. A higher possibility of necrosis
ing source. Next, packing is performed to confine blood loss, in- can be expected in the segmental osteotomy and more than 9 mm
crease vascular contraction, and enhance visualization. After find- of maxillary movement. The following considerations can help
ing the related vessel, ligation or electrocautery is recommended. minimize the ischemic condition: dividing the maxilla into as few
In case of continuing hemorrhage, thrombin impregnation gauze segments as possible, avoiding creating small segments anteriorly,
or resorbable hemostatic materials, such as Surgicel (oxidized cel- maintaining palatal mucosa integrity, and not performing sagittal
lulose), Avitene (microfibrillar collagen), or Gelfoam (absorbable segmentation in the midline that have thin mucosa and thick
gelatin sponge), can be applied under pressure. In case of persis- bony structure.
tent low-pressure bleeding, usually caused by pterygoid plexus, Intraoperative descending palatine artery rupture can decrease
packing will stop bleeding at the first stage. However, bleeding the maxillary blood supply to 50% on the first day, but the con-
may continue after removing it. In this situation, a tail of packing tralateral arteries will compensate for the issue to some extent.

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 CHAPTER 61 Maxillary Orthognathic Surgery 311

Debridement only
Apply a tissue Antibiotic 1 (when and where
Rule out splint the area of
Obviate mobility dressing such as hyperbaric
impingement
Vaseline gauze oxygena necrosis is well
distinguishable)b

• Fig. 61.8 Management of avascular necrosis. aIts long-term positive impact has not been proven yet.
bMinimal bone should be removed, usually sufficient only to remove conspicuous necrotic section. No
efforts should be made for primary closure. Last, extraction, bone grafting, and implant placement may
be required.

Additionally, postsurgical thrombosis and palatal mucosa perfora- Maxillary sinusitis is a rare complication caused by preexisting
tion can also decrease maxillary blood supply. This issue can cause sinus disease or residual nonviable bone fragments in the sinus.
tooth or bone necrosis, periodontal defects, and even losing the Thus, evaluating the presence of preoperative sinonasal pathology
entire maxilla in severe instances. Maintenance of optimal hy- is essential.
giene, antibiotic therapy, heparinization, and hyperbaric oxygen
may improve the situation and prevent secondary infections. It Relapse and Malpositioning
may be necessary to reposition the bony segment to solve the
problem. It is worth mentioning that the later the intervention, Early and late onset relapses hold a considerable rate of up to
the worse the situation will get. The workflow shown in Fig. 61.8 6.4% of all complications. Relapses after all translational and ro-
is recommended to manage avascular necrosis. tational movements of maxilla are clinically acceptable and below
2 mm. Long-term skeletal stability is expected to occur over the
Tooth Injuries first 6 months, but long-term outcomes are unclear. Late relapse
often develops between months 6 and 12.
The main cause of teeth injury is creating osteotomy lines closer Suboptimal condylar seating and slippage at the osteotomy site
than 5 mm to the root apices. It can more commonly occur can lead to early relapse. Late relapse is associated with surgical
beyond 6 mm of maxillary impactions. Negative pulp vitality test displacement specifics (i.e., type, direction, and magnitude) and
results after surgery can resolve after a while. This may be caused condylar resorption. Bite force, amount of surgical translation,
by a loss of nerve supply to the maxillary teeth on maxillary move- bone grafting, tension balance from surrounding tissues and mus-
ments. However, resolution is expected over 18 months to 2 years. cular attachments, stabilization technique, rotational degree of
Teeth maintain their viability from the collateral blood supply. split segments, and surgeon’s skills determine the positioning of
Even in the case of long-term negative vitality response, endodon- segments. Facial asymmetry and class II and III dentofacial defor-
tic treatment is not indicated unless other signs of pulp necrosis mities hold great chances of postoperative relapse.
are present (e.g., lesion formation or color alternation). Most deviated results were inspected in superoinferior direction,
Dental damage can also occur because of interdental osteoto- especially after widening and downward movements. Translated
mies and fixation screws. Fixation screws are reported to contact superior movements are more stable than inferior repositioning.
adjacent teeth in 12% of cases. However, not all proximal con- Relapses after superior repositioning can be attributed to ap-
tacts lead to pulp necrosis. Blood flow after vertical interdental plication of elastics. Inferior movement relapses can be related
osteotomies significantly decreases in the first 4 postoperative to occlusal forces. The impeding impact of bone grafting on
days. Thus, creating a 2-mm distance at the cementoenamel junc- postoperation relapse is controversial.
tion level and a 4-mm distance at the root apex during the orth- Pitch holds the highest relapse rates with higher degree of coun-
odontic treatment phase between the teeth adjacent to the inter- terclockwise rotation, among all rotational movements. This might
dental osteotomy is recommended. be caused by the wide bony interface with counterclockwise rota-
tion, causing a delayed healing and subsequent relapse episode.
Infection Muscular tensions may be associated with slight relapses of yaw
rotations. Incomplete seating of condyles can cause postoperative
Cellulitis, abscess, maxillary sinusitis, and osteomyelitis are pos- anterior open bite. Application of a manual upward pressure on
sible postoperative infections. Postsurgical site infections can oc- mandibular angles prevents condylar displacement after maxillary
cur in 1.4% to 33.4% of cases. No consensus regarding antibiotic hinge at a posterior prematurity during positioning of the maxil-
therapy protocol and an indication of prophylaxis in this proce- lomandibular unit. A complete paralysis period is necessary during
dure is present. Witherow and Naini recommend the following fixation. Horizontal collapse of the posterior maxilla, namely the
trajectory: intravenous antibiotics at induction and two postop- osseous horizontal relapse after segmental Le Fort osteotomies or
erative doses with 8-hour intervals. Oral antibiotics are often ad- lateral tipping of molars, can clinically present as relapse of open
ministered for 5 days, but some units only rely on perioperative bite or fixation release at monthly follow-ups. This must be con-
doses. Smoking and poor oral hygiene can significantly increase sidered because the highest fixation failure rate (1.7%) is conse-
the risk of infection. quent to maxillary orthognathic surgeries.
Minor infections (i.e., superficial wound infections) can be Aggressive maxillary mobilization and passive repositioning with
managed by small incisions, drainage, and applying antibiotic no interferences followed by rigid internal fixation enhance long-
coverage. Meanwhile, major infections require intensive debride- term stability. Half of secondary operations are needed because of
ment, bone grafting, or both. relapse and may be indicated if maxillary overimpaction occurs.

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312 S E C TI O N Orthognathic Surgery

regarding tip rotation and the nasolabial angle. Esthetic outcomes

Postoperative Nasal Deformity after minor tip change are often feasible, but major tip changes
Significant changes in nasal anatomy secondary to maxillary repo- necessitate concomitant rhinoplasty.
sitioning rely on the intimate influence of the maxilla and its
overlying soft tissue. A multitude of changes in the turbinate, the Discussion
nasal septum, and the nasal valve can be expected, including sep-
tal bowing or deviation, alar base widening, nasal tip rotation, and Traditionally, diagnosis and treatment planning accompany
alternations in the anatomy of the upper lip, nasal supratip de- imprecisions mainly caused by analyzing a 3D object in two di-
pression, and nasal dorsum. mensions with multiple structures being superimposed. Com-
Septal malposition after Le Fort osteotomy can cause nasal puter-assisted 3D evaluations enable surgeons to analyze the
deviation before and during surgery and after extubation. Given skeletal, dental, and soft tissue relations more accurately and to
that compression or dislocation of septum is most commonly visualize hidden yaw, pitch, or roll problems; bony asymmetries;
caused by inadequate trimming of the nasal crest or septum, pre- and occlusal plane discrepancies that may be missed in conven-
and postoperative inspection of the septum is necessary. A twist- tional diagnosis methods.
ing dorsum can also be caused by inadequate septal reduction. In the treatment planning phase, 3D analyses are more useful
The presence of a partially deflated cuff for extubation can also in complicated cases, such as patients with syndromes, clefts, or
result in septal dislocation. This accentuates the importance of asymmetries. This is because of the necessity of skeletal and dental
manual inspection of the nares after extubation. movements in several dimensions. The operation can be virtually
Septal deviation during superior maxillary repositioning can performed on augmented models. The impact of treatment on the
be prevented by adequate inferior reduction of the vomer and soft tissue can be simultaneously visualized. VSP allows the sur-
cartilaginous septum, forming a deep groove in the superior por- geon to evaluate a set of surgical scenarios in three spatial planes
tion of maxilla and septum stabilization in the midline. If preven- and benefits the workflow both time- and precision-wise, while
tive measures are conducted successfully, asymmetry may be only alleviating the risk of many consequent errors and complications,
caused by postoperative edema, which resolves spontaneously. such as invading vital structures.
Three management methods exist for septal deviation, which are In the conventional approach, improper mounting of casts, ref-
immediate manual repositioning, reoperation for caudal septum erence line errors, facebow transferring inaccuracies, and errors in
reduction, and late septoplasty. If the patient has undergone rigid measuring the surgical displacement may cause some imprecisions
fixation and the airway is not obstructed, temporary unilateral in transferring the treatment plan to the surgical procedure. Com-
nasal packing on the deviated side can be used. Immediate reop- puter-aided design and manufacturing–fabricated splints overcome
eration for cephalic septum trimming or considering a trough in many of these inaccuracies while being most used to define the
maxillary crest may be indicated. To retain septal position, it can transverse relationship of the jaws with each other and the cranium.
be secured to the ANS. Upon intraoperative inspection of septal In the conventional approach, the vertical position of the max-
deviation, a closed septal reduction can be done. If not, reduction illa is confirmed by extraoral landmarks. However, skin move-
can be performed in the office under local anesthesia or sedation. ments can decrease the accuracy of the measurements. Meanwhile,
For cases wherein inadequate reduction of caudal septum is noted surgeons cannot accurately measure vertical displacement because
or patient does not have significant breathing or cosmetic difficul- of the triangular effect, which prevents the surgeon from measur-
ties, standard septorhinoplasty can be attempted after complete ing pure vertical distances between the landmarks. VSP enables
resolution of edema and soft and hard tissue healing. transferring the predesign vertical position to the operation room
Disarticulation of the septum from the nasal crest during sur- with bone-supported or tooth- and bone-supported osteotomy
gery and maxillary impaction leads to maxillary encroachment. and repositioning guides.
Thus, positioning of the septum must be considered during maxil- To sum up, VSP can aid surgeons in diagnosis, treatment
lary impaction. After impaction surgeries, the overlying soft tissue planning, surgical procedure, and postoperative evaluation of
loses its support and results in a rather aged appearance. Neglect- orthognathic surgery. However, the cost-effectiveness of using
ing this may lead to deviation, airflow obstructions, unfavorable this technology in uncomplicated cases and the emerging tech-
columella position, and nasal tip deviation. Obstructed nasal nologies’ precision should be considered in daily practice. Indeed,
valves may also represent septal deviation. VSP is imperfect and may accompany errors of less than 1 mm
Alar width and nasal tip projection are highly dependent on in linear and 1 degree in angular measurements.
the final maxillary position. To correct nasal base width, an alar
base cinch suture can maintain the original width. Maxillary ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
movements that predispose tip change must be anticipated complete set of bibliography.

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Bibliography Donaldson CD, Manisali M, Naini FB: Three-dimensional virtual surgi-

cal planning (3D-VSP) in orthognathic surgery: advantages, disad-
Aboul-Hosn Centenero S, Hernández-Alfaro F: 3D planning in orthog- vantages and pitfalls, J Orthod 48(1):52-63, 2021.
nathic surgery: CAD/CAM surgical splints and prediction of the soft Elnagar MH, Aronovich S, Kusnoto B: Digital workflow for combined
and hard tissues results—our experience in 16 cases, J Craniomaxil- orthodontics and orthognathic surgery, Oral Maxillofac Surg Clin
lofac Surg 40(2):162-168, 2012. North Am 32(1):1-14, 2020.
Acebal-Bianco F, Vuylsteke PL, Mommaerts MY, et al: Perioperative Epker BN: Vascular considerations in orthognathic surgery: II. Maxillary
complications in corrective facial orthopedic surgery: a 5-year retro- osteotomies, Oral Surg Oral Med Oral Pathol 57(5):473-478, 1984.
spective study, J Oral Maxillofac Surg 58(7):754-760, 2000. Eshghpour M, Mianbandi V, Samieirad S: Intra- and postoperative com-
Becelli R, De Ponte FS, Fadda MT, et al: Subnasal modified Le Fort I for plications of Le Fort I maxillary osteotomy, J Craniofac Surg 29(8):
nasolabial aesthetics improvement, J Craniofac Surg 7(5):399-402, e797-e803, 2018.
1996. Fernández Sanromán J, Costas López A, Fernández Ferro M, et al:
Bendor-Samuel R, Chen YR, Chen PK: Unusual complications of the Le Subnasal modified Le Fort I osteotomy: indications and results,
Fort I osteotomy, Plast Reconstr Surg 96(6):1289-1296, 1995; discus- J Craniomaxillofac Surg 42(4):347-350, 2014.
sion 1297. Ferneini EM, Castiglione CL, Banki M: Complications in maxillofacial
Bendrihem R, Vacher Ch, Fohlen A, et al: Anatomic basis of Le Fort 1 cosmetic surgery, Cham, 2018, Springer International Publishing.
impaction osteotomy: a radiological study, Surg Radiol Anat Ferri J, Druelle Ch, Schlund M, et al: Complications in orthognathic
39(11):1209-1214, 2017. surgery: a retrospective study of 5025 cases, Int Orthod 17(4):
Beshkar M, Hasheminasab M, Mohammadi F: Benign paroxysmal posi- 789-798, 2019.
tional vertigo as a complication of orthognathic surgery, J Craniomax- Fonseca RJ, Turvey TA, Marciani RD: Oral and maxillofacial surgery
illofac Surg 41(1):59-61, 2013. (vol III), St. Louis, MO, 2009, Elsevier.
Bjerke BT, Zarrabian M, Aleem IS, et al: Incidence of osteoporosis-re- Friedrich RE, Scheuer HA, Höltje W: The effect of bisphosphonate
lated complications following posterior lumbar fusion, Global Spine J medication on orthodontics and orthognathic surgery in patients with
8(6):563-569, 2018. osteogenesis imperfecta, GMS Interdiscip Plast Reconstr Surg DGPW
Brady SC, Courtemanche AD, Steinbok P: Carotid artery thrombosis 8:Doc06, 2019.
after elective mandibular and maxillary osteotomies, Ann Plast Surg Gaitan-Romero L, Shujaat S, Ma H, et al: Evaluation of long-term hard
6(2):121-126, 1981. tissue relapse following surgical-orthodontic treatment in skeletal class
Brijs K, Peeters H, Politis C: Orthognathic surgery in patients with sys- II patients: a systematic review and meta-analysis, Int J Oral Maxillo-
temic diseases, Oral Maxillofac Surg 27(2):235-243, 2023. fac Surg 50(4):477-486, 2021.
Buchanan EP, Hyman CH: LeFort I osteotomy. In Khechoyan D, editor: Girotto JA, Davidson J, Wheatly M, et al: Blindness as a complication of
Seminars in Plastic Surgery, New York, 2013, Thieme Medical. Le Fort osteotomies: role of atypical fracture patterns and distortion
Bykowski MR, Hill A, Garland C, et al: Ruptured pseudoaneurysm of of the optic canal, Plast Reconstr Surg 102(5):1409-1421, 1998.
the maxillary artery and its branches following le fort i osteotomy: Götzfried HF, Thumfart WF: Pre- and postoperative middle ear function
evidence-based guidelines, J Craniofac Surg 29(4):998-1001, 2018. Cao and muscle activity of the soft palate after total maxillary osteotomy
R, Li L, Cao Y: Application of three-dimensional technology in or- in cleft patients, J Craniomaxillofac Surg 16(2):64-68, 1988.
thognathic surgery: a narrative review, Eur Rev Med Pharmacol Sci Gulabivala K, Naini F: The orthodontic-endodontic interface. In
26(21):7858-7865, 2022. Endodontics, ed 4, St. Louis, 2014, Mosby.
Carlos E, Monnazzi MS, Castiglia YMM, et al: Orthognathic surgery Gurusamy K, Aggarwal R, Palanivelu L, et al: Systematic review of ran-
with or without induced hypotension, Int J Oral Maxillofac Surg domized controlled trials on the effectiveness of virtual reality training
43(5):577-580, 2014. for laparoscopic surgery, Br J Surg 95(9):1088-1097, 2008.
Carlson BC, Robinson WA, Wanderman NR, et al: A review and clinical Haas Junior OL, Guijarro-Martínez R, Sousa Gil AP, et al: Stability and
perspective of the impact of osteoporosis on the spine, Geriatr Orthop surgical complications in segmental Le Fort I osteotomy: a systematic
Surg Rehabil 10:2151459319861591, 2019. review, Int J Oral Maxillofac Surg 46(9):1071-1087, 2017.
Casap N, Rushinek H: Minimally invasive orthognathic surgery. Han JJ, Hwang SJ: Evaluation of early postoperative healing of pterygo-
In Nahlieli O (ed): Minimally Invasive Oral and Maxillofacial maxillary region after LeFort I osteotomy with total maxillary setback
Surgery, Berlin, Heidelberg, 2018, Springer Berlin Heidelberg, movement, Oral Surg Oral Med Oral Pathol Oral Radiol 118(6):647-
pp 109-116. 654, 2014.
Cousin AS, Bouletreau P, Giai J, et al: Severity and long-term complica- Hanu-Cernat LM, Hall T: Late onset of abducens palsy after Le Fort I
tions of surgical site infections after orthognathic surgery: a retrospec- maxillary osteotomy, Br J Oral Maxillofac Surg 47(5):414-416, 2009.
tive study, Sci Rep 10(1):12015, 2020. Heifetz-Li JJ, Mechas N, Deitrick P: How accurate are patient-specific
Damrongsirirat N, Kaboosaya B, Siriwatana K, et al: Complications re- osteotomy guides and fixation plates in orthognathic surgery? Adv
lated to orthognathic surgery: a 10-year experience in oral and maxil- Oral Maxillofac Surg 3:100124, 2021.
lofacial training center, J Craniomaxillofac Surg 50(3):197-203, 2022. Humber CC, Lanigan DT, Hohn FI: Retrograde hemorrhage (hemolac-
Daniel RK, Glasz T, Molnar G, et al: The lower nasal base: an anatomical ria) from the lacrimal puncta after a Le Fort I osteotomy: a report of
study, Aesthet Surg J 33(2):222-232, 2013. 2 cases and a review of the literature, J Oral Maxillofac Surg 69(2):
Dao DPD, Le PH: Anatomy, head and neck: eye levator anguli oris 520-527, 2011.
muscle. In StatPearls, March 17, 2023, StatPearls Publishing. Jones LC, Jaskolka M: Perioperative management of the orthognathic
Delmotte C, Depeyre A, Barthelemy I, et al: Postoperative visual loss: a patient. In Fonseca RJ (ed): Oral and Maxillofacial Surgery, Amsterdam,
report of one patient with unilateral blindness after orthognathic 2018, Elsevier.
surgery, J Craniofac Surg 30(1):223-225, 2019. Joss CU, Vassalli IM: Stability after bilateral sagittal split osteotomy ad-
DeSesa C, Steinbacher DM: Orthognathic technique: Le Fort I and bi- vancement surgery with rigid internal fixation: a systematic review,
lateral sagittal split osteotomy (BSSO). In Steinbacher D, editor: J Oral Maxillofac Surg 67(2):301-313, 2009.
Aesthetic Orthognathic Surgery and Rhinoplasty, Hoboken, New Jersey, Khojasteh A, Mohaghegh S: Orthognathic surgery for management of
2019, Wiley Online Library, pp 505-515. gummy smile, Dent Clin North Am 66(3):385-398, 2022.
DeSesa C, Tuggle C, Steinbacher DM: Nasal considerations and orthogna- Khojasteh A, Bastami F, Alikhasi M: Implant-assisted orthognathic sur-
thic surgery. In Steinbacher Derek, editor: Aesthetic orthognathic surgery gery. In Keyhan SO, et al (eds): Integrated Procedures in Facial Cosmetic
and rhinoplasty, Hoboken, NJ, 2019, Wiley Online Library, pp 421-445. Surgery, Cham, 2021, Springer International Publishing, pp 687-702.

t.me/Dr_Mouayyad_AlbtousH
312.e2

Kikuta S, Iwanaga J, Watanabe K, et al: Correction of the topographic Nugent DJ, Romano AA, Sabharwal SH, et al: Evaluation of bleeding
relationship between the depressor septi nasi and incisivus labii supe- disorders in patients with Noonan syndrome: a systematic review, J
rioris: application to cosmetic surgery on the lip and nose, Plast Re- Blood Med 9:185, 2018.
constr Surg 145(3):524e-529e, 2020. O’Ryan F, Carlotti A: Nasal anatomy and maxillary surgery. III. Surgical
Kim D, Kuang T, Rodrigues YL, et al: A new approach of predicting fa- techniques for correction of nasal deformities in patients undergoing max-
cial changes following orthognathic surgery using realistic lip sliding illary surgery, Int J Adult Orthodon Orthognath Surg 4(3):157-174, 1989.
effect, Med Image Comput Comput Assist Interv 11768:336-344, 2019. O’Ryan F, Schendel S: Nasal anatomy and maxillary surgery. I. Esthetic
Kim D, Kuang T, Rodrigues YL, et al: A novel incremental simulation of and anatomic principles, Int J Adult Orthodon Orthognath Surg
facial changes following orthognathic surgery using FEM with realis- 4(1):27-37, 1989.
tic lip sliding effect, Med Image Anal 72:102095, 2021. O’Ryan F, Schendel S: Nasal anatomy and maxillary surgery. II. Unfavor-
Kim JW, Chin B-R, Park H-S, et al: Cranial nerve injury after Le Fort I able nasolabial esthetics following the Le Fort I osteotomy, Int J Adult
osteotomy, Int J Oral Maxillofac Surg 40(3):327–329, 2011. Orthodon Orthognath Surg 4(2):75-84, 1989.
Kim YK: Complications associated with orthognathic surgery, J Korean Papadopoulos MA, Christou PK, Christou PK, et al: Three-dimensional
Assoc Oral Maxillofac Surg 43(1):3-15, 2017. craniofacial reconstruction imaging, Oral Surg Oral Med Oral Pathol
Klemm E, Stösslein F, Mürbe B: [Arteriovenous fistula of the maxillary Oral Radiol Endod 93(4):382-393, 2002.
artery, eustachian tube dysfunction and tinnitus after Le Fort I oste- Peled M, Ardekian L, Krausz AA, et al: Comparing the effects of VY
otomy], HNO 49(3):216-219, 2001. advancement versus simple closure on upper lip aesthetics after Le
Lampen N, Kim D, Fang X, et al: Deep learning for biomechanical Fort I advancement, J Oral Maxillofac Surg 62(3):315-319, 2004.
modeling of facial tissue deformation in orthognathic surgical plan- Perciaccante VJ, Bays RA: Principles of maxillary orthognathic surgery.
ning, Int J Comput Assist Radiol Surg 17(5):945-952, 2022. In Miloro M, editor: Peterson’s Principles of Oral and Maxillofacial
Lanigan DT, Romanchuk K, Olson CK: Ophthalmic complications as- Surgery, 3rd ed, London, 2012, BC Decker, p 7.
sociated with orthognathic surgery, J Oral Maxillofac Surg 51(5):480- Popat H, Richmond S: New developments in: three-dimensional plan-
494, 1993. ning for orthognathic surgery, J Orthod 37(1):62-71, 2010.
Li B, Shen S, Jiang W, et al: A new approach of splint-less orthognathic Proffit WR, Turvey TA, Phillips C: The hierarchy of stability and predict-
surgery using a personalized orthognathic surgical guide system: a ability in orthognathic surgery with rigid fixation: an update and ex-
preliminary study, Int J Oral Maxillofac Surg 46(10):1298-1305, 2017. tension, Head Face Med 3(1):21, 2007.
Li J, Ver Berne J, Shujaat S, et al: Influence of systemic comorbidities on Reyneke JP: Essentials of Orthognathic Surgery, USA, 2010, Quintessence.
the complications of orthognathic surgery: a scoping review, J Stoma- Robl MT, Farrell BB, Tucker MR: Complications in orthognathic sur-
tol Oral Maxillofac Surg 123(6):e956-e961, 2022. gery: a report of 1,000 cases, Oral Maxillofac Surg Clin North Am
Liebregts J, Baan F, Lierop P, et al: One-year postoperative skeletal stabil- 26(4):599-609, 2014.
ity of 3D planned bimaxillary osteotomies: maxilla-first versus man- Robl MT, Farrell BB, Tucker MR: Complications in orthognathic sur-
dible-first surgery, Sci Rep 9(1):3000, 2019. gery: a report of 1000 cases, Oral Maxillofac Surg Clin 26(4):599-609,
Lin HH, Lonic D, Lo LJ: 3D printing in orthognathic surgery—a litera- 2014.
ture review, J Formos Med Assoc 117(7):547-558, 2018. Rodrigo C: Induced hypotension during anesthesia with special reference
Louis PJ, Waite PD, Austin RB: Long-term skeletal stability after rigid to orthognathic surgery, Anesth Prog 42(2):41-58, 1995.
fixation of Le Fort I osteotomies with advancements, Int J Oral Max- Rosén A, Modig M, Larson O: Orthognathic bimaxillary surgery in two
illofac Surg 22(2):82-86, 1993. patients with osteogenesis imperfecta and a review of the literature,
Malik NA: Textbook of oral and maxillofacial surgery, New Delhi, 2012, Int J Oral Maxillofac Surg 40(8):866-873, 2011.
Jaypee, pp 637, 635, 929–930. Schendel SA, Mason ME: Adverse outcomes in orthognathic surgery and
Marais J, Brookes GB: Secretomotor rhinopathy after Le Fort I maxillary management of residual problems, Clin Plast Surg 24(3):489-505,
osteotomy. Case report, Int J Oral Maxillofac Surg 22(1):17-19, 1993. 1997.
Meewis J, Govaerts D, Falter B, et al: Reaching the vertical versus hori- Seo K, Tanaka Y, Terumitsu M, et al: Characterization of different pares-
zontal target position in multi-segmental Le Fort I osteotomy is more thesias following orthognathic surgery of the mandible, J Oral Maxil-
difficult, but yields comparably stable results to one-segment osteot- lofac Surg 63(3):298-303, 2005.
omy, Int J Oral Maxillofac Surg 47(4):456-464, 2018. Shujaat S, Shaheen E, Politis C, et al: Three-dimensional evaluation of
Miloro M: Microneurosurgery. In Miloro M, Kolokythas A, editors: long-term skeletal relapse following Le Fort I maxillary advancement
Management of Complications in Oral and Maxillofacial Surgery, ed 2, surgery: a 2-year follow-up study, Int J Oral Maxillofac Surg 51(4):501-
Hoboken, NJ, 2022, Wiley Online Library, pp 451-464. 508, 2022.
Mobarak KA, Espeland L, Krogstad O, et al: Mandibular advancement Sousa CS, Turrini RNT: Complications in orthognathic surgery: a compre-
surgery in high-angle and low-angle class II patients: different long- hensive review, J Oral Maxillofac Surg Med Pathol 24(2):67-74, 2012.
term skeletal responses, Am J Orthod Dentofacial Orthop 119(4):368- Steel BJ, Cope MR: Unusual and rare complications of orthognathic sur-
381, 2001. gery: a literature review, J Oral Maxillofac Surg 70(7):1678-1691, 2012.
Monteiro Carneiro NC, Voss Oliveira D, Henrique Real F, et al: A new Swennen GR: 3D virtual treatment planning of orthognathic surgery, New
model of customized maxillary guide for orthognathic surgery: preci- York, 2017, Springer, pp 217–277.
sion analysis, J Craniomaxillofac Surg 48(12):1119-1125, 2020. Swennen GR, Mollemans W, Schutyser F: Three-dimensional treatment
Mostoufi B, Caccamese JF: Computer-assisted orthognathic surgery planning of orthognathic surgery in the era of virtual imaging, J Oral
from prediction to navigation. In Keyhan SO, editor, et al: Integrated Maxillofac Surg 67(10):2080-2092, 2009.
Procedures in Facial Cosmetic Surgery, Switzerland AG, 2021, Springer, Tabrizi R, Sadeghi HMM: Complications of orthognathic surgery. In A
pp 703-726. Textbook of Advanced Oral and Maxillofacial Surgery, London, vol 3,
Muradin MSM, Seubring K, Stoelinga P, et al: A prospective study on the 2016, IntechOpen.
effect of modified alar cinch sutures and VY closure versus simple Teemul TA, Perfettini J, Morris DO, et al: Postoperative avascular necro-
closing sutures on nasolabial changes after Le Fort I intrusion and sis of the maxilla: a rare complication following orthognathic surgery,
advancement osteotomies, J Oral Maxillofac Surg 69(3):870-876, J Surg Case Rep 2017(1):rjw240, 2017.
2011. Thereza-Bussolaro C, Galván Galván J, Pachêco-Pereira C, et al: Maxillary
Newhouse RF, Schow SR, Kraut RA, et al: Life-threatening hemorrhage osteotomy complications in piezoelectric surgery compared to con-
from a Le Fort I osteotomy, J Oral Maxillofac Surg 40(2):117-119, ventional surgical techniques: a systematic review, Int J Oral Maxillofac
1982. Surg 48(6):720-731, 2019.

t.me/Dr_Mouayyad_AlbtousH
 312.e3

Thiem DGE, Schneider D, Hammel M, et al: Complications or rather mystery of the “Le Fort I lip”, J Craniomaxillofac Surg 44(12):1917-
side effects? Quantification of patient satisfaction and complications 1921, 2016.
after orthognathic surgery—a retrospective, cross-sectional long-term Waite PD, Tejera TJ, Anucul B: The stability of maxillary advancement
analysis, Clin Oral Investig 25(5):3315-3327, 2021. using Le Fort I osteotomy with and without genial bone grafting, Int
Tiner BD, Van Sickels JE, Schmitz JP: Life-threatening, delayed hemor- J Oral Maxillofac Surg 25(4):264-267, 1996.
rhage after Le Fort I osteotomy requiring surgical intervention: report of Wieczorek A, Loster JE: Activity of the masticatory muscles and occlusal
two cases, J Oral Maxillofac Surg 55(1):91-93, 1997; discussion 93-94. contacts in young adults with and without orthodontic treatment,
Tomasetti BJ, Broutsas M, Gormley M, et al: Lack of tearing after Le Fort BMC Oral Health 15(1):116, 2015.
I osteotomy, J Oral Surg 34(12):1095-1097, 1976. Wiesmann T, Castori M, Malfait F, et al: Recommendations for anesthe-
Tsay CJ, Sawh-Martinez R, Bruckman K, et al: Do vertical soft tissue and sia and perioperative management in patients with Ehlers-Danlos
actual bony landmarks correlate in Le Fort I orthognathic surgery?, syndrome (s), Orphanet J Rare Dis 9(1):1-9, 2014.
J Oral Maxillofac Surg 77(4):828-833, 2019. Witherow H, Naini FB: Le Fort I osteotomy and maxillary advancement.
Turvey TA, Fonseca RJ: The anatomy of the internal maxillary artery in In Naini F, Gill D, editors: Orthognathic Surgery, Hoboken, NJ, 2016,
the pterygopalatine fossa: its relationship to maxillary surgery, J Oral Wiley Online Library, 2016, pp 397-421.
Surg 38(2):92-95, 1980. Xi T, Koning M, Bergé S, et al: The role of mandibular proximal segment
Ueeck BA, Osborn TM, Jo C: Maxillary orthognathic surgery. Clinical rotations on skeletal relapse and condylar remodelling following bilateral
review of oral and maxillofacial surgery-Pageburst E-Book on Kno2: sagittal split advancement osteotomies, J Craniomaxillofac Surg 43(9):
Clinical review of oral and maxillofacial surgery-Pageburst E-Book on 1716-1722, 2015.
Kno, 2013, p 300. Yang HJ, Hwang SJ: Postoperative stability following maxillary down-
Valstar MH, Baas EM, Te Rijdt JP, et al: Maxillary sinus recovery and ward movement with Le Fort I inclined osteotomy at the lateral nasal
nasal ventilation after Le Fort I osteotomy: a prospective clinical, en- cavity wall, J Craniomaxillofac Surg 40(8):793-798, 2012.
doscopic, functional and radiographic evaluation, Int J Oral Maxillo- Zaroni FM, Correia Cavalcante R, da Costa DJ, et al: Complications
fac Surg 42(11):1431-1436, 2013. associated with orthognathic surgery: a retrospective study of 485
Van Camp N, Aerden T, Politis C: Problems in the orofacial region as- cases, J Craniomaxillofac Surg 47(12):1855-1860, 2019.
sociated with Ehlers-Danlos and Marfan syndromes: a case series, Br Zaytoun HS Jr, Phillips C, Terry BC: Long-term neurosensory deficits
J Oral Maxillofac Surg 58(2):208-213, 2020. following transoral vertical ramus and sagittal split osteotomies for
Van Sickels J, Salman SO: Complications in orthognathic surgery. In mandibular prognathism, J Oral Maxillofac Surg 44(3):193-196,
Miloro M, et al (eds): Peterson’s Principles of Oral and Maxillofacial Sur- 1986.
gery, Cham, 2022, Springer International Publishing, pp 2039-2069. Zellin G, Rasmusson L, Pålsson J, et al: Evaluation of hemorrhage de-
Vercruysse H Jr, Van Nassauw Luc, Miguel-Moragas JS, et al: The effect pressors on blood loss during orthognathic surgery: a retrospective
of a Le Fort I incision on nose and upper lip dynamics: unraveling the study, J Oral Maxillofac Surg 62(6):662-666, 2004.

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Maxillomandibular Surgery for
Apertognathia
J AI K. ME DI R AT TA a n d K E V I N L. R I E C K

CC before orthognathic surgery because these surgical procedures can

either cause or exacerbate preexisting TMD symptoms. Some sur-
A 17-year-old White female is referred by her orthodontist for geons recommend simultaneous orthognathic and temporoman-
combined surgical–orthodontic management of her anterior open dibular joint (TMJ) surgery in select cases of preexisting anterior
bite (AOB; apertognathia) and mandibular hypoplasia. The pa- disk displacement; however, this issue is highly controversial. Total
tient complains: “I have difficulty eating and would like to have TMJ joint reconstruction in conjunction with orthognathic surgical
my open bite fixed.” correction for select malocclusions can be accomplished predictably.
Patients presenting for orthognathic surgical correction of
skeletal deformities or malocclusions often have functional prob- PMHX/PSHX/Medications/Allergies/SH/FH
lems. Correction of these issues can also impact the patient’s facial
appearance. It is essential to differentiate the degree of functional Noncontributory.
versus cosmetic dissatisfaction. Successful outcomes require this Elective orthognathic surgery should be avoided in patients
distinction to be well integrated into the surgical plan. classified as being American Society of Anesthesiologists (ASA) III
or higher unless their health issues can be clinically improved
HPI before the procedures. Many patients who have failed nonsurgical
management of obstructive sleep apnea have comorbidities quali-
The patient reports difficulty chewing certain foods because of the fying them for an ASA II or III status. These patients may un-
AOB and is also concerned about her facial profile, including her dergo maxillomandibular advancement or orthognathic surgical
retrusive chin. She admitted a history of thumbsucking, however, procedures electively when optimized and typically will do well.
she denied a history of tongue thrusting. The cause of AOB can Preoperative anesthesia evaluation as well as a discussion of risks
be as simple and straightforward as a digital habit or multifacto- are especially important when working with patients with an ASA
rial and related to skeletal, neuromuscular, or respiratory factors. II class or higher. Consideration for postoperative recovery in the
Tongue thrusting is a difficult parameter to rule out, and an un- intensive care unit may be indicated.
recognized tongue-thrusting habit can cause future relapse of
surgical and orthodontic treatment. Macroglossia should also be
recognized and treated as needed by tongue reduction surgical
Examination
procedures if deemed appropriate. The examination of a patient for orthognathic surgery can be di-
As a teenager, the patient completed extensive orthodontic vided into four components: TMJ, skeletal, dental, and soft tis-
therapy attempting to close her AOB; however, this progressively sue. Skeletal discrepancies, either hypoplasia or hyperplasia,
relapsed over time. Although relapse is unfortunate for the patient, should be assessed in three dimensions: transverse, anteroposte-
orthodontic closure of a larger AOB does have a high relapse rate. rior (AP), and vertical. As for all surgical patients, the airway,
One week before her orthognathic surgical consultation, the pa- cardiopulmonary, neurologic, and other organ systems should be
tient had orthodontic appliances placed by her orthodontist once fully assessed in anticipation of the use of general anesthesia.
again to begin her definitive correction for this problem. The pa- The maxillofacial examination of the current patient pro-
tient was congenitally missing the right maxillary third molar, but ceeded as follows.
the remaining third molars are full bony impactions. Most sur- 1. TMJ component
geons prefer that impacted mandibular third molars be extracted • The muscles of mastication and the TMJ capsule are non-
at least 6 months before mandibular sagittal split osteotomy pro- tender, with no evidence of clicking or crepitus, which is typi-
cedures to avoid complications related to fixation. Maxillary mo- cally seen with disk position or integrity issues. The maximal
lars do not necessarily need to be removed in advance. The patient interincisal opening is 45 mm, with good excursive move-
has no history or symptoms of temporomandibular joint disease ments and no deviation upon opening or closing, consistent
(TMD). Preexisting TMD should be recognized and addressed with a normal TMJ examination.

313
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314 S E C TI O N Orthognathic Surgery

2. Skeletal component • The mandibular arch form is good. There is no mandibular

• There is no vertical orbital dystopia. The intercanthal distance occlusal cant.
is 31 mm. A normal range is 30 to 34 mm. The intercanthal 4. Soft tissue component
distance varies with ethnicities, and individualized care should • The upper lip has adequate thickness and length.
reflect these considerations. The nose is straight and coincident • The nasolabial angle is 85 degrees (normal is 100 degrees 6
with the facial and skeletal midline. Malar eminences are 10 degrees).
within normal limits. • The nasal contour is within normal limits (dorsum, alar
a. Transverse dimension base, tip).
• The maxillary dental midline is coincident with the fa-
cial midline. Imaging
• The mandibular dental midline is 1 mm right of the
maxillary dental midline. Panoramic radiograph and lateral cephalometric radiographs are
• The chin point is 2 mm right of the maxillary midline. the minimum imaging modalities necessary for orthognathic
• The maxillary occlusal plane is canted down 1 mm on surgery. Preoperative profile, frontal (repose and smiling), and
the right at the canine. occlusal photographs should be obtained. Advances in computer-
• The mandibular angles are level. aided design and computer-aided manufacturing technology has
• The maxillary arch width is adequate. contributed to break throughs for treatment planning in orthog-
b. AP dimension nathic surgery beyond virtual surgical planning (VSP). The com-
• Overjet is 6 mm. bined orthodontic and orthognathic surgery digital workflow
• The nasolabial angle is 110 degrees (normal is 100 de- requires cone-beam computed tomography (CBCT) and digital
grees 6 10 degrees). impressions for VSP, orthodontic treatment planning, and fabri-
• The labiomental fold is deep. cation of patient-specific implants (PSI) (i.e., custom cutting
• The chin is retrognathic. guides and titanium fixation plates).
• The profile is brachycephalic. The current patient’s panoramic radiograph showed normal
c. Vertical dimension bony architecture of the condylar head and no other pathology.
• The maxillary incisor length is 10 mm. The right maxillary third molar was missing, and the left maxillary
• Upper incisor show is 3 mm at rest. Ideally, there are 2 and left and right mandibular third molars were full bony im-
to 4 mm of tooth show at rest and 8 mm in full smile. pacted with minimal root formation (Fig. 62.2A).
In an esthetically pleasing smile line, the gingival papilla A lateral cephalogram was obtained with the patient in centric
or up to 1 mm of gingival margin is visible at full smile. relation and the lips in a relaxed or repose position (Fig. 62.2B).
• AOB is 7 mm. Cephalometric analysis revealed AP maxillary hypoplasia (Table
3. Dental component 62.1). It is important to note that measurements differ for Whites,
• Open bite is 7 mm at incisors and 3 mm at canines, with Asians, African Americans, and other races and ethnicities. Com-
divergent occlusal planes (Fig. 62.1). parative normal values for this patient are listed in Table 62.1.
• Overjet is 6 mm (normal is 3.5 mm 6 2.5 mm).
• A class II relationship is present at the first molars and ca- Labs
nines bilaterally.
• The arch width is adequate on handheld articulated models. Baseline hemoglobin and hematocrit are the minimum preopera-
• The curve of Spee has been leveled. tive laboratory values necessary for orthognathic surgery in an
• The dentition is in good repair. The third molars were not otherwise healthy patient if required by anesthesia or hospital
visible on clinical examination. admissions. No bloodwork is required in a young, healthy patient
classified as ASA I or ASA II who has an otherwise negative
medical history. A pregnancy test (urine pregnancy test or serum
b-human chorionic gonadotropin) is warranted for females of
childbearing age. Although blood loss requiring transfusion ther-
apy is uncommon for orthognathic surgery, baseline hemoglobin
and hematocrit values are helpful in cases of excessive blood loss
to determine the need for transfusion or to guide fluid resuscita-
tion. Because the need for transfusion of blood products is rare, a
type and screen is generally not indicated. The current patient had
normal values with a hemoglobin of 13.1 mg/dL and hematocrit
of 40.2%.

Assessment
Maxillary and mandibular hypoplasia, resulting in apertognathia
and a class II skeletal facial deformity.

Treatment
• Fig. 62.1 Preoperative intraoral view revealing anterior open bite. (Courtesy Treatment of patients with significant AOB typically involves a
of Dr. Vincent J. Perciaccante.) combined orthodontic and surgical approach for stable long-term

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 CHAPTER 62 Maxillomandibular Surgery for Apertognathia 315

B
• Fig. 62.2 A, Preoperative panoramic radiograph demonstrating impacted left maxillary and mandibular
third molars and an anterior open bite. B, Preoperative lateral cephalogram showing the apertognathia
and degree of mandibular hypoplasia. (Courtesy of Dr. Vincent J. Perciaccante.)

TABLE
62.1 Cephalometric Analysis

Patient in Figs. 62.1 to 62.4 Normal Parameters for White Patients Patient Notes
Cranial base angle: normal SN-basion angle: 129 degrees 6 4 degrees
SN to FH angle: 7 degrees 6 4 degrees
SNA: 74 degrees 80 degrees 6 3 degrees Patient’s value is suggestive of a maxillary AP
deficiency relative to the cranial base
Harvold differencea: 18 mm Females: 27 mm Patient’s value is suggestive of mandibular
Males: 29 mm hypoplasia
SN-MP: 47 degrees SN-MP: 32 degrees 6 10 degrees FH-MP: 22 Patient’s MP is steep
FH-MP: 33.5 degrees degrees 6 6 degrees
Long axis of upper incisor to SN angle: 102 degrees 104 degrees 6 4 degrees
Long axis of lower incisor to MP angle: 95 degrees 90 degrees 6 5 degrees
Upper lip to E-plane: 22 mm 23 mm 6 2 mm
Lower lip to E-plane: 12.5 mm 22 mm Patient’s value shows a retrusive soft tissue chin
and a concave profile
a
The Harvold difference is the distance from condylion to pogonion minus the distance from the condylion to A point.
AP, Anteroposterior; FH, Frankfurt horizontal; MP, mandibular plane; SN, Sella-nasion; SNA, Sella-nasion, A point.

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results. Patients generally have identifiable skeletal and dental the standard of care for these procedures. Preoperative records are
abnormalities. A coordinated approach involving an orthodontist obtained and correlated with either CBCT or medical-grade CT
and an oral and maxillofacial surgeon requires a close working data for this analysis. The surgeon then plans the case virtually
relationship to meet the needs of the patient and ensure the best with a biomedical engineer. Appropriate splints, custom cutting
outcomes. The goals of presurgical orthodontic therapy are to: guides, and PSIs if desired are forwarded for the surgical proce-
• Align and level the occlusion. dure. The details of this technique are discussed in Chapter 64. If
• Coordinate the maxillary and mandibular arches. Progress for the open bite is to be closed with maxillary surgery alone, the
this case was monitored with handheld plaster models. Intra- maxillary cast is set to the ideal occlusion with the opposing
oral scans and digital impressions can also be used to track mounted mandibular cast. An occlusion set with a small posterior
treatment. open bite maximizes the amount of incisor overlap and reduces
• Eliminate dental compensations in preparation for surgical relapse. Small posterior open bites can be easily closed orthodon-
correction of the skeletal deformities. tically, especially in young patients. Surgically created posterior
It is important to avoid any unstable orthodontic movement open bites allow maximal overlap of the anterior teeth, reducing
such as closing AOBs by extruding maxillary or mandibular ante- the risk of relapse. A thin interocclusal splint is made to stabilize
rior teeth or widening the posterior maxillary horizontal dimension the occlusion intraoperatively during rigid fixation of the maxilla.
by tipping the molars because these can contribute to orthodontic If a segmental osteotomy is performed, the splint is made with a
relapse in the future. Postsurgical orthodontics is aimed at creating palatal strap and wired to the maxillary dentition during the heal-
a final, stable occlusion and closing any posterior open bites that ing phase to minimize the risk for horizontal collapse and relapse
resulted from or were a part of the planned surgical correction. of the malocclusion. Various fixation techniques can be used, de-
Most orthodontists use retainers for maintenance of the final pending on the clinical situation and the surgeon’s preference. The
occlusal relationship and alignment. maxilla is generally fixated with four-point fixation (at the piri-
Orthognathic surgical treatment options and plans for closure form rim and zygomaticomaxillary buttress bilaterally) using 1.5-
of an AOB include Le Fort I osteotomy with posterior impaction or 2-mm bone plates or alternatively with PSI. The mandible can
and anterior advancement, allowing the mandibular arc of rota- be fixated using position screws or rigid fixation plates including
tion to close the AOB, which is determined by model mounted PSI if indicated with monocortical screws.
or virtual model surgery. The surgeon can control the vertical In the current patient, a LeFort I osteotomy and bilateral sagit-
position of the maxilla and incisors because the mandibular arc of tal split osteotomies were used to correct the AOB and to advance
rotation and model setup determine the final position of both the the hypoplastic mandible (Fig. 62.3). The maxilla was advanced
maxilla and mandible. Mounted model surgery is important to 2 mm at the incisors and 2.5 mm at the anterior nasal spine. The
determine the AP position of the maxillomandibular unit when it posterior maxilla was impacted 3 mm, and the anterior maxilla
is set at the desired vertical position. VSP has replaced the his- was impacted 0.5 mm. The mandible was allowed to autorotate
torical use of articulator models in contemporary surgical ap- and was surgically advanced. It is important to realize the differ-
proaches. A LeFort I osteotomy alone can be considered in the ence between net move (total change in position) and surgical
following situations: move (surgical change in position after accounting for autorota-
• The mandible is in good position (i.e., dental midline and tion). The patient underwent postoperative orthodontic treat-
chin midline coincident with the facial midline). ment, and the orthodontic appliances were removed 6 months
• There is no mandibular occlusal cant. after surgery. Fig. 62.4 shows the final occlusion.
• The mandible is aligned with the face in a symmetrical
fashion. Complications
• The mandibular arc of rotation positions the maxilla into a
good AP position while maintaining an appropriate chin Complications of maxillary and mandibular surgery are discussed
projection. in teaching cases elsewhere in this book. An important complica-
• A segmental Le Fort I osteotomy is indicated when a trans- tion related to orthognathic surgery for closure of an AOB is
verse deficiency or a dual occlusal plane exists. long-term stability of the final occlusion (relapse). Several mea-
• Maxillomandibular surgery (i.e., LeFort I and sagittal split sures can be taken to minimize this outcome:
or vertical ramus osteotomies) may be warranted when • Sound orthodontic therapy
skeletal deformities exist in both the maxilla and mandible, • Patient compliance with postoperative retainers
and the mandibular position and arc of rotation cannot be • Avoidance of unstable maxillary or mandibular surgical move-
used to position the maxilla. This is described further in the ments
discussion section. • Immediate postoperative malocclusion or AOB usually results
• Although controversial and historically considered an un- from failure of fixation; failure to seat the condyles correctly
stable movement (before the advent of rigid fixation), man- during fixation; or inadequate maxillary impaction, causing
dibular osteotomies with surgical counterclockwise rotation the condyles to be malpositioned. It is generally recommended
of the dentate mandibular segment can be used in select that any postsurgical malocclusion be corrected promptly, after
clinical situations to successfully close AOBs. Frequently, the diagnosis has been confirmed, because maintaining the
occlusal equilibration is required to remove any prematuri- patient in intermaxillary fixation to treat the problem simply
ties that can cause an unstable occlusion. delays and complicates future treatment.
After the surgical treatment plan has been developed, the sur-
geon can proceed with model surgery to fabricate one or more Discussion
surgical splints on mounted models. Contemporary orthognathic
surgical planning, splint fabrication, and custom cutting guides The prevalence of an AOB or apertognathia is 0.6% to 16.5%,
with accompanying PSI can be done virtually. This has become varying by age and ethnic group. Depending on its cause, an AOB

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 CHAPTER 62 Maxillomandibular Surgery for Apertognathia 317

B
• Fig. 62.3 A, Postoperative panoramic radiograph showing the rigid fixation hardware. B, Postoperative
lateral cephalogram showing correction of the apertognathia and an esthetically pleasing facial profile.
(Courtesy of Dr. Vincent J. Perciaccante.)

only caused by a steep mandibular plane angle, or both the max-

illa and mandible.
Closing a large anterior open with orthodontic therapy alone
is frequently complicated by relapse. A combined orthodontic
and surgical modality offers the most stable result. Pre- and post-
operative orthodontic therapy is mandatory for most orthogna-
thic surgical procedures, except for some cases involving sleep
apnea surgery. During the preoperative orthodontic phase, the
maxillary and mandibular arch forms are idealized. The occlusion
is leveled by eliminating the curve of Spee. Dental compensations
are reduced or eliminated by correcting proclined or retroclined
incisors. The arch space is evaluated to predict whether it will al-
low these changes; leveling the curve of Spee, aligning the teeth to
proper arch form, and retracting proclined incisors require more
arch space. This can be accomplished by interproximal stripping
or bicuspid extractions when crowding is an issue.
The LeFort I osteotomy alone (without mandibular surgery)
• Fig. 62.4 Postoperative intraoral view revealing the final occlusion. for correction of an AOB is indicated when the mandible is in an
(Courtesy of Dr. Vincent J. Perciaccante.) ideal position. This includes the mandibular midline coincident
with the facial midline, absence of mandibular occlusal cant, and
the mandible’s AP position is within normal limits or only a mild
can be categorized as either predominantly of dental origin with- AP hypoplasia. In the case of mild AP hypoplasia, posterior max-
out a skeletal component as seen with a digital or abnormal illary impaction allows autorotation of the mandible forward,
tongue habit or as a skeletal abnormality most commonly caused increasing the AP projection and therefore potentially negating
by posterior maxillary hyperplasia with or without a dental com- the need for mandibular surgery. Closure of the open bite cannot
ponent. The skeletal deformity in skeletal open bite can be in the be esthetically successful with maxillary surgery alone if the
maxilla only caused by an elongated posterior maxilla, mandible mandible is in an asymmetric position. Setting the maxilla to an

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318 S E C TI O N Orthognathic Surgery

asymmetric mandible produces poor esthetic results, especially if at rest and during full smile dictates the anterior vertical posi-
there is a maxillary AP discrepancy. When the mandible has a tion of the maxilla and the amount of impaction or disimpac-
significant midline discrepancy or an occlusal cant, a double jaw tion using the mandible’s arc of rotation. Closing an open bite
procedure is necessary to correct the mandibular discrepancies. with mandibular surgery alone is generally considered a less
Also, the AP position of the mandible must allow autorotation of stable movement and is not recommended by most surgeons,
the maxilla to a possible and acceptable AP position, which can although it has been recently described for cases involving a
be verified only by VSP or mounted model surgery. smaller open bite. Rigid fixation must be used to secure the
In cases of AOB in which the maxilla is deficient in the AP mandibular segments and thus minimize the risk for any relapse.
dimension, advancing the maxilla and impacting it posteriorly Orthognathic surgical cases are highly successful at addressing
closes the open bite, with improved long-term stability. Ad- the skeletal deformities present in patients with significant mal-
vancement and impaction of the maxilla represent the most occlusions not manageable with conventional orthodontics
stable long-term procedures in the hierarchy of possible orthog- alone. Close collaboration with our orthodontic colleagues to
nathic surgical movements. The posterior teeth may need to be refine the occlusal details ensures proper long-term function for
positioned in slight infraocclusion to allow for overcorrection of these patients.
the overlap. When maxillary surgery alone is performed, the fi-
nal maxillary position and occlusion are dictated by the position ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
of the mandible and its arc of rotation. The desired tooth show complete set of bibliography.

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 318.e1

Bibliography Kelly JE, Sanchez M, Van Kirk LE: An assessment of the occlusion of the
teeth of children 6-11 years, United States, Vital Health Stat 11
(130):1–60, 1973.
Abbasi S, Rahpeyma A, Shooshtari Z, et al: Bimaxillary orthognathic Lee CC, Wang TT, Caruso DP, et al: Orthognathic surgery in older pa-
surgery does not induce obstructive sleep apnea in skeletal class III tients: Is age associated with perioperative complications? J Oral
patients, J Oral Maxillofac Surg 80(8):1340-1353, 2022. doi:10.1016/j. Maxillofac Surg 80(6):996-1006, 2022. doi:10.1016/j.joms.2022.
joms.2022.04.010. 01.018.
Alkhayer A, Piffkó J, Lippold C, et al: Accuracy of virtual planning in Lopez-Gavito G, Wallen TR, Little RM, et al: Anterior open-bite maloc-
orthognathic surgery: a systematic review, Head Face Med 16(1):34, clusion: a longitudinal 10-year postretention evaluation of orthodon-
2020. doi:10.1186/s13005-020-00250-2. tically treated patients, Am J Orthod 87(3):175-186, 1985.
Al-Moraissi EA, Wolford LM, Perez D, et al: Does orthognathic surgery Murphy WK, Laskin DM: Intercanthal and interpupillary distance in the
cause or cure temporomandibular disorders? A systematic review and black population, Oral Surg Oral Med Oral Pathol 69(6):676-680,
meta-analysis, J Oral Maxillofac Surg 75(9):1835-1847, 2017. 1990. doi:10.1016/0030-4220(90)90346-t.
doi:10.1016/j.joms.2017.03.029. Passeri LA, Choi JG, Kaban LB, et al: Morbidity and mortality rates after
Badiali G, Bevini M, Ruggiero F, et al: Validation of a patient-specific maxillomandibular advancement for treatment of obstructive sleep
system for mandible-first bimaxillary surgery: ramus and implant apnea, J Oral Maxillofac Surg 74(10):2033-2043, 2016. doi:10.1016/j.
positioning precision assessment and guide design comparison, Sci joms.2016.04.005.
Rep 10:13317, 2020. Available at: https://doi.org/10.1038/s41598- Reichert I, Figel P, Winchester L: Orthodontic treatment of anterior
020-70107-w. open bite: a review article—is surgery always necessary? Oral Maxil-
Burford D, Noar JH: The causes, diagnosis and treatment of anterior open lofac Surg 18(3):271-277, 2014. doi:10.1007/s10006-013-0430-5.
bite, Dent Update 30(5):235-241, 2003. doi:10.12968/denu.2003. Rijpstra C, Lisson JA: Etiology of anterior open bite: a review, J Orofac
30.5.235. Orthop 77:281-286, 2016. Available at: https://doi.org/10.1007/
Chen Z, Mo S, Fan X, et al: A meta-analysis and systematic review com- s00056-016-0029-1.
paring the effectiveness of traditional and virtual surgical planning for Wan Z, Shen SG, Gui H, et al: Evaluation of the postoperative stability
orthognathic surgery: based on randomized clinical trials, J Oral of a counter-clockwise rotation technique for skeletal class II patients
Maxillofac Surg 79(2):471.e1-471.e19, 2021. doi:10.1016/j. by using a novel three-dimensional position-posture method, Sci Rep
joms.2020.09.005. 9:13196, 2019. Available at: https://doi.org/10.1038/s41598-019-
Gander T, Bredell M, Eliades T, et al: Splintless orthognathic surgery: a 49335-2.
novel technique using patient-specific implants (PSI), J Craniomaxil- Wolford LM, Goncalves JR: Surgical planning in orthognathic surgery
lofac Surg 43:319-322, 2015. and outcome stability. In Brennan PA, Schliephake H, Ghali GE, et al
Greenlee GM, Huang GJ, Chen SS, et al: Stability of treatment for ante- (eds): Maxillofacial Surgery, 3rd ed, St. Louis, 2017, Elsevier,
rior open-bite malocclusion: a meta-analysis, Am J Orthod Dentofacial pp 1048-1126.
Orthop 139(2):154-169, 2011. doi:10.1016/j.ajodo.2010.10.019.

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63
Distraction Osteogenesis
C E S AR A. G UE RR E R O and G I S EL A C O NTA S T I B O C C O

CASE 1 Assessment
Severe nasal deformity with asymmetry, severe maxillary deficiency,
CC severe class III malocclusion, and procumbent lower lip.
An 18-year-old patient with unilateral cleft lip and palate wants Treatment
to improve his esthetics and function (Fig. 63.1).
• Presurgical orthodontics mechanics for 6 months before the
surgery to align and level and improve 1MPA (Mandibular
HPI plane angle)
The patient underwent surgery at 3 months of age for cleft lip • Maxillary high Le Fort I advancement via distraction osteogen-
repair, and later at 18 months, his palate was closed. He under- esis (Fig. 63.2)
went speech therapy and presented with no hypernasality, glottal • Transverse maxillary widening
stops, or pharyngeal fricatives. • Alveolar bone grafting from mandibular bone obtained from
the osteotomies, adding bone morphogenetic protein–2 and
three-dimensional (3D) closure (eFig. 63.3)
Examination • Mandibular subapical osteotomy, removing teeth #21 and #28
and closing the spaces
Alert and in no distress; anxious about the possible treatment. • Lower lip mucosa 5-mm resection at the subapical incision to
Vital signs. Within normal limits. improve lower lip balance with the upper lip (eFig. 63.4)
Nose. Deviated nasal pyramid, deviated septum, asymmetric • Extraction of teeth #6, #7, #17, and #32
alas, After the orthognathic surgery was finalized, the anesthesia
Oral cavity. Severe class III malocclusion, severe maxillary tube was changed to the oral route, and rhinoplasty was per-
teeth misalignment, missing several upper teeth, a small alveolar formed. It was an open rhinoplasty with lateral cartilage resection
fistula into the nose. Lip and palate scars. Perinasal deficiency, and repositioning, Weir procedure, and lateral nasal osteotomies
lower lip procumbent. and repositioning. A splint was placed over the nose at the end of
the surgery. The distractors were activated 1 week after surgery, 1
Imaging mm a day for 10 consecutive days. Appliances were removed 6
months after surgery after the maxilla was very stable. This was
Severe maxillary deficiency, with teeth #1, #6, #7, #16, #17, and done in the clinic under intravenous sedation.
#32 impacted. Right alveolar cleft and missing teeth #10 and #11. Orthodontics resumed 3 weeks after surgery, and active treat-
Sella-nasion, A point, 75; SN, B point, 81; ANB (Anterior ment was completed in 18 months. Retention was then maintained
Nasal Spine), –6. (eFig. 63.5).

319
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320 S E C TI O N Orthognathic Surgery

A B

• Fig. 63.1 A and B, Severe maxillary hypoplasia secondary to unilateral cleft lip and palate.

• Fig. 63.2 Maxillary high Le Fort I advancement via distraction osteogenesis.

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320.e1 SE C TI O N Orthognathic Surgery

B
A

E
C

• eFig. 63.3 A–F, Serial radiographs showing the results of distrac-

tion osteogenesis and alveolar bone grafting from mandibular bone
F obtained from the osteotomies, adding bone morphogenetic pro-
tein–2 and three-dimensional closure.

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320.e2S E CT I O N Orthognathic Surgery

A B

• eFig. 63.4 A–C, Outcome of mandibular subapical osteotomy, removing teeth #21 and #28 and closing
the spaces. Lower lip mucosa 5-mm resection at the subapical incision to improve lower lip balance with
the upper lip.

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320.e3S E C T I O N Orthognathic Surgery

A B

C D E

• eFig. 63.5 A–E, Pre- and postoperative photographs after 18 months.

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 CHAPTER 63 Distraction Osteogenesis 321

no space between the right mandibular lateral and premolar. Her

CASE 2 chin was deficient (eFig. 63.6).

CC Assessment
A 17-year-old patient came to the clinic with poor dental occlu- Maxillary transverse deficiency, missing tooth #10, mandibular trans-
sion after 3 years of orthodontics. Her main concerns were her verse deficiency, chin anteroposterior deficiency, and dental malocclu-
upper dental midline, which was 3.5 mm deviated to the left, and sion with crowding.
her lower left canine, which was completely outside the mandibu-
lar arch. Her bite was off, and she had facial muscle pain. Treatment
HPI After complete orthodontics evaluation, maxillary and mandibu-
lar Hyrax devices were installed 3 days before the surgery. The
She had a congenitally missing #10 tooth. Her orthodontist following were done:
closed the dental space with braces, and after treatment, her right • Right maxillary widening (7 mm) and superior repositioning
lower canine does not fit into the mandibular arch. She wants to (3 mm)
have the dental midline corrected and to have straight lower • Mandibular widening via distraction osteogenesis at site #27
teeth. • Chin advancement using a horizontal osteotomy at the sym-
physeal area (5 mm) (eFig. 63.7)
Examination Activation started 7 days after surgery, and after 14 days she
was sent to the orthodontist for full brackets installation. Acrylic
Alert and in no distress; anxious about the possible treatment. was applied over the screws to stabilize the distractors, and a plas-
Vital signs. Within normal limits. tic tooth was fixated to a bracket on either distraction site. Three
Oral. The maxillary dental midline was 3.5 mm deviated to months later, the appliances were removed, a transpalatal bar was
the left, and she was missing the left maxillary lateral incisor. The installed, and full mechanics were applied to finish the orthodon-
orthodontist closed the dental space by applying mechanics. Con- tics treatment within 18 months (eFig. 63.8).
sequently, she was showing gingiva on the right maxilla; there was Eight months after surgery, a dental implant was inserted in site
a medial and lower movement of the whole segment. Also, #10, and an immediate provisional crown was fixated (eFig. 63.9).
because of the major Bolton discrepancy, there was no space for Four months later, the braces were removed, and the final crown
the right mandibular canine, and it was completely buccal with was fabricated and installed (eFig. 63.10).

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 CHAPTER 63 Distraction Osteogenesis 321.e1

A B

C D

• eFig. 63.6 A–E, A 17-year-old patient with maxillary transverse deficiency, missing tooth #10, mandibular
transverse deficiency, and chin anteroposterior deficiency.

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 CHAPTER 63 Distraction Osteogenesis 321.e2

A
B

C D

• eFig. 63.7 A–E, Surgical techniques for chin advancement and subsequent application of appliances to
finish the orthodontics treatment.

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 CHAPTER 63 Distraction Osteogenesis 321.e3

A B

• eFig. 63.8 A and B, Three months after removal of appliances.

A B

• eFig. 63.9 A–E, Pre- and postoperative radiographs at 8 months

D with a dental implant inserted in site #10 and an immediate
provisional crown.

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 CHAPTER 63 Distraction Osteogenesis 321.e4

A B

D E

• eFig. 63.10 A–G, Removal of braces and final crown fabrication and installment.

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 CHAPTER 63 Distraction Osteogenesis 321.e5

F G

• eFig. 63.10, cont’d

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322 S E C TI O N Orthognathic Surgery

CASE 3 Principles of Distraction Osteogenesis

CC ciple of “tension–stress” that allows bone and surrounding soft

tissue lengthening through a progressively controlled fracture
A 4-year-old patient was referred from the children’s hospital. Her separation by means of a distraction device.
pediatrician and neurologist diagnosed severe sleep apnea and
malnutrition, and the family was seeking treatment for her severe Biology Principles of Distraction
obstructive sleep apnea.
Osteogenesis
HPI Protocol of Distraction
The patient fell from her mother’s arms at 12 months of age. She Distraction osteogenesis is indicated for patients with deficiencies
had a small laceration underneath her chin, and soon after, her or bone discontinuity who have adequate blood supply, quantity
right deciduous central incisor turned black. Progressively, her and quality of bone, and ideal surrounding tissues and are reliable
mouth could not open. She was not gaining much weight and so they understand and follow postoperative instructions.
started snoring. She was getting very little sleep and was moody Osteotomy. The incision and soft tissue reflection to perform
and irritable. She was evaluated by her pediatrician, who recom- the surgery must be as limited as possible to not diminish the
mended a consultation with neurology and oral and maxillofacial blood supply, which is mainly responsible for healing and miner-
surgery because lack of sleep and limited mandibular range of alization. The bone cut is done under abundant irrigation, ideally
motion (eFig. 63.11). Ringer’s lactate, and every effort is made to avoid bone overheating
and soft tissue damage. After the bone is fractured, the soft tissues
Examination are carefully and meticulously closed in layers. The presence of the
distraction device under the periosteum would limit the bone heal-
Vital signs: Stable. Irritable, nervous child. ing, contract the distraction chamber, and permit saliva and con-
The clinical evaluation was remarkable for a very small man- tamination into the distraction area. Ideally, the distraction device
dible and no mandibular opening. The airway was obstructed should be placed away from the osteotomy site.
when the patient was lying on her back; she could breathe better Latency period. After the osteotomy is performed and soft tis-
on her side. Her hygiene was acceptable, understanding her in- sues are carefully closed, the distraction device must be activated to
ability to open her mouth. She presented with a small scar under open the bony gap 1 or 2 mm. This space will fill with blood that
her chin. organizes and advance to collagen fibers to bridge the gap; it takes
between 6 and 7 days to be developed. Also, undifferentiated cells
Assessment and morphogenetic proteins accumulate to the sides of the frac-
ture. This timing with no distraction activation and patient after
Severe mandibular deficiency, bilateral temporomandibular joint orders of being on a liquid diet is called the latency period.
(TMJ) ankylosis, and severe sleep apnea. Activation period. After the 7 days of resting, while the col-
lagen fibers develop, the activation of the appliance starts. This is
Treatment either 1 mm a day, at once or divided in two or three times a day,
or half a millimeter for very small bony fragments as in alveolar
• Major mandibular advancement via distraction osteogenesis distraction or compromised blood supply situation. This is called
• Bilateral TMJ arthroplasties (second surgical stage) the rhythm and rate of distraction, which is the number of activa-
• Surgical-orthodontics after the facial growth was completed tions and how often. The collagen fibers are stretched slowly and
(eFig. 63.12) progressively until the desired move has been accomplished. The
The surgery was performed immediately to advance the mandi- space created within the fractured bony parts is called the distrac-
ble, intubating the patient with nasal endoscopy. The Risdom ap- tion chamber; the chamber box has six walls, two bony and four
proach was used to section the posterior mandible bilaterally, and limited by periosteum. The whole chamber is filled with collagen
internal distractors were fixated to the mandible. A latency period fibers and for mineralization gets nutrients from the neighbor-
of 5 days was elapsed, and activation for 35 days was executed to hood tissues. The patient is maintained on a liquid diet until the
obtain 35-mm advancement. The appliances were maintained in end of the activation period, when acrylic is applied to the distrac-
position for 10 months. Radiographs showed bone radiopacity at tor, becoming rigid, and the diet is advanced to a soft diet.
the distraction chamber. Consolidation. The time between the end of the activation
Bilateral TMJ arthroplasties were performed with interposi- and complete chamber bone mineralization is the consolidation
tional silastic, fixated with bicortical screws to keep the prosthesis period. Many variables are involved in this critical period, includ-
in position. The patient was intubated again via nasoendoscopy, ing the quality and quantity of the origin bone, amount of move-
which was much easier this time because the airway was dramati- ment, age of the patient, rigidity of the appliance, and the surgical
cally opened with the mandibular advancement. The distractors site. The new instrumentation and miniaturized distractors allow
were removed during the same surgical stage (eFig. 63.13A to E). the presence of the surgical devices for much longer periods, per-
The patient underwent orthodontics and orthognathic surgery mitting advance mineralization before considering removal of
at age 16 years. The teeth were aligned and leveled, and a Le Fort appliances. The basic rule is the distractors are after once adequate
I osteotomy and chin advancement were executed without com- radiopacity is observed in the radiographs. There was a tendency in
plications. Six months later, the orthodontics braces were re- the beginning years of distraction osteogenesis, because extraoral
moved and followed with removable retainers (eFig. 63.13F to I). appliances were used, to remove the appliances before proper

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322.e1 SE C TI O N Orthognathic Surgery

A B

• eFig. 63.11 A and B, A 4-year-old patient diagnosed with severe sleep apnea and malnutrition, seeking
treatment for her severe obstructive sleep apnea.

B
A

C • eFig. 63.12 A–C, Surgical-orthodontics upon completion of fa-

cial growth.

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322.e2S E C T I O N Orthognathic Surgery

A B C

D E

• eFig. 63.13 A–I, Before and after mandibular distraction osteogenesis, Le Fort osteotomy, and chin
advancement.

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322.e3S E C T I O N Orthognathic Surgery

F G

H I

• eFig. 63.13, cont’d

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 CHAPTER 63 Distraction Osteogenesis 323

mineralization to avoid the psychological impact and reduce scar distraction gap; the peripheral vascular supply extends into the
formation around the surgical facial pins; major relapse and need chamber and stars mineralization; and osteoblasts proliferate
for secondary surgeries were common findings. Other surgeons within the collagen matrix and start osteoid deposition, creating
suggested to rigidly fixate the bone fragments after the distraction bone spicules. Also, chondroblasts start chondroid depositions
activation was accomplished, understanding there were two major but in a minor proportion depending on the rigidity and stability
surgical interventions. of the distraction frame; if excess movement is present, more fi-
Intraoral, transconjunctival, and coronal approaches permit brous and cartilage production will be seen. These islands of car-
surgeons to perform distraction osteogenesis without facial scars, tilage are enveloped in the bone matrix with no clinical meaning
and using new miniaturized distraction devices, allows prolonging unless it is abundant. The mineralization occurs from both ends
the consolidation period without considering removing the appli- of the bony walls and from the periosteal layer in the periphery.
ances. After the activation elapses, the mineralization starts at the The bridge in the center is the last area to consolidate. Haversian
two bony walls, with major contributions from the periosteum. remodeling is the last stage of cortical healing and brings maturity
The mineral depositions begin at either end of the chamber, ad- and mechanical stability.
vancing into the midchamber, leaving a fibrous island in the
middle, called the fibrous interzone, that reduces slowly and pro- Muscle Lengthening
gressively until complete disappearance. When this occurs, the
consolidation period has been completed, and the patient is ad- Most surgeons understand distraction osteogenesis as bone length-
vised to have the distractors removed. ening, and the surrounding tissues should “just” accommodate;
This healing process of mineralization and bone maturation however, important functional and relapse issues are related to the
starts after the activation is completed, and it takes from 2 to fact that as muscles lengthen, different healing processes become
24 months, according to the different variables, especially the relevant to the health and position of the bone.
amount of movement and the age of the patient. Creating a curve The distraction movement lengthens the striated muscle, and
or molding the regenerate is difficult, because the biology only ex- the adaptation is usually well tolerated when the direction is par-
plains the biomechanical concept of lengthening the bone from allel to the distraction. The areas M and Z are stretched initially;
point A to point B. There is no other bone shape possible but a this creates pressure at the origin and insertion of the muscle,
straight line between the two separate points. Also, the longer the stimulating the creation of new sarcomere at either end, the myo-
bone movement is, the narrower the midchamber portion is going tendinous junction, or it could create new ones within the muscle
to be because the periosteum layer contracts as we further activate mass (intercalary new sarcomeres). As distraction activation con-
the distraction device; this phenomenon is called hourglass defor- tinues, the muscle’s inner pressure increases, provoking fiber rup-
mity, which is particularly important because this is the weakest ture; these may heal by muscle regeneration or by sclerosis and
point in the bone, the point where posttreatment fractures are seen. fibrosis. Divided activation decreases muscle damage because
Remodeling period. After the distractors are removed, the higher DNA synthesis occurs with multiple small activations
healed bone undergoes regular tension from the muscles, normal (e.g., four activations of 0.25 mm in 24 hours).
biting forces, and the soft tissues surrounding the bones exerting After lengthening, some patients show mandibular hypomo-
regular tension over the tissues; this will transform the bone and bility. This is secondary to muscle edema and spasm as well as
allow definitive healing and final reshaping. muscle widening when forces are applied in a plane perpen-
The distraction osteogenesis healing process affects differently dicular to the muscle insertion. Active physiotherapy is manda-
the tissues involved in maxillary and mandibular lengthening. tory to all patients, indicating opening goals and mandibular
translation, in the early postoperative phase. In any event, there
are situations when distraction osteogenesis should be per-
Biology formed in different surgical stages to avoid the functional com-
Bone Lengthening plications and relapse of large movements; lengthening of over
25% of the original bone size should be evaluated carefully. It
After the osteotomy has been performed, the latency period occurs, is also important to measure the different muscles involved in a
and the activation has been completed, the created distraction predetermined direction. For example, a 20-mm mandibular
chamber filled with collagen fibers will undergo cell differentiation. anteroposterior advancement in the mandibular angle in a
Mesenchymal cells situated in the periphery of the osteotomy gap 80-mm-long mandible is 20% of bone lengthening, but it is
will invade the chamber and turn into osteoblasts, chondroblasts, 35% for the geniohyoid muscle and 40% widening in the
or fibroblasts depending on strain magnitude, rigidity of the callus, masseter muscle. Both muscles will be very affected in relation
and movement. Different histologic patterns can be observed in the to postoperative contraction, relapse, and functionally; hypo-
various stages of bone healing. mobility is usually seen.
The histologic pattern within the distraction chamber is uniform,
and bone differentiation and metabolism depend on mechanical Nerve Lengthening
loading. Bone healing is caused by maturation of the collagen tem-
plate and osteoid deposition by osteoblast proliferation; levels of The nerve lengthening in craniomaxillofacial surgery is not as
osteocalcin and osteonectin are increased as woven and lamellar important as it would be in orthopedic surgery, in which femur
bone develops. Even though there are osteoid deposition with con- or tibia lengthening greater than 25% would produce paralysis of
tributions from the endosteum (both bony walls) and periosteum, the limb compared with paresthesia of the lower lip. However,
the latter is more important and justifies the noninvasive surgical understanding the physiology and biology of the distraction may
technique maintaining the periosteal layer intact. help in reducing this nerve injury problem.
New tissue formation occurs in a direction parallel to the vec- The surgical plan should avoid lengthening the nerve if possi-
tor of traction. Also, spindle-shaped fibroblasts appear in the ble. In the mandible scenario, using sagittal split or body osteotomies

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324 S E C TI O N Orthognathic Surgery

anterior to the mental nerve would allow major movements with- the bone side, and there is a final lower level on the invaded PDL
out injuring the mandibular nerve. Distraction osteogenesis is side. The rhythm of distraction should be slower and the rate
usually indicated in clinical situations when traditional surgery decreased to overcome the problem. By distracting the bones in a
with minor movements would not obtain the desired goal. Avoid- slower fashion, the gingival tissues are maintained at the original
ing the mandibular body area where the nerve is in the canal good level, and the maturation process is also slower, but the
should be the obvious reasoning. Advancing the distal segment gingival level and tooth movement should be adequate at the end
after sagittal split osteotomy or anterior to the mental nerve should of treatment, with no sequelae.
permit the surgeon the desired advancement without dealing with The teeth should be maintained apart as the distraction process
the alveolar nerve. develops by means of metallic ligatures, avoiding teeth inclina-
Histologically, after distraction, there are three possibilities. tions or translation into the distraction chamber. When the bone
First, the nerve may show perineural thickening and decrease reaches moderate mineralization, the teeth should be moved
surface area of axons, various axonal abnormalities, myelin thick- bodily into the distraction gap, slowly and progressively, around
ening, and disruption of the lamellar pattern. There is a direct 1 mm a month per side. For inclined teeth that need to be set
relationship between the number of millimeters and nerve upright, moving them into the collagen fibers net before enough
changes. Second, the nerve could be damaged during surgery, bone maturation will only bring complications, orthodontic treat-
showing no axonal connection and fibrosis. Third, a distractor ment delays, and the already mentioned complications of gingival
screw is placed within the nerve canal, and neural structures are recessions and dental necrosis. On the other hand, when the
damaged or displaced. orthodontic treatment is not initiated after 2 months of consoli-
dation because of patient irresponsibility or the orthodontist be-
Distraction Osteogenesis and the ing afraid of dealing with the patient after surgery, the mineraliza-
Periodontal Ligament tion will continue, converting the regular soft bone into
well-calcified and often hypermineralized bone, with subsequent
The periodontal fibers are divided into gingival, transseptal, alveo- alveolar contraction and decreasing bone height. This clinical
lar crestal, horizontal, oblique, and apical; their main purpose is stage is complicated to mobilize the teeth into the newly formed
tooth attachment and support during function. When the osteot- bone, delaying the treatment time and even making it impossible
omy is planned to be performed between teeth, careful evaluation to completely close the dental diastema.
and orthodontic involvement are necessary. Enough bone between
the roots is fundamental, and the surgery has to be meticulous Indications
with thin saws after weakening the bone with a 701 bur and final-
izing the cut with a spatula osteotome; copious irrigation is used This technology is indicated for patients presenting with severe
to avoid bone overheating and teeth necrosis. The ideal scenario is mandibular deficiency (.10 mm), temporomandibular arthritis,
a fracture within the bone with two complete bony walls with no sleep apnea, previous failures in advancing the mandible, and in-
perforations to the periodontal ligament. Even though no com- adequate anatomy (syndromic mandibles).
munication is found to the Periodontal Ligament (PDL), the
transseptal fibers will be stretched as the activation is followed. Contraindications
This interdental tension will incline the teeth into the chamber
into immature tissues, with possible complications such as gingival Intraoral distraction osteogenesis biology is based on sound surgi-
recessions, ankylosed teeth, interdental fibrosis, or dental pulp cal principles that depend on vascularity and bone quantity and
necrosis with color changes. The orthodontist has to integrate the quality. It should not be applied after radiotherapy or conditions
teeth on either side with brackets ligated with metallic ligature, in involving very poor bone. Also, this technology requires patient
a figure-of-8 pattern, to ensure no mobility after activation and and family collaboration.
allow the formation of immature bone and progress in time into
maturity. The soft tissues are lengthened, separating the bone from New Miniaturized Intraoral Distractors
saliva and food contamination into the developed distraction
chamber. The teeth will be moved medially after 10 to 12 weeks of Technology and instrumentation advances allow clinicians to use
consolidation, by a controlled slow progressive movement, of smaller, more comfortable intraoral devices. These developments
about 1 mm per month per side. Usually a plastic tooth or pontic have improved surgical outcomes because the appliances may re-
(with a bracket) is fixated between the teeth ligated with metallic main in position for longer periods, without patient inconve-
ligatures to the brackets. The pontic is reduced on either side every nience, allowing a more complete bone consolidation period,
4 weeks to allow teeth mobilization by a chain elastic fixed to the with no relapse and no complications after removal of distractors.
brackets. This movement should not be commenced before 3 The activation devices also have been modified to permit ac-
months of consolidation to ensure moving them into mature bone. cess in remote locations in the facial skeleton and to be easily
This protocol guarantees excellent bone height, good bone archi- removed after finishing by twisting the activation bar in the other
tecture, intact dental roots, and excess of interdental papillae. This direction.
last feature is secondary to gingival tissue lengthening; as the teeth Some appliances have internal mechanisms to change the vec-
are brought together, there is an excess of interdental gingival tissue tor of distraction during the activation phase to ensure adequate
that will mature and contract according to the crestal bone height. occlusion and ideal bone repositioning. Others could change the
If the osteotomy is performed without enough bone space vector at the end of distraction by removing and replacing certain
between the roots, the PDL or the dental root could be exposed screws in the anterior plate.
to the distraction chamber. The biological process is different; the
collagen fibers will be formed from one side, with a much lower ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
level on the tooth side. The bone maturation is much stronger on complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 324.e1

Bibliography Guerrero C, Rivera H, Mujica E, et al: Principles of distraction osteogen-

esis. In Bagheri S, Bell B, Khan H (eds): Current Therapy in Oral and
Maxillofacial Surgery, St. Louis, 2012, Elsevier, pp 101-111.
Bell W, Gonzalez M, Samchukov M, et al: Intraoral widening and Guerrero C: Intraoral bone transport in clefting, Oral Maxillofac Surg
lengthening the mandible by distraction osteogenesis and histogene- Clin North Am 14:509-523, 2002.
sis, J Oral Maxillofac Surg 57:548-562, 1999. Guerrero C: Intraoral distraction osteogenesis. In Selected readings in oral
Cheung LK, Lo J: Distraction of Le Fort II osteotomy by intraoral dis- and maxillofacial surgery, vol 10, Dallas, 2002, University of Texas
tractor: a case report, J Oral Maxillofac Surg 64:856-860, 2006. Southwestern Medical Center at Dallas, pp 1-30.
Chin M, Toth B: Le Fort III advancement with gradual distraction using Guerrero C: Maxillary intraoral distraction osteogenesis. In Arnaud E,
internal devices, Plast Reconstr Surg 100(4):819-830, 1997. Diner PA (eds): Proceedings of the 3rd International Congress on Facial
Ching E, Figueroa A, Polley J: Soft tissue profile changes after maxillary Distraction Processes; 2001 June 14–16; Paris, France, Bologna, Italy,
advancement with distraction osteogenesis by use of rigid external 2001, Monduzzi Editore, pp 381-387.
distraction device: a 1-year follow-up, J Oral Maxillofac Surg 58:959- Guerrero C: Rapid mandibular expansion, Rev Venez Ortod 48:1-2, 1990.
969, 2000. Ilizarov G: The principles of the Ilizarov methods, Bull Hosp Joint Dis
Cohen S, Burstein F, Stewart M, et al: Maxillary-midface distraction in Orthop Inst 48:1, 1988.
children with cleft lip and palate: a preliminary report, Plast Reconstr Ilizarov G: The tension-stress effect on the genesis and growth of tissues.
Surg 99:1421-1428, 1997. In Ilizarov G (ed): Transosseous Osteosynthesis, Germany, 1992,
Figueroa A, Polley J: Management of the severe cleft and syndromic Springer-Verlag, pp 137-255.
midface hypoplasia, Orthod Craniofac Res 3:167-179, 2007. Ilizarov G: The tension-stress effect on the genesis and growth of tissues:
Figueroa A, Polley J: Introduction of a new removable adjustable intra- part I. The influence of stability on fixation and soft tissue preserva-
oral maxillary distraction system for correction of maxillary hypopla- tion, Clin Orthop 238:249-281, 1989.
sia, J Craniofac Surg 20 suppl 2:1776-1786, 2009. Ilizarov G: The tension-stress effect on the genesis and growth of tissues:
Gonzalez M, Guerrero C, Ding M: Distraction osteogenesis. In Bagheri part II. The influence of the rate and frequency of distraction, Clin
S, Bell B, Khan H, (eds): Current Therapy in Oral and Maxillofacial Orthop 239:263-285, 1989.
Surgery, St. Louis, 2012, Elsevier, pp 658-670. Kessler P, Wiltfang J, Schultze-Mosgau S, et al: Distraction osteogenesis
Guerrero C, Bell W, Gonzalez M, et al: Intraoral distraction osteogenesis. of the maxilla and midface using a subcutaneous device: report of four
In Fonseca RJ (ed): Oral and Maxillofacial Surgery, Philadelphia, PA, cases, Br J Oral Maxillofac Surg 39:13-21, 2001.
2000, W.B. Saunders, pp 343-402. Polley J, Figueroa A: Maxillary distraction osteogenesis with rigid external
Guerrero C, Bell W, Gonzalez M, et al: Intraoral distraction osteogenesis. distraction, Atlas Oral Maxillofac Surg Clin North Am 7(1):15-28, 1999.
In Fonseca RJ (ed): Oral and Maxillofacial Surgery, vol 2, Philadel- Samchukov M, Cherkashin A, Makarov M, et al: Muscle adaptation dur-
phia, PA, 2000, W.B. Saunders, pp 359-402. ing single and double level tibial lengthening. In Stein H, Suk S,
Guerrero C, Bell W, Gonzalez M, et al: Maxillary advancement com- Leung P et al (eds): SIROT 99 International Research Society of Ortho-
bined with posterior palate reposition via distraction osteogenesis: a paedic Surgery and Traumatology, Sydney, Australia, April 16-19, 1999,
case report. In Samchukov ML, Cope JB, Cherkashin AM, (eds): Tel Aviv, 1999, Freund Publishing House, pp 460-465.
Craniofacial Distraction Osteogenesis, St. Louis, MO, 2001, Mosby, Samchukov M, Cope J, Cherkashin A: Craniofacial Distraction Osteogen-
pp 531-534. esis, St. Louis, 2001, CV Mosby.
Guerrero C, Bell W, Meza L. Intraoral distraction osteogenesis. Maxillary Schendel S, Delaire J: Facials muscles: form, function and reconstruction
and mandibular lengthening, Atlas Oral Maxillofac Surg Clin North in dentofacial deformities. In Bell W, Proffit W, White R (eds): Surgi-
Am 7(1):111-151, 1999. cal Correction in Dentofacial Deformities, Philadelphia, 1980, WB
Guerrero C, Bell W: Intraoral distraction. In McCarthy JG (ed): Distraction Saunders, pp 259-280.
of the Craniofacial Skeleton, New York, NY, 1999, Springer-Verlag, Shokirov S, Wangerin K: Transantral distraction device in correction of severe
pp 219-248. maxillary deformity in cleft patients, Stomatologija 13(1):25-32, 2011.
Guerrero C, Gonzalez M, Dominguez E: Bone transport by distraction Wangerin K, Gropp H: Die intraorale Distraktionsosteotomie des mik-
osteogenesis for maxillomandibular reconstruction. In Bell W, Guer- rogenen Unterkiefers zur Beseitigung der Atemwegsobstruktion,
rero C (eds): Distraction Osteogenesis of the Facial Skeleton, Hamilton, Dtsch Z Mund Kiefer Gesichtschir 18:236, 1994.
2007, BC Decker, pp 501-519.

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Virtual Surgical Planning for
Orthognathic Surgery
J AI K. ME DI R AT TA a n d K E V I N L. R I E C K

CC Further maxillofacial examination proceeded as follows.

1. Skeletal aspects
A 16-year-old male presents for combined surgical and orthodon- • Significant facial asymmetry is present.
tic correction of his facial asymmetry and apertognathia. He de- • Midpoints
scribes his chief complaint as an inability to bring his anterior • The upper dental midline is 5 mm to the patient’s right.
dentition into occlusion, which makes eating difficult. He is also • The lower dental midline is 2 mm to the patient’s right.
concerned about his facial asymmetry and weak-appearing chin. • The chin point is 4 mm to the patient’s right.
When orthognathic surgery is considered, it is important al- • Vertical: The occlusal plane is canted upward to the patient’s
ways to assess the patient’s chief complaint as it relates to function right.
and esthetics to ensure that any planned surgical intervention • Profile: convex
adequately addresses the patient’s concerns and to fully inform the • Chin: retrusive. Signs of mentalis strain are evident (indicative
patient about any anticipated changes in facial appearance as a of muscular activity to assist with lip closure or competency).
result of the surgery. • Nose: large
• Nasolabial angle: obtuse (normal is 100 degrees 6 10 degrees)
HPI • Throat length: short
2. Lips
The patient has a significant past medical history of bilateral reti- • The upper lip is in normal anteroposterior position.
noblastoma, which was treated at 5 months of age by enucleation • The lower lip is protrusive.
of the left globe and radiotherapy of the right orbit. Significant • Incompetent, open 11 mm.
facial asymmetry caused by radiotherapy-induced growth distur- • The upper lip is thin.
bance is readily evident. The patient had been in orthodontic • The lower lip is thick and protrusive.
therapy for 15 months before this consultation. He is primarily 3. Dentition
concerned about masticatory dysfunction. His deformity consists • AOB malocclusion with contact only on posterior first and
of anterior open bite (AOB) and facial asymmetry with diminished second molars bilaterally. Complete orthodontic appliances are
right periorbital volume and enophthalmos. His first premolar in place.
teeth have been removed in preparation for the surgery. He is miss- • Upper incisor to lip line at repose is 5 mm.
ing teeth #1 and #32, and teeth #16 and #17 remain impacted. • Upper incisor to lip line smiling is 11 mm with 0 mm of gin-
gival display.
PMHX/PSHS/Medications/Allergies/SH/FH • Lower incisor show to lip line at repose is 3 mm of exposed.
• Lower incisor show to lip line at smiling is 10 mm exposed.
Bilateral retinoblastoma, with the left globe treated by enucleation • No centric relation or centric occlusion discrepancy noted.
and the right eye with radiotherapy at 5 months of age. No his- • No macroglossia noted.
tory of recurrence. At present, the patient denies any regular use
of medications and has no drug allergies. Imaging
Examination Although this chapter focuses on the use of three-dimensional
(3D), computer-assisted surgical simulation software in conjunc-
General. No acute distress, well nourished, and appropriate men- tion with a preoperative computed tomography (CT) scan, pan-
tal capacity. oramic and cephalometric radiographs continue to be used by
Head. Growth status complete. Orbital prosthesis present in some clinicians to assist in preoperative surgical planning. Practi-
left orbit. The right periorbital region is diminished in volume, tioners may choose to obtain these radiographs separately; how-
with the presence of enophthalmos and decreased projection of ever, they are easily generated from CT or cone-beam CT (CBCT)
the right zygomatic buttress and arch. data set manipulation via a number of software programs.

325
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 326 S E C TI O N Orthognathic Surgery

For the current patient, recent panoramic and cephalometric of the asymmetry also likely requires other surgical intervention
radiographs (Fig. 64.1A and B) were available at the time of con- to augment or modify the underlying skeletal anatomy or adjunc-
sultation and revealed impacted teeth #16 and #17, in addition to tive soft tissue procedures to improve local deficiencies. Definitive
considerable facial asymmetry. The vertical ramus height of the correction of the soft tissue structures of the face is likely best
mandible was measured as 1 cm shorter on the right than on the done in a staged fashion after the underlying bony foundational
left (disruption of the growth center of the mandible secondary to reconstruction is complete and has had some time to heal. Surgi-
radiotherapy or to altered growth of the functional matrix of the cal intervention requires osteotomies of both the maxilla and
face on the right side), and cephalometrics revealed obvious aper- mandible, preceded by precise preoperative planning, to achieve
tognathia, as noted on clinical examination (Fig. 64.1C). CT both functional and improved esthetic correction.
imaging was obtained after the initial consultation, which corre- Surgical planning has historically used two-dimensional radio-
lated with the radiographic findings and provided additional in- graphs and mounted model surgery to simulate the planned surgi-
formation regarding the hypoplastic nature of the right facial cal movements. Acrylic surgical splints (intermediate or final)
skeleton and its contributions to the facial asymmetry. The CT were then fabricated to assist with positioning of the jaws intraop-
imaging protocol used for virtual surgical planning (VSP) is ex- eratively. This technique has a history of documented success. The
tremely important, and the surgeon must adhere to it closely for current use of CT and VSP software in a preoperative workup
accuracy of procedures and splint fabrication. provides precision and detail of movements in three dimensions
not previously available. This technology has been readily avail-
Labs able since 2010 and continues to be further refined, thereby
continually enhancing outcomes. By evaluating maxillary and
The patient’s current medical status and planned surgical inter- mandibular movements in relation to the entire facial skeleton in
ventions did not require preoperative laboratory assessment, al- a virtual 3D model, the surgeon can make more accurate deci-
though some patients may require specific labs based on their sions and predictions, and precise splints can then be printed for
medical history. the case, thereby eliminating the need for any traditional model
surgery.
Assessment
Treatment
Marked facial asymmetry secondary to radiation therapy for retino-
blastoma, occlusal dysfunction as a result of underlying hypoplastic Isolated cases of apertognathia historically have been treated with
right mandibular body, AOB, and significant occlusal cant. a Le Fort I osteotomy involving posterior impaction and some
Correction of this type of asymmetric deformity requires com- maxillary advancement. Alternatively, isolated mandibular sur-
bined surgical and orthodontic treatments. Complete correction gery consisting of bilateral sagittal split ramus osteotomies and

• Fig. 64.1 Preoperative panoramic (A) and cephalometric (B) radio-

graphs show impaction of tooth #16 and tooth #17, along with exten-
sive facial asymmetry. The vertical height of the mandible is 1 cm
C shorter on the right than on the left. Observable apertognathia can be
seen on the clinical view (C) and on the cephalometric radiograph.

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counterclockwise rotation of the mandible to close the AOB is mandible locked in final occlusion, mild adjustments are made to
possible, assuming rigid fixation is used. The current patient has a the yaw of the entire maxillomandibular complex, allowing for a
combination of apertognathia and significant facial asymmetry, more favorable overlap of the mandibular proximal and distal seg-
which makes any attempts at isolated treatment of the maxilla and ments (Fig. 64.2F). Clearly, selected areas of bony reduction or
mandible futile. Facial asymmetry cases require a great deal of modification or the placement of bone shims in certain areas may
preoperative planning to ensure that the deformity is corrected be necessary to allow for ideal positioning of the proximal and
appropriately. distal segments of the mandible in cases such as this. Postoperative
Virtual surgical planning software, marketed and used by vari- panoramic and lateral cephalometric radiographs reveal stable
ous modeling companies, can assist the surgeon in making impor- fixation and the correction of skeletal asymmetries, in addition to
tant, complex decisions. The planning software is complicated to the enhanced chin position as predicted by the use of VSP tech-
learn and is time-consuming as well. These cases are typically nology (Fig. 64.3). Presently, most surgeons would obtain a post-
planned in conjunction with an engineer who is facile with the operative CT or CBCT to assess outcomes and forgo standard
manipulation of the software. This combined with the surgeon’s radiograph assessment.
expertise allows for rapid virtual planning of the case and predict- Modifications and changes in VSP continue to evolve. As such,
able results. To use such planning, the surgeon must obtain spe- contemporary surgeons must stay up to date regarding these ad-
cific preliminary records. This includes: vancements. Many of these newer and developing techniques are
• Clinical assessment measurements (i.e., midline discrepan- perhaps best used after the surgeon has completed numerous tra-
cies, facial asymmetries, tooth-to-lip position) ditional orthognathic surgical procedures, including using VSP.
• Clinical photographs (frontal, lateral, repose, smiling, and Nuances of these techniques may affect the outcomes in surgeons
occlusal images) who are less experienced.
• CT or CBCT scan with the patient in centric relation One example of this advancing technology is the use of pa-
(seated condyles) tient-specific customized cutting guides and bone plates. This
• Intraoral scans (e.g., iTero, 3-Shape) of the dental arches technology and approach can be extremely useful for the manage-
independently and with the patient in centric occlusion to ment of asymmetry cases. It draws on aspects from traditional
demonstrate the preoperative bite registration VSP and then further augments the planning such that with in-
These records are then uploaded to the modeling company credible attention to detail at the time of the procedure, fixation
along with a tentative plan for the surgical procedure which would of osteotomies in both the maxilla and mandible can be com-
include the anticipated procedures and movements. A web-based pleted without the use of intermediate splints. Treatment begins
meeting is then arranged to plan the surgical case in detail with the with the CT or CBCT date and generation of a heat map to assess
engineer. This meeting allows the surgeon and the modeling team the best bone available for the predictive holes and cutting guide
to make precise movements of the maxillomandibular complex by (Fig. 64.4). The predictive holes can then be used for the actual
visualizing bony osteotomies, condylar position, and overlaps and fixation plates as well (Fig. 64.5). After these have been deter-
gaps between bony segments. Changes in roll, pitch, and yaw of mined, rigid titanium-based cutting guides are fabricated and
the segments can be adjusted, thereby creating the most favorable secured to the area of interest at the time of surgery using the
and stable osseous position of all segments. Such capabilities are preplanned holes (Fig. 64.6). It is very helpful to have three areas
particularly invaluable in facial asymmetry cases. of stabilization to minimize alterations in plate position and
In the current patient, a Le Fort I osteotomy and bilateral therefore minimize the potential for postoperative malocclusion.
sagittal split ramus osteotomy were used to correct the aperto- The cutting guide frequently incorporates fixation at the zygo-
gnathia and facial asymmetry (Fig. 64.2A). The Le Fort procedure matic buttress, piriform rim, and the occlusion as well by means
was performed first; an intermediate splint was used to level the of an “arm” that extends toward the occlusion and rests on a se-
maxillary occlusal plane and align the dental midline with the cure and predictable location (Fig. 64.7). Surgeons with extensive
facial midline. The maxilla was impacted 7.3 mm posteriorly and experience using VSP principles understand that virtually every
3.5 mm anteriorly, with 6.1 mm of impaction on the left and movement is possible digitally. The engineers assisting with the
0.9 mm on the right. After rigid fixation of the maxilla, bilateral planning are facile at the software manipulation and can provide
sagittal split ramus osteotomies were performed, bringing the essentially whatever the surgeon desires, but we must remember
dentition into final occlusion using the final splint. This case what will actually be possible intraoperatively. After the predictive
demonstrates the quality and precision of movements afforded holes and plates are generated, a drill angulation assessment is
by the use of preoperative planning software. As shown in undertaken and should be carefully reviewed to make sure that
Fig. 64.2B, the maxillary dental midline is coincident with the one can actually position a surgical drill in the planned areas
facial midline; however, the maxillary yaw is shifted significantly intraoperatively (Fig. 64.8). One must realize the hard and soft
to the patient’s left. Fig. 64.2C illustrates the yaw correction of the tissue constraints at play in positioning the surgical drill to secure
maxilla, which places the maxilla in the most ideal yaw, pitch, and the cutting guide and eventually the actual fixation plate. Fig. 64.9
roll position. After the maxillary movements have been planned, illustrates a secured cutting guide in place for a maxillary osteot-
the mandible is brought into the final occlusion based on the omy. As mentioned, this technique has numerous nuances but
preoperative intraoral scans provided to the modeling company. can also be very helpful in managing complex orthognathic surgi-
Visualization of the mandibular osteotomies and the gaps natu- cal procedures. It presents with several challenges encountered in
rally created by the asymmetric movements of the mandible are the learning curve. Some of these are outlined along with associ-
easily reviewed and examined (Fig. 64.2D). As noted, the overlap- ated solutions in Fig. 64.10. Surgeons should spend the time to
ping aspects of the proximal and distal segments are less than ideal become very familiar with this approach before offering it to pa-
(Fig. 64.2E), and fixation in this position would require a great tients for correction of their malocclusions. Extensive knowledge
deal of adjustment to the proximal segment or result in flaring of of how to convert back to traditional methods and having appro-
the right mandibular condyle. However, with the maxilla and priate backup splints for this if necessary is paramount.

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328 S E C TI O N Orthognathic Surgery

• Fig. 64.2 Computer-aided surgical simulation planning. A, Composite skull

model showing original condition of apertognathia and facial asymmetry. B,
Inferior view showing that the maxillary dental midline is coincident with the
facial midline, whereas the maxillary yaw is shifted greatly to the left. C, Infe-
rior view showing the maxilla in the ideal yaw, pitch, and roll position. D, Left
posterior view showing the mandibular osteotomies and the gaps caused by
the asymmetric movements of the mandible. E, Frontal view demonstrating
E the overlapping aspects of the proximal and distal segments. F, Postopera-
tive computer simulation after maxillary and mandibular surgery.

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 CHAPTER 64 Virtual Surgical Planning for Orthognathic Surgery 329

• Fig. 64.3 Postoperative panoramic (A) and cephalometric (B) radio-

graphs showing stable fixation, correction of the skeletal asymmetries,
C and enhancement of the chin position. C, Postoperative clinical view
no longer shows apertognathia.

4.00 mm

3.00 mm

2.00 mm

1.00 mm

0.00 mm

• Fig. 64.4 Heat map generated from computed tomography (CT) and cone-beam CT data using Hounsfield
units to assess bone density and the best locations for placement for predictive holes for eventual fixation
of the cutting guides and bone plates. (Courtesy of Stephanie Drew, DMD, FACS.)

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330 S E C TI O N Orthognathic Surgery

Predictive
holes

• Fig. 64.8 Drill angulation map depicting the screw hole angle and drill
• Fig. 64.5 Predictive holes generated from heat map data show the angle for all the fixation holes in the cutting guide and fixation plates. Care-
overlap of the cutting guide and bone plates. (Courtesy of Stephanie ful evaluation of the orientation of the drill pathway should be undertaken
Drew, DMD, FACS.) to make sure that it is a possibility intraoperatively. (Courtesy of Stephanie
Drew, DMD, FACS.)

• Fig. 64.9 Intraoperative example of a cutting guide in place for a maxillary

osteotomy. (Courtesy of Stephanie Drew, DMD, FACS.)

• Fig. 64.6 Cutting guide demonstrating multiple points of stabilization Challenges and Opportunities
including the occlusion. This case involves a wedge reduction of the max-
illa for impaction. (Courtesy of Stephanie Drew, DMD, FACS.) Challenges Solutions

Guide does not ft Use intermediate splint as a

save
Guide not stable Use an occlusal arm as a third
point of orientation
Plate does not ft Use standard plates as a save
Bone not in correct position
Guide hole wrong orientation Check your plan for hole
to drill orientation
Guide hole too tight and bits Check slot size if you are to
break use ultrasonic
Osteotomy slot too tight for
pie-zo/ultrasonic cutter
Holes over thin bone, screws Check bone thickness and
strip hole position

• Fig. 64.7 Image depicting the articulated arms of the cutting guide from the • Fig. 64.10 Summary of some challenges to patient-specific cutting guides
occlusal aspect. This offers an additional point of stabilization for this hardware, and plates as well as some opportunities for managing the problems.
further enhancing predictability. (Courtesy of Stephanie Drew, DMD, FACS.) (Courtesy of Stephanie Drew, DMD, FACS.)

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 CHAPTER 64 Virtual Surgical Planning for Orthognathic Surgery 331

Complications patient. The patient may not perceive a need for correction or may
have unrealistic expectations of what can truly be accomplished;
Orthognathic surgery requires attention to detail and an excellent both are important aspects of surgical planning.
knowledge of facial anatomy to minimize surgical complications. Significant asymmetries require a great deal of surgical experi-
Failure to appreciate the patient’s specific anatomy and poor surgi- ence and skill because they can involve a variety of tissues and oc-
cal technique can lead to intraoperative complications; however, cur in multiple planes making correction complex. In the current
unforeseen complications also can occur in any orthognathic pro- patient, the asymmetry was caused by radiotherapy at a young age,
cedure. Such complications may include nerve injury, bleeding, secondarily altering the growth of a variety of tissues at a variety of
unfavorable fractures, and technical difficulties in bony position- levels. Orthognathic surgery in this patient was the first phase of
ing and fixation. The goal of every orthognathic surgeon should treatment in correcting his asymmetries. Future plans for facial
be to minimize the risk of these complications by understanding augmentation by alloplastic or autogenous means are desired by
the patient’s specific anatomy and undertaking sound preoperative the patient. Understanding the limits of orthognathic surgery in
planning. The use of VSP software provides the surgeon with ad- correction of asymmetries is also important. Additional procedures
ditional means to better understand these case-specific details. may be required to achieve balance in facial esthetics.
Specific anatomic structures, such as the neurovascular bundles in Diagnosis of facial asymmetry begins with a thorough clinical
the mandible, can be highlighted and referenced to the anticipated evaluation. Although the methodologies by which a surgeon may
osteotomies for improved safety. clinically evaluate a patient may differ, a detailed, systematic, and
Complications of maxillary and mandibular orthognathic sur- comprehensive approach is required as the first step in the evalu-
gery are discussed in greater detail elsewhere in this text. ation of potential orthognathic patients. As discussed previously,
the adjunct information obtained from 3D imaging techniques
Discussion and the use of VSP can enhance the surgeon’s ability to properly
diagnose and treat the details of facial asymmetry. However, as
Facial asymmetry is ubiquitous among individuals to some degree. with generic model surgery, a firm understanding of this technol-
These asymmetries obviously vary in severity and may be perceived ogy is paramount to using it properly in the treatment of our
differently by different individuals. Recognition of asymmetry is patients. As with all advancements in medical technology, the
crucial in examining a patient for potential orthognathic surgery primary goal should be to enhance the clinician’s ability to im-
because some asymmetries are subtle, but others are more obvious. prove patient care.
It is the responsibility of the clinician and surgeon to understand
the patient’s perception of his or her facial asymmetries because the ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
practitioners’ perceptions may not coincide entirely with that of the complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 331.e1

Bibliography Orentlicher G, Goldsmith D, Horowitz A, et al: Applications of 3-dimen-

sional virtual computerized tomography technology in oral and maxil-
lofacial surgery: current therapy, J Oral Maxillofac Surg 68:1933, 2010.
Alkhayer A, Piffkó J, Lippold C, et al: Accuracy of virtual planning in Quevedo LA, Ruiz JV, Quevedo CA: Using a clinical protocol for orthog-
orthognathic surgery: a systematic review, Head Face Med 16:34, nathic surgery and assessing a 3-dimendionsal virtual approach: cur-
2020. Available at: https://doi.org/10.1186/s13005-020-00250-2. rent therapy, J Oral Maxillofac Surg 69:623, 2011.
Badiali G, Bevini M, Ruggiero F, et al: Validation of a patient-specific Schendel S, Jacobson R: Three-dimensional imaging and computer simu-
system for mandible-first bimaxillary surgery: ramus and implant lation for office-based surgery, J Oral Maxillofac Surg 67:2107, 2009.
positioning precision assessment and guide design comparison, Sci Schouman T, Rouch P, Imholz B, et al: Accuracy evaluation of CAD/
Rep 10:13317, 2020. Available at: https://doi.org/10.1038/s41598- CAM generated splints in orthognathic surgery: a cadaveric study,
020-70107-w. Head Face Med 11:24, 2015. Available at: https://doi.org/10.1186/
Chen Z, Mo S, Fan X, et al: A meta-analysis and systematic review com- s13005-015-0082-9.
paring the effectiveness of traditional and virtual surgical planning for Stokbro K, Aagaard E, Torkov P, et al: Virtual planning in orthognathic
orthognathic surgery: based on randomized clinical trials, J Oral surgery, Int J Oral Maxillofac Surg 43(8):957-965, 2014. doi:10.1016/j.
Maxillofac Surg 79(2):471.e1-471.e19, 2021. doi:10.1016/j. ijom.2014.03.011.
joms.2020.09.005. van Riet TCT, Klop C, Becking AG, et al: Management of asymmetry,
Farrell BB, Franco PB, Tucker MR: Virtual surgical planning in orthog- Oral Maxillofac Surg Clin North Am 35(1):11-21, 2023. doi:10.1016/j.
nathic surgery, Oral Maxillofac Surg Clin North Am 26(4):459-473, coms.2022.06.013.
2014. doi:10.1016/j.coms.2014.08.011. Wolford LM: Facial asymmetry: diagnosis and treatment considerations.
McCormick SU, Drew SJ: Virtual model surgery for efficient planning In Fonseca RJ (ed): Oral and Maxillofacial Surgery, 2nd ed, vol III, St.
and surgical performance, J Oral Maxillofac Surg 69:638, 2011. Louis, 2009, Saunders.
Meger MN, Fatturi AL, Gerber JT, et al: Impact of orthognathic surgery Xia JI, Gateno J, Teichgraeber JF: Computer-aided surgical simulation for
on quality of life of patients with dentofacial deformity: a systematic orthognathic surgery. In Bagheri SC, Bell RB, Khan HA (eds): Current
review and meta-analysis, Br J Oral Maxillofac Surg 59(3):265-271, Therapy in Oral and Maxillofacial Surgery, St. Louis, 2011, Saunders.
2021. doi:10.1016/j.bjoms.2020.08.014.

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65
Inferior Alveolar Nerve Injury
SE PID E H S A B O O R E E , R O G E R A . M E Y E R , a n d S H A H R O K H C . B AG H ER I

CC pharynx are normal. There are no abnormal neck masses, and the
carotid pulses are normal.
A 24-year-old male is referred for evaluation and treatment of Cranial nerves (CNs). CNs II through XII are normal except
numbness and pain in his entire lower lip, chin, and gums. for the right mandibular branch of CN V (CN V3). Neurosen-
sory testing indicates abnormal findings at all three levels
HPI along this nerve distribution on the right side: level A (two-point
discrimination and brush stroke direction), level B (contact
The patient had a Le Fort I osteotomy, bilateral mandibular detection), and level C (sharp or blunt and thermal discrimina-
sagittal split osteotomy (BSSO), and genioplasty for correction tion). He also exhibits allodynia (painful response to a nonpainful
of his midface deficiency, mandibular asymmetry, and microge- stimulus) and hyperpathia (delayed painful response that in-
nia 5 months earlier. Operative report from surgery did not in- creases in intensity with repeated stimulation [crescendo] and
dicate visualization of the inferior alveolar nerves (IANs) or persists for a period of time after removal of the stimulus
mental nerves (MNs), and no injuries were noted to have oc- [afterglow]).
curred intraoperatively. After surgery, he continued to have
complete numbness of his lower lip, chin, and mandibular labial Imaging
gingiva bilaterally at 6 weeks. His left lower lip and chin numb-
ness on the left side started to improve afterward and is now A cone-beam computed tomography scan shows plates and screws
back to baseline sensation, but the right lower lip stayed com- stable at Le Fort site as well as plates with noncortical screws bi-
pletely anesthetic until 2 months ago, when he started experi- laterally at BSSO sites that are not superimposed on the IAN ca-
encing painful sensations to any stimulation to this area. He nal. The horizontal osteotomy for the genioplasty appears to be in
reports having a very painful sensation when brushing his teeth, proximity of the mental foramen (Fig. 65.1).
eating, washing his face, and shaving, and this sensation seems
to be getting worse and lasting longer. Diagnostic Blocks
Local anesthetic blocks (2% lidocaine with 1:100,000 epineph-
PMHX/PDHX/Medications/Allergies/SHX/ rine) was administered in the right pterygomandibular space to
FHX determine if allodynia is triggered centrally or peripherally. Relief
of allodynia and hyperpathia after a few minutes of this procedure
The patient is in good general health. His only other previous indicated that the source of this pain is distal to the site of injec-
surgery was removal of wisdom teeth at age 18 years. He takes no tion. With this result, surgical exploration of this site and repair
chronic medications and has no known allergies. or reconstruction of this nerve would be an appropriate treatment
option for symptomatic relief in this patient.
Examination
Labs
General. The patient is a well-developed, well-nourished young
adult male with a normal facial profile. He is in no acute distress. There are no studies indicated for the routine evaluation of a pe-
His vital signs are normal, and his weight is 178 lb. ripheral nerve injury, and this patient has no medical history or
Maxillofacial. There is no facial edema. There is no temporo- physical findings that require specific blood or urine investigation.
mandibular joint or masticatory muscle tenderness. The nasal
passages are patent, and the nasal septum is in the midline. There Assessment
is no evidence of recent trauma to the lower lip. Unassisted maxi-
mal interincisal opening is 40 mm. There are orthodontic appli- This patient’s right IAN and MN injury findings are consistent
ances on both dental arches, and the dental occlusion is class I. with neurotmesis based on Seddon classification or grade V injury
Intraoral surgical incisions are well healed. Oral hygiene is fair, based on Sunderland classification (see Table 29.1), with recently
with accumulated plaque on anterior mandibular dentition be- developed allodynia and hyperpathia in the region of the right
cause of elicited pain while brushing. The tongue, palate, and CN V3 distribution.

332
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 CHAPTER 65 Inferior Alveolar Nerve Injury 333

A
160 (mm)

R L

200
0 (mm)
Upper-lower limit Focal trough Preview

B
• Fig. 65.1 A, Cone-beam computed tomography (CBCT) reconstruction showing internal fixation screws in
the maxilla and mandible corresponding to the Le Fort I, bilateral sagittal split ramus osteotomy, and genio-
plasty surgery. Screws are located above the inferior alveolar canal in the right mandible. The genioplasty
osteotomies appear to transect the inferior alveolar nerves bilaterally. B, CBCT panoramic reconstruction film
demonstrating inappropriate horizontal osteotomy cuts that are too close to the mental foramina; these in-
advertently crossed the inferior alveolar canals, causing bilateral inferior alveolar nerve injuries.

t.me/Dr_Mouayyad_AlbtousH
334 S E C TI O N Orthognathic Surgery

In an injury in which there has been persistent anesthesia for

longer than 3 months, the prognosis for meaningful spontaneous
improvement or full recovery of sensory function is dismal. When
painful symptoms develop, it is important to treat them early (i.e.,
within 6–9 months after injury) to minimize the chance of a
chronic, intractable pain syndrome. This can be a debilitating
condition interfering with the normal daily activities of these pa-
tients and often develops in patients with neuropathic pain sec-
ondary to a known nerve injury that are left untreated beyond 12
months after the incident. The current patient is approaching that
critical timeline; therefore, it is important that treatment for pain
control be initiated forthwith.

Treatment
The primary goal of intervention in patients with neuropathic pain is
for symptomatic relief. Multiple pharmacologic treatment options are A
available for treatment of neuropathic pain specifically associated Nerve graft and Position of Area of prior
with the trigeminal nerve. First-line treatment for trigeminal neural- repositioned IAN/MN mental foramen genioplasty osteotomy
gia pain treatment is use of low-dose carbamazepine (anticonvulsant)
twice daily. Other commonly used pharmacologic interventions for
neuropathic pain include other anticonvulsants (gabapentin and
pregabalin), tricyclic antidepressants (amitriptyline), serotonin nor-
epinephrine reuptake inhibitors (duloxetine, venlafaxine), and some
muscle relaxants (baclofen). All these interventions require several
weeks of use before showing any signs of relief and can lead to a va-
riety of unwanted side effects. Our patient was started on low-dose
carbamazepine, and he experienced minimal improvement in his al-
lodynia symptoms after 6 weeks of use. This improvement, however,
was not significant enough for him to want to continue with this
treatment, and he returned to further discuss his treatment options.
The most difficult determination in the surgical approach to an
IAN injury from sagittal split ramus osteotomy (SSRO) is locat-
ing the site of the injury. Proximally, the IAN can be injured dur-
ing the SSRO from surgical incisions, stretching of the soft tissue,
osteotomies, stretching or crushing injury caused by mandibular B
segments at the new position, or injury from fixation devices.
Distally, this nerve can be injured at the mental foramen from • Fig. 65.2 A, Exposure of the mandible, mental nerves, and inferior alveolar
nerve (IAN) via a circumvestibular incision. The black lines outline the prior
surgical exposure or osteotomies made for genioplasty.
genioplasty osteotomy line that transects both IANs. The IANs can be fur-
Ideally, exposure of the nerve should be made through a single ther exposed posteriorly by extension of the incision. B, Reconstruction of
surgical incision, allowing visibility and for access for surgical the right IAN using an peripheral nerve allograft. MN, Mental nerve.
manipulations, including neurorrhaphy or reconstruction of a
nerve gap (see Table 29.2). Historically, the transcervical approach
for this procedure has been described, but it is not these authors’ found to be intact. The remaining IAN was exposed by removal of
approach of choice for this procedure. overlying lateral mandibular bone with a high-speed drill, fine osteo-
In the current patient, transoral surgical approach was used to tomes, and curettes. There was a complete discontinuity defect of
expose the IAN and MN. The patient was advised of all possible the right IAN at its junction with the MN (Fig. 65.2B). Inspection
complications and possible outcomes and planned to undergo pro- under magnification (foot-controlled operating microscope with
cedures after obtaining informed consent. The patient was taken to ports for the surgeon, assistant, or camera or surgical loupes of 32.5
the operating room, and general oral endotracheal anesthesia was to 35.0, depending on surgical needs and the surgeon’s preference)
administered. The face and perioral region were sterilely prepped revealed that the proximal stump of the IAN had formed scarring
and draped. A pharyngeal pack was inserted, and the mouth was and possible neuroma. Distally, the MN was found to be intact with
thoroughly rinsed with chlorhexidine solution. Right-sided IAN its three branches proceeding into the buccal mucosa. Stump ends
blocks and infiltration of local anesthesia were performed with 2% of the IAN and MN were prepared for reconstruction by making a
lidocaine and 1:100,000 epinephrine. An incision was made along sharp straight incision 2 mm proximal to the ends where scarring
the previously made SSRO incision scar on the right side and ex- and distortions were noted. These stump ends were sent for patho-
tended anteriorly along the vestibule to have exposure of the right logical evaluation (later verified by the pathologist’s report as
IAN and MNs. A full-thickness mucoperiosteal flap was elevated. neuroma). This left a significant nerve gap of 2 cm. A processed
The incision was then extended anteriorly to expose the genioplasty heterogenous nerve graft was placed in between these two segments.
hardware. Right SSRO and genioplasty hardware were removed. This nerve graft was secured to the proximal segment of the nerve
The left MN was identified and found to be intact (Fig. 65.2A). The using interrupted 8-0 nylon sutures placed circumferentially through
proximal portion of the IAN entering the mandibular foramen was the epineural layer of IAN to the nerve graft. This process was then

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 CHAPTER 65 Inferior Alveolar Nerve Injury 335

repeated to secure the distal segment of this nerve graft to the MN. The entire operative site was thoroughly irrigated with sterile
The reconstructed nerve was entubulated by a processed nerve cuff. saline. The mentalis muscle was reapproximated using 4-0
(A nerve cuff enhances the healing process in the nerve by prevent- Monocryl sutures in an interrupted fashion. The mucoperiosteal
ing percolation of blood and ingrowth of scar tissue between the flap was then reapproximated and closed using closed 3-0 chro-
nerve stumps.) mic sutures. The throat pack was removed, and the oral cavity and
Alternately, the nerve gap can be reconstructed using an autog- pharynx were irrigated and suctioned. A pressure dressing was
enous nerve graft. Commonly used donor nerves are the great applied externally to the chin and mandible. The patient was ex-
auricular nerve (GAN) in the neck or the sural nerve (SN) in the tubated successfully and transferred to the postanesthesia care
lower extremity (Fig. 65.3). unit and then home.

A B

C D

• Fig. 65.3 Exposure of the inferior alveolar nerve (IAN) via a transcu-
taneous approach. A, The damaged IAN segment has been removed.
B, Exposure of the great auricular nerve (GAN) (cradled by a nerve
hook) in the right side of the neck. The external jugular vein (arrow) is
an important adjacent anterior landmark. C, A 3-cm graft has been
harvested from the donor right GAN. D, The right IAN nerve gap has
been reconstructed with the GAN autogenous graft (arrows indicate
the suture lines). E, Reconstructed right IAN using the GAN graft. The
E reconstructed right IAN has been encircled by an absorbable collagen
nerve cuff (arrows indicate the ends of the cuff).

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336 S E C TI O N Orthognathic Surgery

TABLE Medical Research Council Scale for Evaluation technical skills of the microsurgeon. A patient in whom the major
65.1 symptom or complaint is numbness or loss of sensation is at
of Peripheral Nerve Function (Modified for the
minimal risk of developing a neuropathic pain syndrome after
Trigeminal Nerve) microsurgical nerve repair. Preoperatively, if a patient’s pain is re-
a
Score Assessment lieved by a local anesthetic block of the suspected nerve, it is rea-
S0 No recovery of sensation
sonable to conclude that the pain is emanating from that nerve
(rather than from the central nervous system [CNS] or a collateral
S1 Recovery of deep cutaneous sensation pathway, such as adjacent sympathetic fibers [so-called sympa-
S2 Return of some superficial pain or tactile sensation thetic-mediated pain], or reflex sympathetic dystrophy) and that
microsurgical intervention could be useful for treatment of this
S21 Same as S2 with hyperesthesia pain (often caused by a neuroma).
S3 Same as S2 without hyperesthesia; static two-point discrimi- Microsurgical operations on the IAN pose risks that are con-
nation .15 mm sidered in the informed consent process and in the planning of
the operation. Because the IAN is subjected to surgical manipula-
S31 Same as S3 with good stimulus localization; two-point dis-
tion from the pterygomandibular space to the mental foramen,
crimination of 7–15 mm
the surgeon must be prepared to expose the nerve in such a way
S4 Same as S31, except two-point discrimination is 2–6 mm that this entire area can be inspected and surgically accessed under
a
direct vision. Therefore, an IAN injury resulting from an SSRO
S3 and S31 indicate useful sensory function. S4 is complete recovery. Hyperesthesia is
an exaggerated stimulus response (e.g., allodynia, hyperpathia, hyperalgesia).
may, in some patients, require exposure through a submandibular
Modified from Meyer RA, Rath EM: Sensory rehabilitation after trigeminal injury or nerve re- skin incision. When a submandibular approach exposes the IAN,
pair, Oral Maxillofac Surg Clin North Am 13(2):365, 2001. the adjacent marginal mandibular branch of the facial nerve (CN
VII) is at risk of injury. Most commonly, this is a temporary in-
jury because of stretching of the soft tissue, resulting in transient
paresis (weakness) of the ipsilateral lower lip musculature with a
The patient did well after surgery. The incision healed nor- “crooked smile” or deficient puckering.
mally. The patient was maintained on clonazepam for 1 month Patient concerns regarding a visible skin scar are addressed by
after surgery. This was then tapered gradually until it was discon- explaining location of the incision, careful cosmetic skin closure,
tinued after the second postoperative month, without return of and possible need for dermal injection of a corticosteroid (e.g.,
neuropathic pain. At 6 months after surgery, the patient started to dilute triamcinolone) in patients with tendency to form hypertro-
notice some tingling on his right lower lip and chin. At 9 months phic scars. Such injections can be repeated postoperatively as
after surgery, the right lower lip, chin, and gingiva began to re- needed.
spond to stimuli. There was no hyperesthesia. Sensory reeduca- The harvesting of an autogenous nerve has its own risks, most
tion exercises for the lower lip, chin, and gingiva were begun and commonly loss of sensation in the area supplied by the harvested
continued three times daily. One year after the operation, the donor nerve. When the GAN is the donor nerve, this causes an-
right lower lip, chin, and labial gingiva responded to painful esthesia of the lower portion of the earlobe and a variable sized
stimuli and static light touch at normal thresholds, and the two- area of skin at the angle of the mandible. This is generally well
point discrimination threshold in the right lower lip was 12 mm tolerated by most patients. Harvesting of the SN leaves the pa-
(Table 65.1). The patient continued sensory reeducation exercises tient with loss of sensation on the lateral aspect of the foot and
for another 6 months. Eighteen months after the surgery, the sometimes the heel. Patients who depend on position sense and
right side had achieved a two-point discrimination threshold of tactile accuracy in their feet (e.g., runners, climbers, and some
11 mm. The patient was free of pain. He was able to chew food, professional athletes) may have difficulty with this sensory deficit.
brush his teeth, wash and shave his face, and speak without diffi- The most feared complication in the donor nerve surgical site is
culty. He was encouraged to continue the daily sensory reeduca- the development of neuropathic pain because of possible develop-
tion exercises. He was satisfied with his sensory function and ment of proximal nerve stump neuroma. This is minimized, or in
ability to perform normal orofacial functions, and he was dis- most cases eliminated, by a nerve redirection procedure in which
missed from care. the proximal stump of the donor nerve is sutured to an adjacent
muscle (the sternocleidomastoid in the neck; the gastrocnemius in
Complications the lower extremity) or by epineurial capping (Fig. 65.4). The
choice of donor nerve depends on the length of nerve needed for
Whenever surgery is performed on a sensory nerve, four possible reconstruction. Generally, about 3 cm is the greatest length of
outcomes must be considered: (1) increased sensory loss (if it was GAN that is available for harvest. Therefore, when the nerve gap
incomplete before surgery) or worsening of neuropathic pain; (2) is greater than 2.5 cm (allowing for contracture of the graft after
minimal, unacceptable, or no improvement; (3) acceptable im- harvesting), the SN (which extends from the popliteal fossa to the
provement; or (4) return of normal or nearly normal sensation or lateral malleus of the ankle) is usually selected for grafting.
total relief of pain. None of these is assured, but maximal likeli- Recently, decellularized human cadaveric nerves (AxoGen,
hood of a successful outcome (outcomes 3 and 4, or grades S3, Inc.) have become available for peripheral nerve reconstruction.
S31, and S4 on the Medical Research Council Scale [MRCS]; see The use of this type of nerve graft eliminates the need for donor
Table 65.1) is significantly related to the time from injury to sur- site surgery. A recent study showed no significant difference be-
gical repair (best results are seen within 6 months; a large drop-off tween use of acellular processed nerve graft versus SN autograft
in the success rate occurs after 9–12 months), the age of the pa- when repairing pediatric obstetric brachial plexus injuries. How-
tient (the success rate decreases after age 45 years for the lingual ever, there are mixed reviews on whether these allogenic nerve
nerve [LN] and age 51 years for the IAN), and the experience and grafts are as effective as gold standard autogenous nerve grafts.

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 CHAPTER 65 Inferior Alveolar Nerve Injury 337

superior border “spreaders” to initiate separation of the proximal

and distal mandibular segments until the IAN is directly visual-
ized, (5) smoothing of bony irregularities between the proximal
and distal segments to prevent impingement of the IAN after
fixation, (6) placement of autogenous or bank bone grafts be-
tween the two segments superior to the IAC before fixation of the
segments, and (7) placing bicortical screws only along the supe-
rior border of the mandible to minimize compression of the IAN
and using monocortical screws no longer than 5 mm to avoid
entering the IAC.
Epineurium and Epineurial
The risk of LN injury is reduced by (1) careful dissection and
A fascicles excised flap subperiosteal elevation of the soft tissue in the retromolar area, (2)
Masseter muscle not allowing the drill to penetrate more than just barely through
the mandibular lingual plate when preparing holes for internal
fixation screws, and (3) selecting fixation screws of the correct
length to prevent impingement of LN.
In performing the horizontal mandibular osteotomy for genio-
plasty, the most important steps for reducing the risk of injury to
the MN are (1) good imaging studies that clearly show the posi-
tion of the mental foramen and its relationship to the IAC, (2)
identifying the mental foramen and protecting the MN when
making the osteotomies, and (3) making the osteotomy cuts suf-
ficiently below the inferior border of the IAC.
Special considerations arise regarding diagnosis, selection of
surgical procedures, and timing of treatment in patients who have
sustained IAN injuries from removal of M3s, maxillofacial
trauma, dental implants, root canal treatment, and ablative tumor
Proximal stump
B Inferior alveolar nerve surgery. (For more information, readers are directed to the perti-
nent references listed in the Bibliography: M3s—Kim et al.,
• Fig. 65.4 Management of the proximal stump of the donor nerve. A, 2012; maxillofacial trauma—Bagheri et al., 2009; dental im-
Epineurial capping. Sufficient epineurium and fascicular material is excised
plants—Bagheri and Meyer, 2011; root canal treatment—Meyer,
to create an epineurial flap. The flap is folded over the exposed axons in
the nerve stump and sutured under magnification with fine, nonreactive 1992; and ablative tumor surgery—Meyer and Bagheri, 2013.)
sutures (i.e., 8-0 or 10-0 nylon). B, Nerve redirection. The proximal stump Because the IAN has a rather straight course within the IAC,
of the donor nerve is mobilized and rotated into contact with adjacent there is often little to be gained by attempting mobilization of the
muscle (i.e., the sternocleidomastoideus in the neck; the gastrocnemius proximal and distal nerve limbs, as can be done with the LN. Some
in the lower extremity). Under magnification, the epineurial margins are surgeons section the incisive nerve (IN) to allow greater mobiliza-
carefully sutured to the muscle, leaving sufficient laxity in the proximal tion and lateralization of the IAN or MN and achieve closure of a
nerve to accommodate bodily movement. (Redrawn from Bagheri SC, small (i.e., ,1 cm) nerve gap without grafting (as was done in the
Meyer RA: Management of mandibular nerve injuries from dental implants, patient described previously). However, after debridement of all
Atlas Oral Maxillofac Surg Clin North Am 19[1]:47-61, 2011.)
abnormal tissue and preparation of the nerve stumps for repair,
nerve gaps in the IAC are often larger than 1 cm and, despite the
additional mobilization created by IN transection, they may not be
Discussion amenable to approximation without tension. Therefore, recon-
struction with either an autogenous nerve graft, a decellularized
The most frequent causes of IAN injury in oral and maxillofacial allogeneic nerve graft, or guided regeneration through a nerve tube
surgery practice, from most common to least common, are (1) is often necessary. All of these have been successful in various situ-
removal of mandibular third molars (M3s), (2) SSRO, (3) maxil- ations, depending on the surgeon’s judgment and experience.
lofacial trauma, (4) dental implants, and (5) root canal treatment. Sensory reeducation is an essential aspect of the care and reha-
Other causes seen less often are biopsies and excision of tumors or bilitation of the patient whose peripheral nerve injury has been
cysts, mandibular ridge augmentation procedures, and injection repaired. As soon as the patient regains responses to painful
of local anesthetics. The treatment of a nerve injury associated stimuli and static light touch (demonstrating that the nerve has
with the SSRO is the most challenging because of an inability to reinnervated the target tissue end organs), a series of stimulating
determine the exact location of IAN injury. exercises on the affected area and the contralateral normal side (or
Proactive measures taken to avoid injuries to the IAN, MN, adjacent tissue in a patient with bilateral nerve injuries) are per-
and LN have lessened the risk of such injuries during orthogna- formed three times daily in front of a mirror with the eyes open
thic surgery (i.e., SSRO and genioplasty) on the mandible in the and then with the eyes closed. Such exercises aid in the recovery
authors’ practice. Steps taken during the SSRO to reduce the risk of graphesthesia (the ability to identify objects by their “feel”) and
of IAN injury include (1) determination of the exact location of localization of a stimulus to its point of origin (loss of this skill is
the IAC with appropriate preoperative imaging studies, (2) pro- termed synesthesia). These exercises also help overcome newly
tection of the IAN where it enters the medial surface of the man- formed abnormal conductions or transmissions to different areas
dibular ramus, (3) making the vertical anterior osteotomy cut of the CNS, adapt to differing impulse conduction speeds, and
just through the buccal cortical bone only, (4) using anterior and decrease or resolve hypersensitivity (aided with neurotropic

t.me/Dr_Mouayyad_AlbtousH
338 S E C TI O N Orthognathic Surgery

medications). Sensory reeducation exercises are performed by the pharmacologic management of chronic neuropathic pain. Aboli-
patient daily until they are satisfied with the result or for at least tion of neuropathic pain soon after its onset reduces the risk of the
1 year, whichever is longer. The patient is monitored by Neuro development of an intractable pain syndrome. When this prob-
Sensory Testing (NST) at bimonthly visits with the surgeon dur- lem has developed in susceptible patients, as early as a few months
ing this time. (For an in-depth discussion of sensory rehabilita- after pain onset in some cases, treatment becomes extremely
tion, readers are referred to the articles by Meyer and Rath, 2001, problematic. The choice of medication and the optimal dose vary
and by Phillips et al., 2011, listed in the Bibliography.) among patients. When a satisfactory level of pain control with
The results of microsurgical repair of the IAN, as assessed by little or no sedation has been established, the medication is con-
NST and graded on the MRCS, are successful in 80% to 90% tinued for at least 6 months before any attempts are made to wean
of patients, depending on several factors. These factors consist the patient off this medication. Cessation is done slowly over a
of the cause of the injury, the length of time from injury to repair, period of several weeks to avoid the risk of withdrawal symptoms,
the age of the patient, and the experience and technical skills of seizures, and so on. If neurotropic medications provide inade-
the microsurgeon. Based on this information, microsurgical repair quate pain relief, some patients may be candidates for narcotic
of peripheral trigeminal nerve injuries is an acceptable and recom- medications or ketamine infusion trials. Because of the chronic
mended treatment for patients who meet the diagnostic criteria and complex nature of this treatment modality, these patients
discussed in this chapter. benefit most from receiving care from a pain management special-
Control of chronic neuropathic pain in a patient who is not a ist for appropriate medication dosage adjustments, alternative
candidate for peripheral nerve surgery or has failed surgical inter- treatment modalities, and close monitoring.
vention is often a difficult problem. Neurotropic medications
such as clonazepam, gabapentin, and pregabalin act directly on ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
pain impulses in the CNS and are generally the initial choices for complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 338.e1

Bibliography LaBanc JP: Classification of nerve injuries, Oral Maxillofac Surg Clin
North Am 4(2):285, 1992.
Lee CH, Lee BS, Choi BJ, et al: Recovery of inferior alveolar nerve injury
Agbaje JO, Lambrichts I, Jacobs R, et al: Neuropathic pain after bilateral after bilateral sagittal split ramus osteotomy (BSSRO): a retrospective
sagittal split osteotomy: management and prevention, Plast Aesthet Res study, Maxillofac Plast Reconstr Surg 38:25, 2016. Available at: https://
2:171-175, 2015. Available at: http://dx.doi.org/10.4103/2347-9264. doi.org/10.1186/s40902-016-0068-y.
160880. Meyer RA, Bagheri SC: Clinical evaluation of nerve injuries. In Miloro
Agbaje JO, Salem AS, Lambrichts I, et al: Systematic review of the inci- M (ed): Trigeminal nerve injuries, Heidelberg, 2013, Springer.
dence of inferior alveolar nerve injury in bilateral sagittal split osteot- Meyer RA, Bagheri SC: Clinical evaluation of peripheral trigeminal nerve
omy and the assessment of neurosensory disturbances, Int J Oral injuries, Oral Maxillofac Surg Clin North Am 19(1):15, 2011.
Maxillofac Surg 44(4):447-451, 2015. Available at: https://doi. Meyer RA, Bagheri SC: Etiology and prevention of nerve injuries. In
org/10.1016/j.ijom.2014.11.010. Miloro M (ed): Trigeminal nerve injuries, Heidelberg, 2013, Springer.
Al-Quliti KW: Update on neuropathic pain treatment for trigeminal Meyer RA, Bagheri SC: Microsurgical reconstruction of the trigeminal
neuralgia. The pharmacological and surgical options, Neurosciences nerve, Oral Maxillofac Surg Clin North Am 25(2):287-302, 2013. Meyer
(Riyadh) 20(2):107-114, 2015. doi:10.17712/nsj.2015.2.20140501. RA, Bagheri SC: Nerve injuries from mandibular third molar re-
Bagheri SC, Meyer RA, Ali Khan H, et al: Microsurgical repair of tri- moval, Oral Maxillofac Surg Clin North Am 19(1):63, 2011.
geminal nerve injuries from maxillofacial trauma, J Oral Maxillofac Meyer RA, Rath EM: Sensory rehabilitation after trigeminal injury or
Surg 67:1791, 2009. nerve repair, Oral Maxillofac Surg Clin North Am 13(2):365, 2001.
Bagheri SC, Meyer RA, Ali Khan H, et al: Microsurgical repair of the Meyer RA: Applications of microneurosurgery to the repair of trigeminal
peripheral trigeminal nerve after mandibular sagittal split ramus oste- nerve injuries, Oral Maxillofac Clin North Am 4(2):405, 1992.
otomy, J Oral Maxillofac Surg 68(11):2770, 2010. Meyer RA: Nerve harvesting procedures, Atlas Oral Maxillofac Surg Clin
Bagheri SC, Meyer RA: Management of mandibular nerve injuries from North Am 9:77, 2001.
dental implants, Atlas Oral Maxillofac Surg Clin North Am 19(1):47, 2011. Miloro M, Kolokythas A: Inferior alveolar and lingual nerve imaging,
Bagheri SC, Meyer RA: Management of trigeminal nerve injuries. In Oral Maxillofac Surg Clin North Am 19(1):35, 2011.
Bagheri SC, Bell RB, Khan HA (eds): Current therapy in oral and Phillips C, Blakey G, Essick GK: Sensory retraining: a cognitive behav-
maxillofacial surgery, St. Louis, 2011, Saunders, pp 224-237. ioral therapy for altered sensation, Oral Maxillofac Surg Clin North
Bates D, Schultheis BC, Hanes MC, et al: A comprehensive algorithm Am 19(1):109, 2011.
for management of neuropathic pain, Pain Med 20(Suppl 1):S2-S12, Roychoudhury S, Nagori SA, Roychoudhury A: Neurosensory distur-
2019. doi:10.1093/pm/pnz075. bance after bilateral sagittal split osteotomy: a retrospective study, J
Essick GK: Comprehensive clinical evaluation of perioral sensory func- Oral Biol Craniofac Res 5(2):65-68, 2015. doi:10.1016/j.jobcr.2015.
tion, Oral Maxillofac Surg Clin North Am 4(2):503, 1992. 04.006.
Gregg JM: Medical management of traumatic neuropathies, Oral Maxil- Schultz JD, Dodson TB, Meyer RA: Donor site morbidity of great au-
lofac Surg Clin North Am 13(2):343, 2001. ricular nerve harvesting, J Oral Maxillofac Surg 50:803, 1992.
Gregg JM: Studies of traumatic neuralgias in the maxillofacial region: Wolford LM, Rodrigues DB: Autogenous grafts/allografts/conduits for
symptom complexes and responses to microsurgery, J Oral Maxillofac bridging peripheral trigeminal nerve gaps, Atlas Oral Maxillofac Surg
Surg 48:135, 1990. Clin North Am 19(1):91, 2011.
Hamant LG, Adelson PD, Kang P, et al: Comparison of autograft versus Woods DD, LaBanc JP: Complications and morbidity associated with
allograft in the surgical repair of pediatric obstetrical brachial plexus trigeminal nerve repairs, Oral Maxillofac Surg Clin North Am 4(2):473,
injuries, J Neurosurg Pediatr 26(3):318-326, 2020. doi:10.3171/2020. 1992.
4.peds2033. Ziccardi VB: Microsurgical techniques for repair of the inferior alveolar
Kim JW, Cha IH, Kim SJ, et al: Which risk factors are associated with and lingual nerves, Oral Maxillofac Surg Clin North Am 19(1):79, 2011.
neurosensory deficits of inferior alveolar nerve after mandibular third Zuniga JR, Meyer RA, Gregg JM, et al: The accuracy of clinical neuro-
molar extraction? J Oral Maxillofac Surg 70(11):2508, 2012. sensory testing for nerve injury diagnosis, J Oral Maxillofac Surg 56:2,
Kornfeld T, Borger A, Radtke C: Reconstruction of critical nerve defects 1998.
using allogenic nerve tissue: a review of current approaches, Int J Mol
Sci 22(7):3515, 2021. doi:10.3390/ijms22073515.

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66
Myofascial Pain Dysfunction
BEDRETTIN CEM SENER

CC Porto de Toledo I, 2016) at the same time. Such an intricate clinical

presentation might misdirect the clinician. In such cases, a detailed
A 32-year-old female presents with a 2.5-month history of daily pain description with the distribution, frequency, quality, and dura-
jaw pain, headache, and ringing ears that is worse in the evenings, tion of pain as well as triggering factors should be investigated in
and she especially has constant stiffness in the mornings. detail. At the same time, presentation of any TMJ-related symp-
toms, such as clicking or crepitation, should be thoroughly identi-
HPI fied. In advanced stages, TMD can not only limit jaw functions but
also decrease life quality and nutrition because of debilitating pain.
The patient reports that the pain is dull while resting but could be
severe, especially during chewing or yawning. Tension and pain PMHX/PDHX/Medications/Allergies/SH/FH
around the jaw and neck areas are constantly present, especially in
the mornings, and worsen throughout the day (characteristic of The patient’s medical and dental histories revealed sleep depriva-
myofascial pain dysfunction [MPD]). When asked to point to the tion and acid reflux. The patient’s social life is uneventful. On the
regions of pain, she readily identifies the areas over her left masseter patient inquiry form, there is a question to evaluate their general
muscle. Chronic fatigue, headaches, and neck and shoulder pain stress level on a scale from zero to 10. Her career is highly stressful.
were overwhelming with deprived sleep quality. (Decreased sleep She scores her stress level 7 to 8 of 10 with these job-related issues.
quality and interruptions are also typical findings for MPD. Like- (Stress, anxiety, and depression disorders are a risk factor for
wise, neck and shoulder pain and headaches are very common MPD.) She works as a human resource associate and has a high-
findings with MPD.) Chewy or hard food makes the pain worse. volume job with several decision-making tasks. Also, the patient
(Increasing pain and muscle fatigue during mastication are typical claims that she also works from home and spends at least 4 to 5
findings in MPD.) Sensitivity on the teeth is also present while hours with her laptop. No remarkable family history is noted.
chewing. (Because of clenching or bruxing, overloaded occlusal
forces would cause teeth sensitivities and might also end with oc- Examination
clusal trauma of cracks on the related teeth.) Besides the migraine-
like headaches, the patient reveals anxiety caused by a high level of General. The patient is a well-developed adult female and looks
stress in her life. (Work-, school-, or social life–related stress can slightly anxious in general.
cause or exacerbate MPD.) She denies any current or prior history Maxillofacial. There is no asymmetry, and no lymph nodes
of clicking or popping sounds (which are seen only with internal are palpable. On palpation, there is tenderness of the masseter,
joint derangements) or crunchy sounds during jaw movements sternocleidomastoid, and trapezius muscles. (The masseter and
(specific finding of degenerative changes of the temporomandibular temporalis muscles are the most involved muscle in MPD.)
joint [TMJ]). She is not aware of any parafunctional habits, such as There is no TMJ capsular tenderness (other than primary TMJ
bruxing or clenching. (Bruxing is grinding of the teeth, and clench- diseases such as infection, inflammation, or traumatic injuries,
ing is isometric constriction of masticatory muscles without moving pain with palpation around the joint is less likely) and no clicks
the mandible. Many patients may be unaware of nocturnal or even or crepitus. The patient has a maximal incisal opening of 18 mm
daytime bruxism or clenching. While grinding their teeth, bruxers with a soft end feel, which can be stretched to 26 mm with pain.
might have a higher chance to be recognized by their partners or (Limited opening because of muscle guarding that can be slowly
household. However, while clenching, no sound can be noticed stretched to a normal opening is consistent with MPD.) There
during sleep. Therefore, identification of a clenching parafunction is no deviation or deflection while opening the mouth. (Devia-
could be difficult. Also, patients with nocturnal bruxing or clench- tion is characteristic finding for anterior disc dislocation with
ing are characteristically worse on waking and improve over the reduction [ADDwR] and deflection is for anterior disc disloca-
course of the day. Patients with TMJ dysfunction (TMD) might tion without reduction [ADDwoR].) Her left and right lateral
present with MPD, internal joint derangements, migraine, dizzi- excursions are 9 and 8 mm, respectively. The remainder of her
ness, or ringing ear problems (Stechman-Neto J, Porporatti AL, physical examination is noncontributory.

341
t.me/Dr_Mouayyad_AlbtousH
342 S E C TI O N Temporomandibular Joint Disorders

Imaging burnout, and chronic fatigue syndrome are similar autonomic

nervous system–related symptoms that can help in the identifi-
A panoramic radiograph is the baseline screening examination of cation of patients under high stress. These problems should be
choice. Although it cannot diagnose MPD, it provides an over- addressed on the patient’s questionnaire or forms. The presence
view of the teeth and bony structures to rule out other possible of high stress is not only a good diagnostic indicator for MPD
pain sources, such as impacted wisdom teeth, dental infection but is also another determining factor in the development of the
focuses, or osteoarthritis of TMJ. Magnetic resonance imaging treatment plan. Patients should be acknowledged about their
(MRI) and computed tomography (CT) scans are ordered based SADD-guided increased muscle tension cycle. During the first
on the clinical suspicion of pathology in conjunction with MPD session, this relationship between their psychosocial condition
(see Chapter 67). However, MRI and CT are not indicated when and MPD must be clearly explained to the patient so they
MPD is the sole clinical diagnosis. The panoramic radiograph in realize that addressing this issue is critical. SADD is the most
the current patient reveals no odontogenic or osseous pathology. challenging factor to eliminate for a successful TMD treatment
outcome.
Labs 2. Postural problems (Koukoulithras I, Plexousakis M, Kolo-
kotsios S, 2021) originating from occupational or social situ-
Laboratory tests are not indicated in the workup of MPD unless ations, such as long-time computer or telephone use or heavy
associated with other suspected or diagnosed medical conditions physical activities. Such factors can solely initiate the MPD
(e.g., rheumatoid arthritis or neuromuscular disorders). A suspi- or can worsen the symptoms synchronously with other fac-
cion of temporal arteritis or any infection possibility would war- tors in the long run. During clenching or bruxing parafunc-
rant further laboratory testing (erythrocyte sedimentation rate tions, not only the masticatory muscles receive high muscle
and C-reactive protein as markers of inflammation) and biopsy of tones, but also the neck and shoulder muscles such as the
the superficial temporal artery. Similarly, patients with metabolic trapezius and sternocleidomastoid cervical muscles contrib-
or genetic disorders should have relevant laboratory workup. ute the constriction activity because of increased muscle tone
controlled by autonomic nervous system upregulation. Thus,
Assessment staying in a nonergonomic position during occupational or
recreational activities puts more load on the neck and shoul-
As shown in the patient’s history, progressive pain description is der muscles in patients with MPD. To relieve the muscle
characteristic in MPD. Similarly, female predilection is also a constrictions or tetanus episodes at the neck and shoulder
characteristic indicator for its diagnosis (Bueno CH, Pereira DD, area, posture corrections should be recommended to the pa-
Pattussi MP, 2018). Besides a detailed clinical examination, his- tient during their daily activities. Referral to a physiotherapist
tory of chief complaints, and the patient’s demographic informa- or occupational therapist should also be considered.
tion, social and family histories (Fillingim RB, Slade GD, 3. Occlusal changes (Okeson JP, 2020). The masticatory muscle
Diatchenko L, 2011); the presence of stress, anxiety, and depres- system needs to adapt to any acute or chronic changes in the
sion; and posture issues play an important role for the diagnosis occlusion system. The changes beyond certain physiologic
of MPD. Similarly, our patient presented SADD, which was di- compensation limits or longstanding minor variations can be
agnosed and treated by her family doctor. Because the prevalence the reason for MPD. During the assessment, these occlusal
of TMD is reported between 7.3% and 30.4% in teenagers and changes should also be identified. The clinician should also
up to 31% for adults and older adult patients (Valesan LF, Da- inquire if the initiation of the patient’s symptoms was after
Cas CD, Réus JC, 2021) (Christidis N, Lindström Ndanshau E, any restoration or orthodontic treatment. For a permanent
Sandberg A, 2019), the volume of this patient population cannot successful treatment result, these occlusion-related factors
be underestimated. As in our patient example, the adult age should also be addressed with a prosthetic rehabilitation,
group is one of the most commonly affected groups. Because of orthodontic treatment, or orthognathic surgery.
unsuccessful treatment attempts, repetitive chair times, and eco- 4. TMJ-related diseases such as ADDwoR or TMJ arthritis
nomic constraints of the patient or the clinician, unfortunately, might trigger muscle constriction as a response to the pain.
this patient group might be frustrated. Even this deadlock condi- 5. Acute trauma in the muscle tissues might create trigger points
tion could aggravate their pain intensity and functional restric- after the injury.
tions. It has well documented that females have two to four times 6. Nutritional deficiencies, especially vitamins B1, B6, and B12
more TMD-related issues than male patients. Moreover, patients and folic acid could be a factor (Koukoulithras I, Plexousakis
with MPD present with high stress, anxiety, or depression in M, Kolokotsios S, 2021).
their histories. Therefore, patients with TMD need to be asked 7. Metabolic disorders, including hypothyroidism, obesity, hy-
about the presence of stress-related factors in detail. Similarly, poglycemia, and hyperuricemia, could contribute.
some posture-related problems can originate or worsen the pres- 8. Patients with genetic disorders related to the musculoskeletal
ent TMD issues. With this regard, for any stress-related issues system, such as Ehlers-Danlos syndrome, can present with
and occupation-related poor posture correlation, there should be severe MPD (Wang TJ, Stecco A, 2021). Also positive family
a part spared in the questionnaire form in TMD evaluation. history is a strong indicator of MPD (Fricton J, 2016)
Main causes of MPD are as follows. (Koukoulithras I, Plexousakis M, Kolokotsios S, 2021).
1. Psychologic or social distress–related stress (Koukoulithras, 9. Inflammatory diseases such as vasculitis, temporal arteritis,
Plexousakis, & Kolokotsios, 2021; Ohrbach & Michelotti, fibromyalgia, and infections, can also contribute.
2018), anxiety, depression disorder (SADD). Autonomic ner- 10. Cancer pain might also trigger MPD (Kalichman L, Menahem
vous system response to emotional disorders or stressing factors I, Treger I, 2019).
causes increased muscle tone, which is the cause of bruxing and Except for acute traumatic injuries, because anterior disk dislo-
clenching. Similarly, gastroesophageal reflux disease, gastric ul- cation is caused by the chronic pulling effect of the superior belly
cers, sleep deprivation, palpitations, tachycardia, hypertension, off the external pterygoid muscle, the presence of joint-related

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 CHAPTER 66 Myofascial Pain Dysfunction 343

signs and symptoms should be investigated for all MPD cases. If of the MPD in the short term. Conservative treatment options
any clicking, popping, or crepitation sounds, deflection, or devia- include reassurance, stress management, posture correction, relax-
tion during jaw opening cannot be identified, TMJ-related prob- ation and stretch exercises, biofeedback, deprogramming occlusal
lems can be ruled out until the second evaluation. It is also a re- splint use, application of heat or icing, massage therapy, nonste-
markable finding that patients with TMJ point out specifically roidal antiinflammatory drugs (NSAIDs), and muscle relaxants.
their TMJ areas. However, patients with MPD readily identify a Because of abuse potential, prescription of anxiolytics should
large pain distribution area extending from the head to the neck preferably be referred to the patient’s family physicians, and coun-
and shoulder. Similarly, patients with MPD can also present with seling must be done with caution. Following the conservative
migraine-type headaches, tinnitus, and dizziness. If the patient has therapy instructions, the patient should be followed up within 2
not been evaluated by a neurologist for migraine headaches after to 4 weeks. During their second visit, an occlusal splint adjust-
the initiation of the treatment, they should be addressed to the ment can be done as needed. Reassessment of pain and function
related specialist. should update the treatment plan. Patients with an improvement
should continue the conservative treatment measures by tapering
Treatment down the frequency and amounts and maintain the occlusal splint
use as long as the bruxing or clenching problem continues.
The current patient was encouraged to manage her stressors more The core management strategy for long-term success is based
effectively by undergoing counseling for stress management and on the elimination of the cause, SADD factors, postural and oc-
using biofeedback to reduce muscle tension. Her family physician clusal corrections, and infections or pathologies. Patients pre-
initiated duloxetine 30 mg/day for minor depression. During the senting with SADDs should be addressed to their physicians to
first appointment, the patient was instructed to avoid chewy learn management by either counseling or medical treatment, if
foods for 2 weeks. At the same time, application of moist heat necessary, with anxiolytics or antidepressants. Awakening the
(using a warm, moist towel) for a few minutes followed by a patient’s self-awareness about daily minor stress management is
gentle massage to the affected muscles at least eight times a day one of the major steps in treatment. Neither the patient nor the
was instructed. A methocarbamol 500 mg and ibuprofen 200 mg clinician should expect a successful result without eliminating
combination once a day after dinner was prescribed together with this component.
pantoprazole. A deprogramming occlusal splint for maxilla with a Patients who do respond to an occlusal splint and have a
hard, flat plane was fabricated, and the patient always wore this significant malocclusion should consider orthodontic treatment
except while eating or brushing her teeth. The splint was adjusted with or without orthognathic surgery. These modalities may offer
on the articulator to eliminate interferences during lateral excur- a long-term solution to MPD, but such major surgical interven-
sions and ensure a 1-mm vertical increase in centric relation. tions are irreversible and have complication risks.
During the second week followup visit, the patient presented Trigger point injections with sham dry needling, saline, or li-
with a nonremarkable improvement and was not able to use docaine injections could be beneficial in patients with acute pain
methocarbamol because of side effects. Splint adjustment was not conditions. For acute or severe MPD-related pain relief, a local
needed. She opted to get botulinum toxin (BTX) treatment. A anesthetic is injected directly into the trigger points on the mus-
total of 100 U of onabotulinum toxin was reconstituted in 2 mL cles. This can provide temporary or sometimes permanent resolu-
of 0.9% sodium chloride and benzyl alcohol solution to achieve tion of muscle pain–related spasm (Tantanatip A, Patisumpita-
5 units/0.1 mL. After reassessment to identify injection spots, wong W, Lee S, 2021). However, patients should be informed
100 U of BTX was administered bilaterally to the masseter, tem- that the pain could return when the local anesthesia effect is gone.
poralis, and trapezius muscles with a 30-gauge ½-inch needle. For Frequent repetitions of trigger point injections might end up with
the medial and lateral pterygoid muscles and tendon of the tem- physical trauma on the muscle tissue (Gattie E, Cleland JA, Snod-
poralis muscle, a 27-gauge ½-inch needle was used. On each grass S, 2017).
temporalis muscle, BTX was administred on four injection sites. Patients with MPD who are refractory to all conservative ap-
At the anterior part, 2.5 U of BTX was administered; at the proaches or cannot tolerate NSAIDs or muscle relaxants can be
middle part, 5 U; at the posterior part 2.5 U, and at its tendon, considered for onabotulinum toxin therapy. It may also be possi-
5 U of BTX. On both masseter muscles, BTX injection was done ble to improve MPD with injection of botulinum toxin into the
at three points, 2 cm apart from each other, and for each point muscle to reduce muscle activity and related occlusal forces. This
5 U BTX was given. On each trapezius muscle, two injection may need to be repeated every 3 to 12 months because of the
points received 5 U BTX for each, 2 cm apart from each other. temporary effect of the botulinum toxin. Patients who can achieve
Also, lateral and medial pterygoid muscles, bilaterally, received SADD management, posture correction, or occlusal adjustment
5 U BTX for each muscle. By 2 weeks, the patient was wearing within this period might not need to repeat the botulinum toxin
the splint only at night and was able to open to 44 mm, with injections. Regeneration of the nerve endings at the motor end-
complete resolution of her pain. She did not require repeat BTX plate of the neuromuscular junction is responsible for cessation of
therapy during the first and third month followups. the clinical effects. Excessive muscle activity alone may not ex-
The treatment of patients with MPD begins with the correct plain most cases of MPD, and the response to botulinum toxin is
diagnosis and the identification of underlying etiologic factors. not predictable. Intraarticular procedures, including arthrocente-
Besides the symptomatic conservative therapy, the treatment plan sis, arthroscopy, and arthroplasty, have no place in the manage-
must address the cause, if possible. ment of isolated MPD.
Regardless, conservative therapy is generally the first-line treat-
ment unless other identifiable associated diagnoses (impacted Complications
wisdom teeth, infection, severe internal derangements, degenera-
tive joint disease, tumors) are present that are thought to exacer- Because the nature of the conservative treatment protocol consists
bate the symptoms of MPD. However, in general, conservative of noninvasive techniques, complications are relatively uncom-
treatment often results in significant improvement on resolution mon and are mostly related to the failure of available treatments

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344 S E C TI O N Temporomandibular Joint Disorders

to alleviate pain, the side effects of medications, or difficulties dropped-eyelid appearance might be observed after injections to
with occlusal splint therapy. the anterior part of the temporalis muscle (Ramos-Herrada RM,
Nonsteroidal antiinflammatory drugs are often helpful and Arriola-Guillén LE, Atoche-Socola KJ, 2022). So far, no fatalities
carry no risk of physiologic dependence, although gastrointestinal related to BTX use for MPD have been reported. Bruising and
irritation or bleeding, platelet dysfunction, increased blood pres- soreness at the injection sites are the most common and minor
sure, and decreased renal function are potential complications. complications. Use of the smallest-gauge needles (30 or 27 gauge)
The use of some muscle relaxants and anxiolytics can be associated could minimize these expectations.
with dependence and abuse, which are compounded by the Most of all, in case of failure of any therapeutic attempts, the
frequently chronic and recurrent nature of MPD. The most com- progress of persistence of MPD would lead to internal derangements.
mon complain about the muscle relaxants are drowsiness, concen-
tration problems, and stomach upset. Discussion
Occlusal splint therapy is not without complications (especially
when the splint is inappropriately designed). Several different types Myofascial pain dysfunction is the most common of all TMDs
of splints are used by prescribing clinicians, and unfortunately, (Fricton J, 2016). Unless there is any underlying systemic cause, it is
there are no clear evidence-based guidelines for splint therapy. Dif- reversible in the initial stages. MPD can manifest with otologic symp-
ferent splints include maxillary, mandibular, flat-plane, anterior toms and migraine-like headaches. These findings might guide the
repositioning, and pivotal splints. Flat-plane occlusal splints, patient to different specialists at the beginning; however, in a thor-
whether maxillary or mandibular, are the most popular and techni- ough evaluation, all these signs and symptoms are valuable clues to
cally the least demanding. Although complications related to lead to the diagnosis of MPD. Otologic symptoms, such as ringing
conservative splint therapy are uncommon, an incorrectly adjusted ears, dizziness, or migraine-like headaches might respond to MPD
splint can result in exacerbation of the preexisting TMJ dysfunc- treatment.
tion, tooth movement, or the development of new symptoms. The main muscles of mastication are the masseter, temporalis,
Shifted teeth could cause permanent changes of the occlusion and and lateral and medial pterygoid muscles. They all function
might need correction with orthodontic treatment. Anterior repo- harmoniously during speech and deglutination. As a result of au-
sitioning splints are occasionally useful in patients with class II tonomic nervous system upregulation to stress and postural prob-
malocclusions and function by holding the mandible in a forward lems in addition to the masticatory muscles, the head, neck, and
position; this unloads the richly innervated retrodiscal tissue shoulder muscles might present with increased muscle tone. As
within the TMJ and helps to reestablish a more normal disk– with any group of muscles, they are susceptible to inflammation,
condyle relationship. This is also another useful tool for the which may in turn cause pain. This is commonly caused by exces-
ADDwR and ADDwoR cases to increase interarticular distance to sive activity of these muscles, but the exact pathophysiology is
allow reduction of the displaced disk. These splints are likely to be likely to be multifactorial. The elimination of the factors causing
associated with permanent occlusal changes, and considerable cli- muscle hyperactivity is mandatory for long-term success. Manage-
nician experience is required in their use. Pivotal splints are rarely ment of the acute symptoms of MPD is generally similar, regard-
used and are thought to function by decreasing masticatory muscle less of the cause. Besides noninvasive and conservative treatment
forces (via periodontally mediated biofeedback). Long-term use of options, BTX use could be beneficial to minimize muscle tension
pivotal splints, especially their use during the nighttime, can easily pain and related muscle relaxant and NSAID use. BTX might aid
cause extrusions of maxillary or mandibular anterior teeth and an to break the pain–muscle constriction–pain positive feedback cycle
increase in vertical height. Eventually, this can aggravate the oc- by decreasing muscle relaxation. Counseling with or without anti-
clusal issues and worsen TMD. depressant use should be delegated to the family physician for
After splint therapy, changes in the occlusion can be seen. permanent solutions for patients who have a high SADD-related
Before splint therapy, patients might have a centric occlusion– cause. All possible systemic and local causes should be investigated.
centric relation discrepancy. A flat-plane occlusal splint may Patient acknowledgment and determination to practice the treat-
eliminate this discrepancy over time, resulting in a less than ideal ment instructions are also vital for a successful outcome. As is often
occlusion when the splint is removed or discontinued. This may the case, no definitive factors can be identified; consequently, a
necessitate continued splint therapy, occlusal adjustment, ortho- generic approach using several modalities must be tailored.
dontics, or orthognathic surgery. In the presence of clicking or popping sounds, clinician should
Repetitive injections of BTX might cause a decreasing effect, consider dealing with internal joint derangements at the same
and the patient may no longer receive the benefit of BTX. Neu- time as with MPD. Similarly, crepitus during jaw movements
tralizing host antibodies against the onabotulinum toxin is shown together with radiographic changes indicates the need for man-
to be the cause. Proper administration of BTX minimizes the side agement of arthritic changes at the same time.
effects, such as unbalanced muscle tone or chewing force weak-
ness (Jadhao VA, Lokhande N, Habbu SG, 2017). The patient ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
should understand that these are temporary findings. Rarely, a complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 344.e1

Kalichman L, Menahem I, Treger I: Myofascial component of cancer

Bibliography pain review, J Bodyw Mov Ther 23(2):311-315, 2019. doi:10.1016/j.
jbmt.2019.02.011.
Bueno CH, Pereira DD, Pattussi MP, et al: Gender differences in tem- Koukoulithras I, Plexousakis M, Kolokotsios S, et al: A biopsychosocial
poromandibular disorders in adult populational studies: a systematic model-based clinical approach in myofascial pain syndrome: a narra-
review and meta-analysis, J Oral Rehabil 45(9):720-729, 2018. tive review, Cureus 13(4):e14737, 2021. doi:10.7759/cureus.14737.
doi:10.1111/joor.12661. Ohrbach R, Michelotti A: The role of stress in the etiology of oral para-
Christidis N, Lindström Ndanshau E, Sandberg A, et al: Prevalence and function and myofascial pain, Oral Maxillofac Surg Clin North Am
treatment strategies regarding temporomandibular disorders in chil- 30(3):369-379, 2018. doi:10.1016/j.coms.2018.04.011.
dren and adolescents—a systematic review, J Oral Rehabil 46(3):291- Okeson JP: Management of Temporomandibular Disorders and Occlusion,
301, 2019. doi:10.1111/joor.12759. ed 8, 2020, Elsevier.
Fillingim RB, Slade GD, Diatchenko L, et al: Summary of findings from Ramos-Herrada RM, Arriola-Guillén LE, Atoche-Socola KJ, et al: Effects
the OPPERA baseline case-control study: implications and future of botulinum toxin in patients with myofascial pain related to tem-
directions, J Pain 12(Suppl 11):T102-T107, 2011. doi:10.1016/j. poromandibular joint disorders: a systematic review, Dent Med Probl
jpain.2011.08.009. 59(2):271-280, 2022. doi:10.17219/dmp/145759.
Fricton J: Myofascial pain: mechanisms to management, Oral and Maxillofac Stechman-Neto J, Porporatti AL, Porto de Toledo I, et al: Effect of temporo-
Surg Clin North Am 28(3):289-311, 2016. doi:10.1016/j.coms.2016. mandibular disorder therapy on otologic signs and symptoms: a system-
03.010. atic review, J Oral Rehabil 43(6):468-479, 2016. doi:10.1111/joor.12380.
Gattie E, Cleland JA, Snodgrass S: The effectiveness of trigger point dry Tantanatip A, Patisumpitawong W, Lee S: Comparison of the effects of
needling for musculoskeletal conditions by physical therapists: a system- physiologic saline interfascial and lidocaine trigger point injections in
atic review and meta-analysis, J Orthop Sports Phys Ther 47(3):133-149, treatment of myofascial pain syndrome: a double-blind randomized
2017. doi:10.2519/jospt.2017.7096. controlled trial, Arch Rehabil Res Clin Transl 3(2):100119, 2021.
Jabbari B: Basics of structure and mechanisms of function of botulinum doi:10.1016/j.arrct.2021.100119.
toxin—how does it work? In Botulinum toxin treatment: what everyone Valesan LF, Da-Cas CD, Réus JC, et al: Prevalence of temporomandibu-
should know, Berlin/Heidelberg, 2018, Springer, pp. 11-17. lar joint disorders: a systematic review and meta-analysis, Clin Oral
Jadhao VA, Lokhande N, Habbu SG, et al: Efficacy of botulinum toxin Investig 25(2):441-453, 2021. doi:10.1007/s00784-020-03710-w.
in treating myofascial pain and occlusal force characteristics of masti- Wang TJ, Stecco A: Fascial thickness and stiffness in hypermobile Ehlers-
catory muscles in bruxism, Indian J Dent Res 28(5):493-497, 2017. Danlos syndrome, Am J Med Genet C Semin Med Genet 187(4):
doi:10.4103/ijdr.IJDR_125_17. 446-452, 2021. doi:10.1002/ajmg.c.31948.

t.me/Dr_Mouayyad_AlbtousH
67
Internal Derangement of the
Temporomandibular Joint
SI N A H A S H EM I and DAV ID J . P S U T K A

CC The intraoral examination reveals a class I occlusion with a

normal overbite and overjet. There are significant wear facets and
A 37-year-old female presents to the office reporting a sudden craze lines on her dentition. These are signs that may point to
onset of reduction in mouth opening and jaw pain. parafunctional habits such as clenching or bruxism. A Mahan’s
Temporomandibular joint dysfunction (TMD) refers to any test is performed to assess for intraarticular pathology. The test is
signs and symptoms that are attributed to pathologies of the tem- performed by having the patient bite on a tongue depressor (at
poromandibular joint (TMJ), the masticatory muscles, or associ- the level of the canine), which loads her contralateral joint. Her
ated structures. Internal derangement of the TMJ is a commonly test result is positive for pain on the left side.
diagnosed disorder under the umbrella term that is TMD, and it
is most frequently seen in females. Imaging
HPI The initial radiographic assessment for all patients with TMD
should start with a panoramic study. It is a readily obtainable,
The patient reports a sudden lancinating pain in her left jaw fol- low-cost, and low-radiation radiograph that can immediately rule
lowed by an inability to open her mouth that occurred while out uncommon disorders causing TMD (tumors, fractures, and
eating lunch. The pain is 8 of 10 on the visual analog scale. It gets so on). The panoramic radiograph can provide a good general
worse with jaw function, including chewing and speaking. She overview of the bony architecture of the TMJs as well as the entire
describes a longstanding “click” in her left joint for many years. mandible. In most patients with TMD, the panoramic examina-
She also reports feeling generally sore in her jaw when she wakes tion will be unremarkable.
up in the morning. She denies any history of trauma. There have For further assessment of the soft tissues surrounding the
been no prior episodes of locking. Her mouth opening has sig- TMJ, including the articular disk, a contrast-enhanced magnetic
nificantly decreased since this incident. There are no associated resonance imaging (MRI) is performed. Obtaining this study in
headaches. Her husband has told her she grinds and clenches her open- and closed-mouth views can identify anterior disk dis-
teeth at night, but she does not wear an occlusal splint. placement (ADD) with or without reduction (Fig. 67.1A and
B). Areas of inflammation, such as synovial enhancement or
PMHX/PDHX/Medications/Allergies/SH/FH joint effusions, can be illustrated on T2-weighted sequences
(Fig. 67.1C).
Her medical history is not significant. Computed tomography scans are often not indicated in pa-
tients with internal derangement unless there are suspicions of
Examination bony pathology from the initial panoramic study.
In the current patient, the panoramic radiograph revealed
The patient appears well and is in no apparent distress. grossly normal condyles without any obvious pathologies. MRI
She is orthognathic in appearance and has balanced facial pro- revealed left ADD without reduction and limited translation on
portions. The ear canals are both patent, and the tympanic mem- the open-mouth view. There were also some signs of osseous de-
branes are normal. There is considerable pain to palpation of her generation and synovitis.
left TMJ. There is no tenderness to her muscles of mastication on
firm palpation. Palpation of her joints reveals no clicking. Her Labs
maximum incisal opening is 12 mm. Normally, an opening click
occurs when the condyle captures an anteriorly displaced disk, Routine lab work is not necessary for the workup of internal de-
and the reciprocal click happens during closure when the condyle rangement of the TMJ. If a patient requires surgery, investigations
returns behind the anteriorly displaced disk. In the case of a non- are dictated by underlying comorbidities and often at the discre-
reducing disk, the condyle merely rotates and does not translate tion of the preoperative clinic after a full history and physical ex-
beyond the articular disk. amination.

345
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346 S E C TI O N Temporomandibular Joint Disorders

an internal derangement. Functional impairments associated with

displaced disks typically include joint pain, limited mouth open-
ing, audible or painful clicks, and locking.
Myofascial pain disorders can often accompany internal de-
rangements and are important to identify because they do not
respond to surgical management.
The Wilkes classification of TMJ internal derangements can be
used to classify the stage of internal derangement according to
their clinical, radiologic, and pathologic findings. In a small num-
ber of patients, this staging system can unfortunately represent a
natural course of their disease progression. Wilkes Classification
A System for Internal Derangement of the TMJ is well described and
classifies the pathology into five categories. Wilkes I is painless
clicking with no locking and no restricted motion. The disc is
normal and slightly anteriorly displaced.
Wilkes II has occasional painful clicking and intermittent
locking. The disc is slightly anteriorly displaced and reduces on
opening. Wilkes III has frequent pain and joint tenderness with
headaches and locking causing restricted motion. Wilkes IV has
chronic pain, headaches, and restricted motion with crepitus. The
disc is anteriorly displaced and does not recapture. Degenerative
changes in the condyle and fossa are seen. Finally, Wilkes V has
variable pain and joint crepitus. The disc is anteriorly displaced
B and does not recapture, with significant deformity and degenera-
tive osseous changes.

Treatment
As previously mentioned, internal derangement occurs when
there is dysfunction associated with an abnormal disk position.
Patients with asymptomatic displaced disks do not have internal
derangement and do not require treatment.
It is important to know that most patients with TMD improve
with time alone. Therefore, the goal of treatment is to begin with
the least invasive therapies with the highest chance of success.
C First-tier treatment is often referred to as conservative or nonsur-
gical (Fig. 67.2). It consists of a multimodal approach to target
• Fig. 67.1 A, Magnetic resonance imaging (MRI) proton density (PD) se- joint load reduction, maintain mouth opening, and reduce the
quence view in closed-mouth position demonstrating anterior disk dis- inflammatory process of the TMJ. A soft diet, control of para-
placement. B, MRI PD view in open-mouth position confirming a nonre-
function with occlusal splints, and muscle relaxants can reduce
ducing disk. C, T2-weighted MRI in closed-mouth position with synovial
enhancement and small effusion.
unnecessary load, and home exercises or physiotherapy can pre-
vent reduced mouth opening from intraarticular adhesions. Add-
ing a course of nonsteroidal antiinflammatory drugs targets the
joint inflammation and pain. Adjuvant treatments such as mas-
In the event of a systemic arthritis, a referral to a rheumatolo- sage, warm compresses, and acupuncture have also been reported
gist would be prudent for a thorough laboratory evaluation at by patients to relieve symptoms.
time of consultation.

Assessment Open joint

Tier surgery
The patient was diagnosed with internal derangement of the left TMJ 3
(ADD without reduction), likely from chronic overload caused by Arthroscopy or
nocturnal parafunction. Tier arthrocentesis
It is imperative to include the etiology or causative factor as 2
part of the diagnosis because the internal derangement itself is
Conservative
merely a sign and symptom that is attributed to an underlying management
pathology (nocturnal parafunction). If you get caught in treating Tier
only symptoms without addressing underlying causes, then all 1
your interventions will yield less than desirable results.
Many patients have anteriorly displaced disks without any
symptoms. It is only when there is a functional impairment that • Fig. 67.2 Treatment pyramid for internal derangement of the temporo-
accompanies an abnormally positioned disk that we can diagnose mandibular joint.

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 CHAPTER 67 Internal Derangement of the Temporomandibular Joint 347

Generally, a course of 3 to 4 weeks of conservative therapy will Arthroscopy involves the insertion of an endoscope, often 1.9
be enough to determine if patients are responders or nonre- to 2.7 mm in diameter, into the superior joint space that projects
sponders. It is imperative not to apply a cookie-cutter approach an image of the optical cavity on a video tower. The benefit is the
and leave patients on conservative therapy for long periods of possibility to visualize the joint space. This can help identify pa-
time without response because this can lead to the development thologies such a synovitis and small disk perforations that can
of chronic pain, frustration, and delays in seeking next-level care. often be too subtle to pick up on a “normal” MRI examination
Historically, patients who failed conservative management im- (Fig. 67.4). Operative arthroscopy involves using a second port to
mediately underwent open joint procedures such as disk plica- biopsy or disrupt adhesions either mechanically or with the use of
tions and arthroplasties, such as condylar shaves. After less than diathermy or more complex procedures such as disk plication.
desirable long-term results and evidence of accelerating condylar Although this procedure is slightly more invasive than arthrocen-
degeneration through these iatrogenic treatments, the paradigm tesis and often requires a general anesthetic, the visual diagnostic
shifted away from internal derangement being a mechanical prob- benefits alone justify its use.
lem. After identification of inflammatory markers and cytokines A small percentage of patients with advanced internal derange-
in the synovial fluid, internal derangement started to be viewed as ment, such as longstanding nonreducing displaced disks with
a biochemical problem. Perhaps this is the explanation as to why deformation or perforations, will invariably fail tier 2 treatment.
many patients have displaced disks without dysfunction. These patients require open joint procedures, such as disk plica-
The next level of treatments, tier 2, encompasses minimally tions, diskectomy, and total joint replacement.
invasive methods, such as arthrocentesis and arthroscopy, that Disk plication involves mobilizing an anteriorly displaced disk
change the joint milieu by washing out the mediators of inflam- and securing it in a more anatomic position with the use of su-
mation and cartilage degradation. tures or bone anchors placed into the condylar head. In a small
Arthrocentesis is a blind technique that uses two needles in- proportion of patients, typically early Wilkes joints with noxious
serted into the superior joint space to distend and flush the joint clicking, good long-term results can be expected. It is a highly
with isotonic fluid (Fig. 67.3). The lavage is arguably the most technique sensitive procedure that does have the propensity to
important aspect of this treatment. There has been much research induce iatrogenic damage if not done properly or performed with
on different types of medications to inject afterward, including poor case selection.
hyaluronic acid to improve mobility and corticosteroids to reduce Diskectomy is reserved for perforated disks or longstanding
inflammation and pain. Recently, there have been promising re- ADD with deformation. With proper patient selection, the suc-
sults with platelet-rich growth factors, particularly in degenerative cess rate can be quite high. Different materials have been used to
joint disease. Although most studies have problems with bias and replace the disk such cartilage, fat, dermis, or temporoparietal
methodology, it seems clear that these medications work well as fascia (Fig. 67.5). The presence or absence of an interpositional
an adjunct to arthrocentesis and are not a replacement of an ac- graft does not seem to alter success rates.
tual and formal lavage. Procedures such as modified condylotomies were used to allow
the mandibular condyle to reposition inferiorly into a more nor-
malized condyle–disk relationship. They had the advantage of
being extraarticular and thus reducing iatrogenic damage to the
joint. They have, however, fallen out of favour because of the risk
of condylar sag and the success rates of minimally invasive meth-
ods such as arthrocentesis and arthroscopy.
Patients with end-stage joint disease and refractory symptoms
require total joint replacement (TJR). The aims of this procedure
are to restore range of motion and address articular sources of pain.
During this procedure, the entire diseased condyle and articular
disk are removed and replaced with a prosthesis made of either
Cr-Co-Mb or a Ti alloy. The fossa prosthesis is made of ultra-high-
molecular-weight polyethylene (Fig. 67.6). It has become widely
accepted that the highest chance of success is always with the first
surgical procedure because of the added scarring and fibrosis that
occur every time the joint is accessed. For this reason, one should
really limit unnecessary surgical procedures and apply an evidence-
based approach to treatment that focuses on proper diagnosis.
In our current patient, despite a short trial of nonsurgical treat-
ment, her pain level remained an 8 of 10, and maximal incisal
opening (MIO) remained 12 mm. She underwent a left TMJ ar-
throcentesis, and her joint space was irrigated with 120 cc of
Ringer’s lactate followed by an injection of 2 cc of hyaluronic
acid. Two weeks after the intervention, her pain level decreased to
2 of 10, and her MIO returned to 42 mm.

Complications
The natural course of disease progression paired with the risks
• Fig. 67.3 Arthrocentesis of the left temporomandibular joint. from delaying appropriate treatment merit discussion. One may

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348 S E C TI O N Temporomandibular Joint Disorders

A B

C D
• Fig. 67.4 Temporomandibular joint arthroscopic views of retrodiscal synovium (A), medial synovial drape
and posterior disk roofing condylar head (B), synovitis and hyperemia of retrodiscal tissues (C), and in-
traarticular adhesion (D).

view nonsurgical treatment as “conservative” and without compli- Open joint procedures are the most invasive and consequently
cations, but this is far from the truth. The risks of developing carry a higher potential for complications. Vascular injury can
chronic pain, central sensitization, and frustration in a patient involve the superficial temporal vessels during early dissection or
who is left on a prolonged period of nonsurgical treatment with- the more medial internal maxillary artery and pterygoid plexus
out any improvement are very real and can negatively affect their during TJR surgery. The facial arteries are also at risk when ap-
quality of life. The goal of nonsurgical treatment is to appropri- proaching the mandible through a cervical incision. Neurologic
ately identify patients who have reversible symptoms and those injury, particularly to the facial nerve, remains the major con-
who require further care. Typically, a 1- to 2-month period of cern. The marginal mandibular branch of the facial nerve has
nonsurgical treatment is enough time for this. It has become ap- been shown in cadaveric studies to be as low as 1.2 cm below the
parent from the literature that unnecessarily delaying arthroscopy inferior border of the mandible in the area of the facial vessels.
and arthrocentesis does in fact lead to poorer outcomes compared The frontal branch of the facial nerve crosses the zygomatic arch
with when these procedures are performed earlier. between 8 and 35 mm from the external auditory canal. Injury
Arthrocentesis is a relatively benign procedure, and complica- can occur during initial dissection but also during overzealous
tions are infrequent. Temporary swelling, facial nerve paresis, and use of cautery near the condylar neck. Temporary weakness to
altered occlusion can be expected from joint space insufflation the frontalis and orbicularis, in the form of eyebrow ptosis and
and extravasation of fluid and local anesthetic. Arthroscopy is also lagophthalmos, can occur from retraction and postoperative
minimally invasive but does require more skill and formal training edema. Fortunately, permanent injury is quite rare. The auricu-
because complications can arise in untrained hands. There have lotemporal nerve supplies sensory innervation to the overlying
been few case reports of middle ear perforation and internal os- skin and can be often damaged during the preauricular incision.
sicle damage. Injury to the facial nerve or temporal vessels can Patients rarely complain of deficits. Rewiring of its parasympa-
occur but are rare because these structures are typically pushed thetic fibers to the parotid with the sympathetic fibers to the
away during trocar insertion. The roof of the glenoid fossa is thin, sweat glands of the skin can lead to gustatory sweating or Frey’s
and perforation into the middle cranial fossa can occur with un- syndrome. The incidence of complications increases after multi-
controlled entry. During operative arthroscopy, instrument break- ple joint surgeries because scarring and fibrosis lead to altered
age can occur if improper techniques are used. anatomy.

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 CHAPTER 67 Internal Derangement of the Temporomandibular Joint 349

A B

C
• Fig. 67.5 A, Right temporomandibular joint diskectomy completed with overlying temporalis fascia flap.
B, Parachuting suture technique for stabilization of the flap. C, Temporalis fascial flap sutured in place.

Discussion
Internal derangement refers to join dysfunction that may arise
from an abnormal disk position. This can manifest as joint pain,
noises, locking, limited range of motion, headaches, and so on.
This is most often caused by joint overload, as in the case of para-
function, which initiates a vicious cycle of inflammatory and
degenerative changes that alter the normal physiologic and bio-
mechanical function of the TMJ. Other causes can include sys-
temic arthropathies or localized pathologies such as neoplasms.
The goals of treatment are to reduce pain, improve mouth
opening, and attempt to arrest the progression of the disease
course. The possibility of disease progression must be explained to
the patient. Most patients with ADD with reduction improve
with time, education, and nonsurgical methods. Those progress-
ing to ADD without reduction or refractory to nonsurgical meth-
ods benefit from earlier arthroscopy or arthrocentesis. Very few
patients end up requiring open joint procedures.

• Fig. 67.6 Prosthetic fossa and condyle after explantation 10 years after ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
surgery caused by a prosthetic joint infection. complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 349.e1

Bibliography McCain JP, Sanders B, Koslin MG, et al: Temporomandibular joint ar-
throscopy: a 6-year multicenter retrospective study of 4,831 joints,
J Oral Maxillofac Surg 50(9):926-930, 1992.
Abramowicz S, Dolwick MF: 20-year follow-up study of disc reposition- Murakami K, Hosaka H, Moriya Y, et al: Oral and maxillofacial surgery
ing surgery for temporomandibular joint internal derangement, J short-term treatment outcome study for the management of tem-
Oral Maxillofac Surg 68(2):239-242, 2010. doi:10.1016/j.joms.2009. poromandibular joint closed lock a comparison of arthrocentesis to
09.051. nonsurgical therapy and arthroscopic lysis and lavage, Oral Surg Oral
Dworkin SF, LeResche L: Research diagnostic criteria for temporoman- Med Oral Pathol Oral Radiol Endod 80(3):253-257, 1995.
dibular disorders: review, criteria, examinations and specifications, Murakami K, Moriya Y, Goto K, et al: Four-year follow-up study of
critique, J Craniomandib Disord 6(4):301-355, 1992. temporomandibular joint arthroscopic surgery for advanced stage
Gonçalves JR, Cassano DS, Rezende L, et al: Disc repositioning. Does it internal derangements, J Oral Maxillofac Surg 54(3):285-291, 1996.
really work?, Oral Maxillofac Surg Clin North Am 27(1):85-107, doi:10.1016/s0278-2391(96)90742-9.
2015. doi:10.1016/j.coms.2014.09.007. Schiffman E, Ohrbach R, Truelove E, et al: Diagnostic criteria for temporo-
Israel HA, Behrman DA, Friedman JM, et al: Rationale for early versus mandibular disorders (DC/TMD) for clinical and research applications:
late intervention with arthroscopy for treatment of inflammatory/ recommendations of the International RDC/TMD Consortium
degenerative temporomandibular joint disorders, J Oral Maxillofac Network* and Orofacial Pain Special Interest Group† HHS Public Ac-
Surg 68(11):2661-2667, 2010. doi:10.1016/j.joms.2010.05.051. cess, Oral Facial Pain Headache 28(1):6-27, 2014.
Israel HA: Internal derangement of the temporomandibular joint: new Wilkes CH: Internal derangement of the temporomandibular joint: patho-
perspectives on an old problem, Oral Maxillofac Surg Clin North Am logical variations, Arch Otolaryngol Head Neck Surg 115(4):469-477,
28(3):313-333, 2016. doi:10.1016/j.coms.2016.03.009. 1989.
Li J, Zhang Z, Han N: Diverse therapies for disc displacement of tem- Ziarah HA, Atkinson ME: The surgical anatomy of the cervical distribu-
poromandibular joint: a systematic review and network meta-analysis, tion of the facial nerve, Br J Oral Surg 19(3):171-179, 1981.
Br J Oral Maxillofac Surg 60(8):1012-1022, 2022. doi:10.1016/j. doi:10.1016/0007-117x(81)90002-0.
bjoms.2022.04.004.

t.me/Dr_Mouayyad_AlbtousH
68
Arthrocentesis and Arthroscopy
BEDRETTIN CEM SENER

CC result, suggesting a right intracapsular source of pain). Intraoral

examination reveals scalloped tongue margins and linea alba
A 35-year-old female reports a restricted mouth opening, which presence bilaterally. Bilateral lateral and medial pterygoid muscles
has not responded any previous treatments, and an intermittent are also tender during examination (Stelzenmueller W, Umstadt
pain 5 of 10 during function and 2 of 10 while resting on her H, Weber D, 2016).
right temporomandibular joint (TMJ) area. A panoramic radiograph reveals no osseous abnormalities but
a deep articular fossa and a steep anterior wall angle on the right
HPI TMJ. Magnetic resonance imaging (MRI) reveals right anterior
disk dislocation without reduction (ADDwoR) and left anterior
The patient is a lecturer and reports a 2-year history of right-sided disk dislocation with reduction (ADDwR) (Fig. 68.1). Subtle ef-
jaw pain that sometimes gives trouble with chewing. The pain is fusion on the left TMJ and mild effusion on the right TMJ are
worsening and is severe enough to limit her diet to soft foods and also reported.
restrict her speaking and lecturing. She also reports a previous
asymptomatic right-sided jaw click, present for many years, which Assessment
stopped about the time she developed the right-sided restriction
and pain. She has occasional neck tension, ringing ears, and a Bilateral myofascial pain dysfunction, painful ADDwoR of the left
change in hearing. TMJ with effusion, Wilkes stage III (see Wilkes staging in the section
on internal derangement of the temporomandibular joint earlier in
PMHX/PDHX/Medications/Allergies/SH/FH this chapter), and (ADDwoR) of the right TMJ.

The patient’s past medical history is noncontributory. She is al- Treatment

lergic to aspirin. She uses over-the-counter vitamin supplements.
She is aware of a nighttime clenching issue. Her dentist fabricated The patient is instructed on the first line of treatment both for
a nightguard, which she has been using for a long time. She has myofascial pain dysfunction (MPD) and internal derangement of
been having physiotherapy, massage therapy and acupuncture, the TMJ, which is conservative management. This may include an
self-treatment such as warm compresses, and diet modification. occlusal splint, nonsteroidal antiinflammatory drugs (NSAIDs)
None could provide major help for jaw opening or pain. with or without muscle relaxants, extraoral heat or ice compres-
sion, a nonchewing diet, physical opening exercises, and massage
Examination therapy. After 4 weeks, her follow-up revealed no improvement
achieved with conservative techniques. Therefore, next-step inter-
General. The patient is a well-developed and well-nourished ventions with minimally invasive techniques should be considered.
female in no apparent asymmetry. The minimally invasive surgical treatments are arthrocentesis
Maxillofacial. There is tenderness on palpation of the masse- and arthroscopy (Al-Moraissi E, 2014), (Murakami K, 2022).
ter, temporalis, sternocleidomastoid, and trapezius muscles Possible association of MPD should always be considered as a
bilaterally. The patient has some restriction and tension with contributing condition and be treated simultaneously with those
movement of her neck. She has right capsular tenderness on pre- surgical methods. Failure of one or both surgical procedures may
auricular and endaural palpation. There is no clicking or crepitus necessitate an open joint procedure, such as arthroplasty. All sur-
on either palpation or auscultation of the TMJs. The patient has gical procedures should be reserved for intracapsular sources of
a maximal interincisal opening of 25 mm, with deviation to the pain or limited function.
right and moderate pain. Her lateral excursive movements are
8 mm to the right and a painful 4-mm movement to the left (sug- Arthrocentesis
gesting decreased right TMJ condylar translation). Protrusive
movement is 7 mm and deviates to the right with pain. She re- The first-line surgical treatment choice for acute or chronic closed
ports pain in the right joint when biting on a tongue blade placed lock ADDwoR, arthralgia, anchored disk in the early stages, syno-
between the molar teeth on the left side (positive Mahan test vitis, and capsulitis tat are not responsive to the conservative

350
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 CHAPTER 68 Arthrocentesis and Arthroscopy 351

A
• Fig. 68.2 Arthrocentesis needle entry points on the tragochantal line.
Point A is 10 mm from the tragus and 2 mm below the line for the first
needle entry. Point B is 20 mm from the tragus and 10 mm below the line
for the second needle entry.

and lateral and medial pterygoid muscles bilaterally. The surgical

field is prepared and draped. The landmarks are identified by
drawing a line extending from the superior aspect of the tragus to
the lateral canthus of the eye. The A point, 10 mm anterior from
B the tragus and 2 mm inferior along the tragocanthal line, is
• Fig. 68.1 A, Magnetic resonance imaging of closed view of the right marked and serves as the initial puncture site. The B point is 20
temporomandibular joint (TMJ) reveals anterior disk displacement. mm anterior of the tragus and 10 mm inferior along the tragocan-
B, Nonreducing disk of the right TMJ while the mouth is opened. thal line and serves as the second puncture point (Fig. 68.2).
Palpating the TMJ while opening and closing to figure out the
joint localization and anatomy is a key for proper insertion of the
needles besides the A and B points. One percent plain lidocaine
treatment, and initial degenerative changes of the TMJ is arthro- is used for local infiltrations to superficial tissues and intra- and
centesis (Nitzan DW, Naaman HL, 2022). Mostly the superior periarticular spaces. A mouth probe or a bite block would be use-
joint space (rarely the inferior joint space) is distended and irri- ful to keep the mouth open to increase the joint surface for needle
gated, and usually some medications or biomaterials are placed entries. An 18-gauge needle is connected to an irrigation tubing
into the joint cavity. A 0.9% saline solution or more preferably and flushed with LR solution and then is inserted into the supe-
lactated Ringer’s (LR) solution is used for the distension and irriga- rior joint space through the A point. To distend the joint space
tion of the upper joint space. By applying the LR solution with with hydraulic pressure, 2 to 5 cc LR solution is applied using a
pressure, the distension can be achieved to increase the vertical 60-mL syringe filled with LR. A second 18-gauge needle can then
joint space. This vertical space improvement allows the articular be inserted into the joint space via point B. Successful placement
disk to return its original place. With the irrigation, removal of of the two needles is confirmed by the outlet of LR solution from
inflammatory molecules and degraded loose proteins and disrup- the second needle. The joint space is then irrigated with 120 to
tion of immature adhesions causing the stuck disk can be achieved. 200 mL of LR solution (Fig. 68.3 and Video 68.1). On comple-
The procedure may result in an improvement in pain and range of tion of the irrigation, one needle can be removed, and an adjuvant
motion clinically. Additionally, reduction of the frequency of click- medication (e.g., hyaluronic acid or corticosteroid) can be in-
ing can also be expected. It should always be supported with the jected into the joint space through the remaining needle. The
continuation of conservative treatments postoperatively. This can mandible is then manipulated by closing and opening maximally.
be accomplished under local anesthesia or sedation. Contraindica- The remaining needle is then removed, and pressure is applied to
tions for TMJ arthrocentesis are fibrous and osseous ankylosis, lo- the injection site for 2 to 3 minutes. Postoperative pressured com-
cal infectious or malignancies, multiple previous attempts, and pression, NSAIDs, a soft diet, and occlusal splint use are sug-
psychiatric illness (Nitzan DW, Naaman HL, 2022). gested. Starting by the next day, mouth-opening exercises should
This method can be done with double needles as first described be instructed. Two weeks later, the patient had a 36-mm interin-
by Murakami et al. (K Murakami, 2022; KI Murakami, Iizuka, & cisal maximum mouth opening and complete elimination of the
Matsuki, 1987) or single special needle which has two lines in- pain during function.
side, one for fluid entry and one for exit. There is no evidence that The anticipated mean reduction in pain with arthrocentesis
dual-puncture is superior to single-puncture arthrocentesis approaches 50%, and the mean increase in the maximum interin-
(Şentürk, Yazıcı, & Gülşen, 2018). The following case demon- cisal opening approaches 15% over baseline. Arthrocentesis is
strates the double-puncture technique. Examination is repeated to most recommended for cases of TMJ arthralgia, restricted mouth
identify the muscles for botulinum toxin (BTX) treatment. Ini- opening, intermittent clicking, and locking in open and closed
tially, 90 units of BTX is administered to the temporalis, masseter, positions (Wilkes II and III).

t.me/Dr_Mouayyad_AlbtousH
352 S E C TI O N Temporomandibular Joint Disorders

• Fig. 68.4 Arthroscope and outflow irrigating needle with egress of lac-
tated Ringer’s solution.

that the medial synovial drape, pterygoid shadow, retrodiskal

synovium, posterior slope of the articular eminence, articular disk
intermediate zone, and anterior recess are visualized. As needed,
inferior joint space can be visualized. Evidence of synovitis, chon-
dromalacia, fibrous adhesions, pseudowalls (synovium-covered fi-
brous attachments), perforations, loose cartilage particles, or other
pathology is readily identified. The joint space is irrigated with 150
• Fig. 68.3 Outflow of lactated Ringer’s solution confirms successful to 200 mL of LR solution under pulsatile digital pressure (Fig.
placement of needles for the arthrocentesis. 68.4). Adhesions can be disrupted with the scope and a lateral
capsular stretch performed (lateral capsular impingement syn-
drome). The 21-gauge needle is then removed, and an adjuvant
Arthroscopy medication (e.g., corticosteroid or hyaluronic acid) is injected
through the trocar. The trocar is removed, and digital pressure is
Arthroscopy is the second-line treatment option when arthrocente- applied for 2 to 3 minutes.
sis cannot solve closed lock and anchored disk problems. This pro- The anticipated mean reduction in pain with arthroscopy ap-
cedure can be performed under local anesthesia, but sedation or proaches 70%, and the mean increase in maximum interincisal
general anesthesia in an ambulatory setting is preferred. Usually, opening approaches 40%.
arthroscopy can be performed with single or dual puncture, de-
pending on how many trocars are used to penetrate the superior Complications
joint space. Either a 30- or 0-degree arthroscope can be useful de-
pending on the entry site or working perspective. The arthroscope Complications associated with TMJ arthrocentesis are rare and
diameter ranges between 1.9 and 2.3 mm. Dual-puncture arthros- similar to those for the arthroscopy procedure. The most common
copy requires higher surgical skills and experience but provides the expectation (95.1%) is the soft tissue swelling because of leakage
opportunity to instrument the joint space with hand instruments, of LR solution during irrigation. This swelling can lead to ipsilat-
motorized shavers, lasers, and coblation devices. The following de- eral open bite (68.8%) because of temporary extended TMJ space.
scription refers to single-puncture arthroscopy (Pandey A, Bhargava External auditory canal blockage can also be expected for a while
D, 2021). (23.5%). The next likely complication is needle trauma–related
The surgical field is prepared, landmarks are identified (as per injuries. The rate of facial nerve injury–related mimic muscle pare-
arthrocentesis), and a local anesthetic is injected into the joint sis is 65.1%. Similarly, some otologic complications such as entry
space and superficial tissues. A sharp obturator or trocar is inserted to the external auditory canal, middle ear, and middle cranial fossa
percutaneously into the superior joint space. The obturator is then can be observed. These injuries might lead to vertigo, preauricular
removed, the trocar is covered with a thumb to prevent backflow hematoma, arteriovenous fistula formation, or instrument break-
of irrigant, and irrigation tubing is connected to the trocar. Minor age in a small number of patients (Nitzan DW, Naaman HL,
pressure is applied on a 60-mL syringe filled with LR solution. 2022) (Vaira LA, Raho MT, Soma D, 2018).
While the superior joint space is distended with the solution, an To avoid swelling, the most common complication, the
18-gauge needle is inserted 4 to 5 mm anteriorly into the superior surgeon should refrain from unnecessary punctures at the TMJ
joint space. Appropriate positioning is confirmed with immediate capsule and should use only two- or one-needle puncture to
egress of the irrigating solution. The arthroscope can then be in- minimize leakage of the LR solution into the peripheral soft tis-
serted through the trocar with clear visualization of the superior sue. This eventually results in immediate swelling at this site. The
joint space. After the arthroscope is inside the anterior-superior pressure application during irrigation can also play an important
joint space, a methodical sweep of the joint space is undertaken so role in liquid leakage. Therefore, the surgeon should refrain from

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 68 Arthrocentesis and Arthroscopy 353

using excessive pressure with the syringe and monitor the periar- treatment. Both minimally invasive techniques must be used only
ticular soft tissue surface distension with another hand while for patients with intracapsular sources of pain or limited function
pushing the syringe plunger. Although no evidence is available to (e.g., internal derangement). When the cost and ease of anesthesia
compare the postoperative swelling after manual and motor- technique, and simplicity of instrumentation are regarded, arthro-
induced irrigation systems, monitoring the soft tissue distension centesis is more advantageous over arthroscopy. Additionally, it
by hand could provide a basic understanding about the soft tissue could be the first-line treatment, especially for the early stages of
tension to the surgeon. Also, the gauge of the point B evacuation internal derangement with pain or restriction (Soni A, 2019). The
needle should be either equal to or larger than the fluid entry complication rates of arthrocentesis and arthroscopy are similar
needle point A gauge so that exit of degraded soft tissue particles (Nogueira EFC, Lemos CAA, Vasconcellos RJH, 2021).
can be eased and leakage can be minimized. As the placement of Temporomandibular joint arthroscopy is indicated over arthro-
hyaluronic acid or glucocorticoid medication is completed, an centesis for repairable disk deformity, intraarticular adhesions,
extraoral dressing can be administered with pressure to minimize osteoarthritis or degenerative arthritis, posttraumatic changes,
the postoperative swelling. and pseudotumours. Besides diagnostic evaluation, irrigation, and
The most common surgical complications are bleeding, drug placement, arthroscopy can be used to obtain a biopsy
instrument breakage, laceration of the external auditory canal, and eliminate fibrous adhesions, lysis, discopexy, and perforated
blood clots in the external auditory canal, lesion of the auricu- disk repair, but the procedure is limited to the surgeon’s experience
lotemporal nerve, paresis of the facial nerve, paralysis of the and instrumentation.
facial nerve, alteration of visual accuracy, lesion of the inferior The removal of fibrous attachments is possible with arthros-
alveolar nerve, cardiac disturbances, and arteriovenous fistula. copy plus it allows a greater mean improvement in maximum
Comparing the single-portal with the double-portal technique interincisal opening. Similarly, arthroscopy is shown to provide
could have a higher complication risk (Ângelo, Araújo, & Sanz, better results in pain decrease postoperatively compared with ar-
2021), (González-García, Rodríguez-Campo, & Escorial- throcentesis. For both procedures, a vigorous postprocedural jaw
Hernández, 2006), (Muñoz-Guerra, Rodríguez-Campo, & Es- exercise regimen, which the patient performs at home for several
corial Hernández, 2013). weeks, is particularly important. Like arthrocentesis, it is also
Because of the higher surgical skills needed for arthroscopy, contraindicated in the presence of bony ankylosis, acute infection,
anatomy-related complications are more likely at the beginning; tumours having risk of metastasis, systemic disorders, and ana-
it becomes increasingly related to instrumentation failures as the tomic alterations to the joint architecture.
surgeon gains more experience. Controversy exists as to whether the injection of adjunct
medication (e.g., corticosteroid, hyaluronic acid, or platelet-rich
Discussion plasma) is of additional benefit after either procedure. The choice
of which medication to use is guided more by the surgeon’s per-
The treatment goal for patients with symptomatic internal de- sonal experience, although current literature provides equivocal
rangement aims to reduce pain, increase range of motion, and support for both medications, depending on the pathology pres-
slow down or stop the progress of the derangement. Patients un- ent and the joint involved. No clear guidelines exist specifically
dergoing any of these procedures should have failed conservative for the TMJ; however, glucocorticoid side effects could be re-
treatment methods before. Conservative treatment must be con- garded for injection.
tinued after these minimally invasive procedures. Ultimately, if
the condition is associated with MPD, the patients would benefit ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
from BTX simultaneously with arthrocentesis or arthroscopy complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 353.e1

Bibliography temporomandibular joint, Cranio 5(1):17-24, 1987. Available at:

https://doi.org/10.1080/08869634.1987.11678169.
Nitzan DW, Naaman HL: Arthrocentesis: what, when, and why? Atlas
Al-Moraissi E: Arthroscopy versus arthrocentesis in the management of Oral Maxillofac Surg Clin North Am 30(2):137-145, 2022. Available
internal derangement of the temporomandibular joint: a systematic at: https://doi.org/10.1016/j.cxom.2022.06.008.
review and meta-analysis, Int J Oral Maxillofac Surg 44(1):104-112, Nogueira EFC, Lemos CAA, Vasconcellos RJH, et al: Does arthroscopy
2014. Available at: https://doi.org/10.1016/j.ijom.2014.07.008. cause more complications than arthrocentesis in patients with inter-
Ângelo DF, Araújo RAD, Sanz D: Surgical complications related to tem- nal temporomandibular joint disorders? Systematic review and meta-
poromandibular joint arthroscopy: a prospective analysis of 39 single- analysis, Br J Oral Maxillofac Surg 59(10):1166-1173, 2021. Available
portal versus 43 double-portal procedures, Int J Oral Maxillofac Surg at: https://doi.org/10.1016/j.bjoms.2021.05.007.
50(8):1089-1094, 2021. Available at: https://doi.org/10.1016/j.ijom. Pandey A, Bhargava D: Fundamentals of temporomandibular joint ar-
2020.07.020. throscopy. In Bhargava D, (eds): Temporomandibular Joint Disorders,
González-García R, Rodríguez-Campo FJ, Escorial-Hernández V, et al: Singapore, 2021, Springer. Available at: https://doi.org/10.1007/978-
Complications of temporomandibular joint arthroscopy: a retrospec- 981-16-2754-5_20.
tive analytic study of 670 arthroscopic procedures, J Oral Maxillofac Şentürk MF, Yazıcı T, Gülşen U: Techniques and modifications for TMJ
Surg 64(11):1587-1591, 2006. Available at: https://doi.org/10.1016/j. arthrocentesis: a literature review, Cranio 36(5):332-340, 2018. Avail-
joms.2005.12.058. able at: https://doi.org/10.1080/08869634.2017.1340226.
Muñoz-Guerra MF, Rodríguez-Campo FJ, Escorial Hernández V, et al: Soni A: Arthrocentesis of temporomandibular joint: bridging the gap be-
Temporomandibular joint disc perforation: long-term results after tween non-surgical and surgical treatment, Ann Maxillofac Surg 9(1):
operative arthroscopy, J Oral Maxillofac Surg 71(4):667-676, 2013. 158-167, 2019. Available at: https://doi.org/10.4103/ams.ams_160_17.
Available at: https://doi.org/10.1016/j.joms.2012.12.013. Stelzenmueller W, Umstadt H, Weber D, et al: Evidence—the intraoral
Murakami K: Current role of arthrocentesis, arthroscopy and open sur- palpability of the lateral pterygoid muscle—a prospective study, Ann
gery for temporomandibular joint internal derangement with inflam- Anat 206:89-95, 2016. Available at: https://doi.org/10.1016/j.aanat.
matory/degenerative disease; pitfalls and pearls, J Oral Maxillofac Surg 2015.10.006.
Med Pathol 34(1):1-11, 2022. Available at: https://doi.org/ Vaira LA, Raho MT, Soma D, et al: Complications and post-operative
10.1016/j.ajoms.2021.03.009. sequelae of temporomandibular joint arthrocentesis, Cranio 36(4):
Murakami KI, Iizuka T, Matsuki M, et al: Recapturing the persistent 264-267, 2018 Available at: https://doi.org/10.1080/08869634.2017.
anteriorly displaced disk by mandibular manipulation after pumping 1341138.
and hydraulic pressure to the upper joint cavity of the

t.me/Dr_Mouayyad_AlbtousH
69
Idiopathic Condylar Resorption*
DAV I D Y. A H N , E L I S E E HL AN D, J AE H . J UN, a n d J A S ON K IM

CC It is important that the surgeon takes a systematic approach

to history taking when they suspect ICR because many local fac-
A 26-year-old female presents seeking treatment to correct her tors (degenerative joint disease, particularly juvenile idiopathic
skeletal malocclusion. She has noticed that her chin has been arthritis, infections leading to reactive arthritis, direct trauma,
receding since her teenage years and that her bite has been wors- prior orthognathic surgery or orthodontic therapy), as well as
ening as well. She has a remote history of pain in her temporo- systemic conditions (rheumatoid arthritis, scleroderma, systemic
mandibular joints (TMJs) but is currently asymptomatic, with no lupus erythematosus, psoriatic arthritis, steroid use) can con-
other symptoms in her TMJs. found the final diagnosis. A thorough documentation of the past
Patients with idiopathic condylar resorption (ICR) are typi- histories, including medical, surgical, social, and family history;
cally identified at the orthodontist’s office or at the oral and max- review of current medications; and allergies is used to help rule
illofacial surgeon’s office, where they complain of progressively out the potential confounders (especially the TMJ-only juvenile
worsening bite or facial esthetics (retruding chin, for example). idiopathic arthritis because this condition clinically appears iden-
They may or may not have concurrent TMJ symptoms (reproduc- tical to ICR). Because the other diagnoses have been ruled out
ible sharp intraarticular ear pain, limited mouth opening, and so and no other explanation can be given for a patient’s condylar
on), so this should not be used to distinguish ICR from other resorption (either unilateral or bilateral), ICR can be considered
TMJ diagnoses. There are certain general clinical features of ICR as a possibility.
(e.g., retrognathia; a high mandibular plane angle; a short lower
facial third, with or without anterior open bite, often involving Examination
bilateral TMJs), but some of these may overlap with other con-
founders, so it is imperative that the surgeon completes the General. The patient is a well-developed and well-nourished fe-
workup starting with a detailed documentation of the patient’s male in no apparent distress.
chief complaint, paying particularly close attention to the pro-
gressivity of the disease process to arrive at the correct diagnosis. Maxillofacial
HPI The patient has normal mouth opening of 52 mm with normal
lateral excursions and protrusion. There is 3 to 4 mm of ante-
The patient initially presented several years ago with a progressively rior open bite with molars and canines in a class II relationship
receding chin and a worsening bite, seeking orthognathic surgery to bilaterally. A discrepancy of 2 to 3 mm was noted between
correct her facial deformity and skeletal malocclusion. Two different centric relation (CR) and centric occlusion (CO). Overjet is
imaging modalities revealed severely resorbed condyles on both 9 mm, which has slightly worsened from 7 mm from 3 years
sides. At that time, she had no associated TMJ symptoms. Potential prior. She does not have any TMJ clicks or pops, nor any repro-
surgical options were discussed, but the patient decided to postpone ducible sharp intraarticular ear pain, but she does have some
her surgery. She then returned 3 years later with a new bilateral dull, throbbing pain to the bilateral masseter and temporalis
myofascial pain and a slightly worsened overjet, desiring to proceed muscles upon palpation. The rest of her clinical examination is
with previously discussed surgery. She denied any trauma to her face unremarkable.
or the jaws, previous orthodontic therapy, or any other jaw surgeries. On clinical examination, the following pattern may be noted
in patients suspected to have ICR, including those with a class II
PMHX/PDHX/Medications/Allergies/SH/FH skeletal malocclusion either with or without an anterior open bite,
retrognathia, a short ramus height with increased mandibular
The patient was taking an oral contraceptive (norethisterone) at plane angle, and positive overjet, all of which can either be pro-
the time of initial presentation 3 years ago but has since discontin- gressive or be in “remission.” Although not absolute, a good
ued its use. The remainder of her past histories is noncontributory. number of these patients tend to be females who are 15 to
35 years of age (several reported female-to-male ratios of 9:1, 8:1,
*The views expressed in this material are those of the authors and do not re- and 13:1). Additionally, it is important to look for and record the
flect the official policy or position of the US Government, the Department of CR-CO shift in these patients because surgical planning must be
Defense, or the Department of the Air Force. based on the CR position.

354
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 CHAPTER 69 Idiopathic Condylar Resorption 355

Imaging
The most frequently used imaging modality by oral and maxillofa-
cial surgeons when evaluating a patient for ICR is the orthopanto-
mogram followed by computed tomography (CT) or cone-beam
CT (CBCT). Other modalities include magnetic resonance imag-
ing, two-dimensional radiography (lateral cephalometric radio-
graph, posteroanterior cephalometric radiograph), and nuclear
imaging. Each has its own set of pros and cons and provides the
surgeon with different information, which together are used to
follow disease progression and help assess resorptive activity. The
orthopantomogram and CT or CBCT provide information on
the structural morphology of the condyle. (The hallmark sign of
ICR is shrinkage in all three planes of dimension, resulting in an
appearance of a miniaturized condyle.) Both can be taken serially A B
over a period of time to help track disease progression. However,
the disadvantage is that time is required to assess the progressivity, • Fig. 69.1 A and B, The patient during the preoperative visit with com-
pleted presurgical orthodontics. The typical features of idiopathic condylar
which is not always accepted by the patient. Nuclear imaging resorption can be appreciated in this series of clinical photos, including
using technetium-99m can provide immediate information on anterior open bite, retrognathism, and a short lower facial third, which
resorptive activity, but it only functions as a timestamp and pro- result from often a bilateral resorption of the condyles. Anterior open bite
vides no information on disease stability and thus should not be may not always be present.
used to determine timing of surgical intervention (i.e., a negative
result does not guarantee that the resorptive process has stopped).
Of note, the only guarantee that the resorptive process has ceased TMJ-only JIA, because the clinical presentation is identical, but
is if the condylar resorption reaches the sigmoid notch. Addition- they have vastly different treatment modalities. JIA is more likely
ally, nuclear imaging is not specific to ICR (i.e., can be positive in to be unilateral; ICR tends to be bilateral. A patient with JIA may
other conditions such as degenerative joint disease). present more often with joint pain and elevated markers of in-
For the current patient, the orthopantomogram and CBCT flammation such as ESR and CRP.
showed severe bilateral condylar resorption, which was worse on
the left than the the right side. In addition, the lateral cephalo- Treatment
metric radiograph demonstrated an anterior open bite with a
steep mandibular plane angle. Currently, there are no universally accepted, evidence-based
guidelines for the management of ICR. Part of the reason for this
Labs is our still evolving and incomplete understanding of this disease
entity’s true etiologic mechanism and pathogenesis. The available
There are no routine laboratory tests specific or sensitive to detect- options (nonsurgical vs surgical) are based on different etiological
ing ICR. However, one may consider the following studies as part theories (hormone-mediated vs avascular necrosis vs dysfunc-
of a comprehensive workup to rule out other systemic and inflam- tional remodeling) and therefore are still controversial.
matory conditions: Successful treatment is determined by the long-term stability
• Antinuclear antibody of the results, which is difficult to attain because of the variability
• Cyclic citrullinated peptide (CCP) in clinical behavior of ICR. For example, the resorptive process
• Human leukocyte antigen can repeat cycles of quiescence and reactivation throughout the
• Rheumatoid factor life of the patient, which adds to the difficulty of establishing a
• Vitamin D diagnosis in the first place. Such variability in clinical behavior
• C-reactive protein (CRP) also complicates choosing the optimal timing for surgery, which
• Erythrocyte sedimentation rate (ESR) also has implications on the success of the chosen surgical modal-
ity. What has been consistently observed over the years is that the
Assessment resorptive process arrests when the condyles have resorbed down
to the sigmoid notch. Therefore, surgical options involving re-
Idiopathic condylar resorption. moval of the condyles have shown stable long-term functional
The diagnosis should be based on patient history, clinical results with very little relapse (TMJ total joint replacement [TJR]
evaluation, and imaging findings. A “typical” ICR patient may be and TMJ reconstruction with autogenous costochondral graft).
a female between 15 and 35 years of age with a high mandibular
plane angle, class II skeletal malocclusion, and a retruded chin Temporomandibular Joint Total Joint
who say their chin position or bite has been worsening over the
years with no other explanation for the observed condylar resorp- Replacement
tion (Fig. 69.1). Important features of ICR in addition to the The rationale for this treatment is the total elimination of the
aforementioned clinical appearance include the characteristic dysfunctional local biologic environment (the articulating sur-
three-dimensional morphology of the resorbed condyle (“minia- faces of TMJ complex, condylar process, and articular eminence)
turized condyle”) and a CR–CO shift (Fig. 69.2). that can offer predictable long-term functional stability. The ad-
Using these findings, it is imperative that the surgeon distin- vantages of this option are that patients can begin immediate re-
guishes ICR from juvenile idiopathic arthritis (JIA), particularly habilitation, which is important for attaining favorable long-term

t.me/Dr_Mouayyad_AlbtousH
356 S E C TI O N Temporomandibular Joint Disorders

A
Right

B Medial 2 3 Central 5 6 Lateral 7

Left

C Medial 2 3 4 5 6 7
• Fig. 69.2 Preoperative imaging demonstrating severe condylar resorption, resulting in clockwise rotation
of the mandible, leading to anterior open bite, and a high mandibular plane angle (A). Notice the morphol-
ogy of the condyle, which is essentially a miniature version of its normal morphology, with the left side
(B) worse than the right (C).

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 69 Idiopathic Condylar Resorption 357

functional results after joint surgery, and there is no donor-site

morbidity. However, the downsides are the limited lifespan of the
prostheses from wear and tear (10–15 years) requiring replace-
ment and the fact that it will not follow patients’ growth.

Condylectomy and Temporomandibular Joint

Total Joint Replacement Reconstruction With
Costochondral Graft
This modality has a similar rationale as TMJ TJR except some of
biologic components are left in place (disk, eminence). Perhaps
the greatest advantage of TMJ reconstruction with costochondral
graft is its growth potential, which is particularly desired in a
growing patient. In brief, after condylectomy via preauricular in-
cision, the fifth to seventh ribs (number and length determined by • Fig. 69.4 Photograph taken after final fixation of the costochondral graft
preoperative planning) are typically harvested for reconstruction to the lateral ramus. The cartilage cap end of the graft is seated directly
against the inferior surface of the articular disk (not shown). The rib is
of the condyle through a right chest incision (Fig. 69.3; the au-
bendable and will not fracture easily as long as force is applied in a con-
thor harvests right rib by convention, but some surgeons may trolled manner in the appropriate vector. After good adaptation of the rib
advocate for harvesting right ribs for left-sided reconstruction and graft to the lateral ramus is confirmed, it is fixated with plates and screws
vice versa). A sufficient length of the rib (5–10 cm) is harvested (titanium plates, lag screws). The patient should be placed in maxilloman-
with 2–3 mm of cartilage cap. The harvested rib is adapted and dibular fixation before fixation of the graft.
fixated to a reconstruction plate using titanium screws with the
cartilage cap portion facing the articular disk. The fixated graft is
then placed through a retromandibular or submandibular incision
and positioned so that the cartilage cap articulates directly with
the inferior surface of the articular disk (Fig. 69.4). The patient is
maintained in maxillomandibular fixation for 10 to 14 days with
approximately 2 mm of posterior open bite using occlusal splint.
The posterior open bite will gradually close as the cartilage cap
remodels over time. Before the closure of the chest incision, Val-
salva maneuver should be performed to identify and repair any
pleural tears. An immediate postoperative chest radiograph is
done to rule out pneumothorax. For the current patient, condy-
lectomy and a costochondral graft were chosen as a treatment
modality. The patient underwent simultaneous three-piece Le
Fort I osteotomy, genial implant, and bilateral malar implants for
enhanced facial esthetics and correction of malocclusion. She was • Fig. 69.5 Intraoperative repair of the pleural tear with a purse-string su-
found to be functionally stable 6 years after her surgery. ture placed around a red rubber catheter. Pleural tear is a complication
that can occur during rib harvest if periosteal dissection at the undersur-
face of the rib is not carefully done. Before closure, the surgical site should
Complications be checked for any tears by flooding the site with saline and then having
anesthesia perform the Valsalva maneuver. A tear is present if bubbles are
The most feared, and major intraoperative complication of costo- seen. When the suture is in place, the catheter is quickly pulled under
chondral graft is pneumothorax (Fig. 69.5). Other long-term suction while anesthesia is performing the Valsalva maneuver. It is impor-
complications include hypertrophic scar formation, keloids, and tant to use the lightest suction possible during this maneuver to avoid
barotrauma to the lungs. The site should be rechecked as described for
any remaining air leaks after the repair. Immediate postoperative chest
radiography should be ordered to rule out pneumothorax.

occasional persistent incisional pain. For a female patient, the

chest incision is placed within the inframammary fold, which can
stay well hidden. Overgrowth of the neocondyle is also a concern
that may predispose patients to additional revision surgeries that
will put facial nerve branches at risk.

Discussion
Idiopathic condylar resorption is a well-documented but rare
• Fig. 69.3 Rib harvest dissection in the right chest was carefully done to condition that poses many challenges for the care management
avoid exposure of a previously placed breast implant in this patient. The team. Steps in management begin with an accurate assessment,
photo was taken after harvest of the fifth rib with approximately 2 mm of which involves careful history taking, a thorough clinical exami-
cartilage cap (graft not shown). nation, and reliable imaging, as well as any pertinent laboratory

t.me/Dr_Mouayyad_AlbtousH
358 S E C TI O N Temporomandibular Joint Disorders

studies. These steps should be taken systematically to rule out any

other possible causes of condylar resorption. Of particular impor-
tance is distinguishing JIA from ICR, especially the TMJ-only
variant, because they can clinically appear identical. when ICR
becomes highly likely for a patient, one should begin the discus-
sion regarding the risks and benefits and limitations of each of the
nonsurgical versus Surgical options, with long-term functional
stability as the primary goal. Both TMJ TJR and condylectomy
with costochondral graft reconstruction can offer long-term func-
tional and esthetic stability (Fig. 69.6). Both can be done either
preemptively or can be done after a period of observation depend-
ing on the patient’s comfort level and acceptance and tolerance of
their current functional and esthetic impairment.

A B ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for

complete set of bibliography.
• Fig. 69.6 Eighteen months after surgery. Condylectomy and temporo-
mandibular joint reconstruction with a costochondral graft can offer stable
long-term functional and esthetic results as shown. The patient’s overbite
and overjet remain at 1 mm, with no motor nerve deficits and slight
right V2 paresthesia. Her maximal incisal opening ultimately improved to
35 mm.

t.me/Dr_Mouayyad_AlbtousH
 358.e1

Bibliography Mercuri LG: A Rationale for total alloplastic temporomandibular joint

reconstruction in the management of idiopathic/progressive condylar
resorption, J Oral Maxillofac Surg 65:1600-1609, 2007.
Abubaker AO, Wassim FR, George CS: Estrogen and progesterone recep- Mitsimponas K, Mehmet S, Kennedy R, et al: Idiopathic condylar re-
tors in temporomandibular joint discs of symptomatic and asymptom- sorption, Br J Oral Maxillofac Surg 56:249-255, 2018.
atic persons: a preliminary study, J Oral Maxillofac Surg 51:1096-1100, Munakata K, Miyashita H, Nakahara T, et al: The use of SPECT/CT to
1993. assess resorptive activity in mandibular condyles, Int J Oral Maxillofac
Alsabban L, Amarista FJ, Mercuri LG, et al: Idiopathic condylar resorp- Surg 51:942-948, 2022.
tion: a survey and review of the literature, J Oral Maxillofac Surg Peacock ZS, Lee CC, Troulis MJ, et al: Long-term stability of condylectomy
76:2316.e1-2316.e13, 2018. and costochondral graft reconstruction for treatment of idiopathic con-
Arnett GW, Milam SB, Gottesman, L: Progressive mandibular retrusion— dylar resorption, J Oral Maxillofac Surg 77:792-802, 2019.
idiopathic condylar resorption. Part I, Am J Orthod Dentofacial Orthop Sansare K, Raghav M, Mallya SM, et al: Management-related outcomes
110:8-15, 1996. and radiographic findings of idiopathic condylar resorption: a system-
Arnett GW, Gunson MJ: Risk factors in the initiation of condylar resorp- atic review, Int J Oral Maxillofac Surg 44:209-216, 2015.
tion, Semin Orthod 19:81-88, 2013. Yuan M, Shen P, Yang C: Do sex hormone imbalances contribute to
Arnett GW, Milam SB, Gottesman L: Progressive Mandibular retru- idiopathic condylar resorption? Int J Oral Maxillofac Surg 50:
sion—idiopathic condylar resorption. Part II, Am J Orthod Dentofa- 1244-1248, 2021.
cial Orthop 110:117-127, 1996.
Link JO, Hoffman DC, Laskin DM: Hyperplasia of a costochondral
graft in an adult, J Oral Maxillofac Surg 51:1392-1394, 1993.

t.me/Dr_Mouayyad_AlbtousH
70
Degenerative Joint Disease of the
Temporomandibular Joint
M I C H A E L M ILO R O

CC TMJ with increasing levels of debilitating pain localized to the

right TMJ.
A 55-year-old female (degenerative joint disease [DJD] has a
higher prevalence with advanced age and in female patients) pres- PMHX/PDHX/Medications/Allergies/SH/FH
ents to your office with a 20-year history of temporomandibular
joint dysfunction (TMD), complaining, “I’ve been through sev- Noncontributory, except for arthritic changes diagnosed in the
eral TMJ surgeries, and now my right joint is very painful and patient’s cervical spine and the proximal interphalangeal joints of
makes grinding noises.” the hands. She has taken NSAIDs as needed for pain over the past
several years. Patients with arthritic degeneration of the TMJ fre-
HPI quently have involvement of other joints that precedes involve-
ment of the TMJ. However, it is possible to have DJD of the TMJ
The patient reports several months of anxiety and stress that she with no evidence of arthritis in any other joints.
relates to the pain centered around her right TMJ; this pain is
most pronounced upon mouth opening during mastication and Examination
speech. She has a long, progressive history of TMJ problems. In
her late teens, she developed bilateral reciprocal TMJ clicking General. The patient is a well-developed and well-nourished
(suggestive of anterior disk displacement [ADD] with reduction), female in moderate distress because of right-sided TMJ pain.
which was confirmed by magnetic resonance imaging (MRI). She Maxillofacial. The patient has no facial swelling or asymme-
also had intermittent right-sided preauricular pain and bilateral try. The right TMJ is exquisitely tender to palpation (upon both
myofascial pain. She was managed nonsurgically with occlusal preauricular and endaural palpation). The left TMJ is nontender.
splint therapy and nonsteroidal antiinflammatory drugs She has limited opening (20 mm) because of pain and a loud,
(NSAIDs). She reported mild improvement and did not pursue bony crepitus of the right TMJ that is easily heard without a
further treatment because she tolerated her discomfort by mini- stethoscope. Lateral excursive movements are limited (3 mm to
mizing masticatory function. In her mid-20s, the right TMJ the left and 6 mm to the right). She has a class I occlusion without
stopped clicking, and she developed an acute closed lock with an open bite. (Advanced condylar degeneration and loss of poste-
severe right-sided pain and restricted left lateral excursive move- rior mandibular height can lead to a contralateral posterior open
ments of the mandible without clicking. (This is consistent with bite or an anterior open bite.) The external auditory canals are
the progression of ADD with reduction to ADD without reduc- clear, and the tympanic membranes appear normal. Her right
tion of the right TMJ.) She underwent right-sided TMJ arthro- preauricular surgical scar is well healed, and cranial nerve VII is
centesis, which provided 8 months of symptomatic resolution. A intact. (Multiple open TMJ procedures increase the risk of cranial
second arthrocentesis procedure was performed, which provided nerve VII injury, especially the frontal or temporal branch.)
only brief additional relief. Subsequent MRI studies showed evi-
dence of ADD and DJD of the right TMJ, with a displaced, de- Imaging
formed, nonreducing disk and evidence of perforation of the
posterior band of the disk in addition to degenerative bony The panoramic radiograph is the initial imaging study of choice for
changes of the TMJ with decreased joint space, flattening of the evaluation of the TMJ. It provides a general overview of the bony
condylar head, and osteophyte formation in addition to ADD morphology of the mandible and condyle. MRI scans, in the
without reduction on the left side with associated degenerative open- and closed-mouth positions, are considered the standard
bony changes. Her surgeon elected to perform a right TMJ diske- when evaluating for TMJ internal derangement to view the disk.
ctomy (removal of the disk) without disk replacement, which re- MRI provides the most detailed information regarding the soft
sulted in an excellent outcome for several years. She now presents tissue structures (disk morphology) and disk position in the open-
with a 2-year history of loud, grinding noises or crepitus (crepitus and closed-mouth positions. (Some patients may not be able to
is a pathognomonic sign of advanced osteoarthrosis) of the right open sufficiently because of pain, ADD without reduction, or

359
t.me/Dr_Mouayyad_AlbtousH
360 S E C TI O N Temporomandibular Joint Disorders

• Fig. 70.1 Panorex showing severe degenerative joint disease of the right
condyle with osteophyte formation and loss of joint space.

closed lock.) A bony window computed tomography (CT) or

cone-beam CT scan is indicated when bony or fibrous ankylosis of
the TMJ or other bony pathology is suspected. A CT scan can be
used to better delineate the bony anatomy of the TMJ and dem-
onstrate any degenerative changes.
For the current patient, the panoramic radiograph demon-
strated evidence of right TMJ osteoarthrosis (small condyle with
arthritic remodeling, likely because of joint overloading and prior
intra-articular surgical procedures), including flattening of the
condylar head, subchondral eburnation (sclerosis), and osteo-
phyte formation. The panoramic radiograph (Fig. 70.1) showed • Fig. 70.3 Magnetic resonance imaging showing degenerative changes
the right condylar head with a loss of normal anatomy, and was of the condyle with loss of the cortical outline, osteophyte formation, and
significantly smaller than the left side, had sharp edges, and had flattening of the condylar head.
lost its cortical definition (signs of advanced degeneration). A CT
scan showed right-sided bony TMJ degenerative changes when scans showed moderate degenerative changes. (Whereas TMJ soft
compared with the left TMJ (Fig. 70.2). Sagittal and coronal MRI tissue anatomy is best seen with T1-weighted images, TMJ in-
flammation and effusions are best seen with T2-weighted images
because they appear with increased signal intensity; Fig. 70.3.)

Labs
No routine laboratory testing is indicated for the workup of pa-
tients with DJD. Clinical suspicion of systemic arthropathies
(e.g., rheumatoid arthritis, systemic lupus erythematosus, psori-
atic arthritis, and gout) would dictate further laboratory testing.
Other laboratory values are obtained based on the medical his-
tory, and the results of nonspecific laboratory studies of inflam-
mation (e.g., C-reactive protein and erythrocyte sedimentation
rate) may be elevated because of chronic inflammation. Baseline
preoperative hemoglobin and hematocrit levels are recommended
for patients undergoing an open joint procedure or total joint
A
reconstruction.

Assessment
DJD of the right TMJ with localized pain on the multiply operated
right side.

Treatment
The goals of treatment for DJD of the TMJ are to decrease pain and
swelling, improve joint function, and limit disease progression.
Generally, treatment follows a stepwise sequence, beginning with
noninvasive or minimally invasive procedures and progressing to
B more advanced surgical treatment modalities when indicated.
Nonsurgical therapy includes a jaw rest regimen, occlusal appli-
• Fig. 70.2 A, Computed tomography reconstruction showing degenera- ances, physical therapy, warm compresses, and NSAIDs. Arthro-
tive joint disease of the right condyle. B, Computed tomography recon- centesis is a minimally invasive treatment modality; however, the
struction showing a normal left condyle. use of intraarticular adjunctive medications (e.g., corticosteroids,

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 70 Degenerative Joint Disease of the Temporomandibular Joint 361

platelet-rich plasma, and hyaluronic acid) is somewhat controver- Complications

sial, with some studies showing benefit of each of these medica-
tions. Arthroscopy does not offer additional outcome benefits over The possible complications of TMJ surgery for the treatment of
arthrocentesis, but it may provide a diagnostic advantage. The patients with DJD are similar to those of open arthrotomy surgery
majority (about 80%) of patients respond, at least in the short for internal derangement or TMJ ankylosis. In addition, hardware
term, to both noninvasive and minimally invasive treatments, failure, with screw loosening, may lead to prosthesis failure. With
perhaps as a result of the joint lavage and clearance of inflamma- alloplastic joint replacement in ankylosis, the prosthetic compo-
tory mediators. nents may act as osteoconductive scaffolds for heterotopic bone
More invasive surgical modalities include open joint (arthrot- formation (heterotopic ossification) and reankylosis, especially if
omy) procedures, such as arthroplasty with osseous recontouring active physiotherapy is delayed or if the patient is noncompliant
of the condyle or glenoid fossa and, if necessary, disk removal or with postoperative rehabilitation. Also, these prosthetic compo-
repositioning. Diskectomy may be performed in conjunction nents may have hardware failure (e.g., screw loosening) and may
with placement of an interpositional material (e.g., autogenous fat require replacement. However, clinical experience shows that re-
graft, dermal graft, alloplastic graft, cadaveric graft, temporalis placement of a functional TMJ prosthesis, without any indication
muscle–fascia flap, ear cartilage). With severe degeneration of the other than time in function, may be unnecessary.
TMJ, reconstruction may be necessary using either autogenous
options (e.g., free fibula flaps, costochondral or calvarial grafts) or Discussion
an alloplastic joint prosthesis. Various stock and custom alloplas-
tic total joint implants are available. Degenerative joint disease is associated with a significant impact on
In the current patient, right total joint replacement was per- quality of life with chronic pain, loss of joint function, bone and
formed using custom prefabricated condylar head and fossa allo- muscle weakness, and disability, with loss of productivity and early
plastic implants (Fig. 70.4). In this surgery, a gap arthroplasty was retirement. Degenerative joint disease is a maladaptive response to
performed with a condylectomy and coronoidectomy to provide mechanical joint loading, leading to inflammation and degeneration
adequate space (2.0- to 2.5-cm minimum distance) for the TMJ of fibrocartilage. During this process, the accumulation of break-
implant, fossa, and condylar prosthesis. A minimally invasive down products (e.g., matrix metalloproteinases, interleukins, free
endaural or preauricular approach can be used. radicals) leads to recruitment of inflammatory mediators, resulting
in a secondary synovitis and capsulitis. The symptomatic inflamma-
tory phase, known as osteoarthritis, may be distinguished from osteo-
arthrosis, which represents an end-stage phase of the spectrum.
Temporomandibular joint dysfunction encompasses several
related disorders of the TMJ. The Research Diagnostic Criteria for
Temporomandibular Disorders classification system organizes
these disorders into three groups: group I (myofascial pain), group
II (internal derangement), and group III (DJD). Although these
entities are interrelated, the data regarding a causative relationship
between internal derangement and DJD have not been definitive.
The epidemiology reveals a bimodal distribution for the incidence
of internal derangement (mean age, 38 years) and DJD (mean
age, 52 years). Studies have shown that degenerative joint changes
may occur in older adult patients who show normal disk position-
ing. Establishing a causative relationship may have significant
clinical implications for treatment planning, although it has been
shown that pain does not correlate well with DJD. Long-term
studies have shown that the initial symptoms of DJD and internal
derangement may follow a self-limiting course, with resolution by
30-year follow-up after nonsurgical therapy.
A Regarding diagnosis, patients usually present with preauricular
pain, with or without edema, which is aggravated by function.
There may or may not be clicking, but crepitus upon palpation
and auscultation is a hallmark of DJD. There may be limited
jaw function with decreased mouth opening and limited lateral
excursions and protrusion. There may also be tenderness to palpa-
tion of the TMJ capsule, muscles of mastication, sternocleidomas-
toid muscle, and trapezius and occipitalis muscles indicative of a
myofascial pain component of the disease process. Because of
condylar resorption, there may also be a malocclusion with open
bite and facial asymmetry. Proper imaging analysis is an impor-
tant adjunct to the clinical examination. In general, MRI is more
B
helpful for delineating disk position, and CT scanning is most
• Fig. 70.4 A, Stereolithic model with wax-up plan for right total alloplastic helpful for visualization of the bony changes associated with DJD.
custom joint replacement. B, Panorex showing right total custom alloplas- Early DJD may not show significant radiographic changes, but
tic joint replacement. advanced disease shows small arthritic condyles, reduced joint

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362 S E C TI O N Temporomandibular Joint Disorders

space, flattening of the condylar head, subchondral bone sclerosis, Treatment is tailored to the individual patient. Various non-
osteophytes (“bird’s beak”), cortical bone erosion, and subchon- surgical modalities are used, including diet modification (soft or
dral cysts (Eli cysts). T1-weighted MRI is helpful for visualizing nonchew diet), NSAIDs, physical therapy, moist heat, botuli-
the soft tissues, disk position, and morphology, but T2-weighted num toxin injections (for myofascial pain), occlusal splints, bite
MRI is useful for evaluating for marrow edema and joint effu- appliances, and night guards. In general, arthrocentesis with
sions. Bone scans (e.g., single-photon emission computed tomog- intraarticular medications (platelet-rich plasma, corticosteroids,
raphy/CT) may show increased metabolic uptake indicative of and hyaluronic acid) can be useful in ameliorating symptoms
inflammation of the TMJ. Arthroscopy may provide visual confir- (decreased pain) and decreasing progression of DJD. For ad-
mation of synovitis, hyperemia, synovial hyperplasia, cartilage vanced DJD, “arthroplasty” with condylar head recontouring
scuffing or degeneration, disk adhesions, and disk perforation. has fallen out of favor, and total joint reconstruction with allo-
Laboratory evaluation can be used to rule out specific systemic plastic joint replacement (costochondral grafting has also fallen
arthropathies (e.g., rheumatoid arthritis) but are not indicated for out of favor) remains an excellent option to restore form and
DJD alone. In general, peripheral blood analysis may shows signs function when performed by surgeons experienced with this
of inflammation with a mild increase in white blood cell count surgical procedure.
and a normal or slightly elevated erythrocyte sedimentation rate
and C-reactive protein. Synovial fluid analysis can identify mark- ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
ers of cartilage degradation (e.g., interleukins, bradykinins). complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 362.e1

Bibliography Hendler BH, Gateno J, Mooar P, et al: Holmium: YAG laser arthroscopy
of the temporomandibular joint, J Oral Maxillofac Surg 50:931-934,
1992.
Auerbach SM, Laskin DM, Frantsve LME, et al: Depression, pain, expo- Indresano AT: Surgical arthroscopy as the preferred treatment for internal
sure to stressful life events, and long-term outcomes in temporoman- derangements of the temporomandibular joint, J Oral Maxillofac Surg
dibular disorder patients, J Oral Maxillofac Surg 59:628-633, 2001. 59:308-312, 2001.
Bays RA: Temporomandibular joint disc preservation, Atlas Oral Maxil- Israel HA, Ward JD, Horrell B, et al: Oral and maxillofacial surgery
lofac Surg Clin North Am 4:33-50, 1996. in patients with chronic orofacial pain, J Oral Maxillofac Surg 61:
Bertolami CN, Gay T, Clark GT, et al: Use of sodium hyaluronate in treat- 662-667, 2003.
ing temporomandibular joint disorders: a randomized, double-blind, Iwase H, Sasaki T, Asakura S, et al: Characterization of patients with disc
placebo-controlled clinical trial, J Oral Maxillofac Surg 51:232-242, displacement without reduction unresponsive to nonsurgical treatment:
1993. a preliminary study, J Oral Maxillofac Surg 63:1115-1122, 2005.
Bjornland T, Larheim TA: Discectomy of the temporomandibular joint: Kalladka M, Quek S, Heir G, et al: Temporomandibular joint osteoar-
3-year follow-up as a predictor of the 10-year outcome, J Oral Maxil- thritis: diagnosis and long-term conservative management: a topic
lofac Surg 61:55-60, 2003. review, J Indian Prosthodont Soc 14:6-15, 2014.
Broussard J: Derangement, osteoarthritis, and rheumatoid arthritis of the Keith DA: Complications of temporomandibular joint surgery, Oral
temporomandibular joint: implications, diagnosis, and management, Maxillofac Surg Clin North Am 15:187-194, 2003.
Dent Clin North Am 49:327-342, 2005. Kutuk SG, Gokce G, Arslan M, et al: Clinical and radiological compari-
Carvajal WA, Laskin DM: Long-term evaluation of arthrocentesis for the son of effects of platelet-rich plasma, hyaluronic acid, and corticoste-
treatment of internal derangements of the temporomandibular joint, roid injections on temporomandibular joint osteoarthritis, J Craniofac
J Oral Maxillofac Surg 58:852-855, 2000. Surg 30:1144-1148, 2019.
Chen D, Shen J, Zhao W, et al: Osteoarthritis: toward a comprehensive Leeuw R, Boering G: Symptoms of temporomandibular joint and inter-
understanding of pathological mechanism, Bone Res 5:1-13, 2017. nal derangement 30 years after non-surgical treatment, J Cranioman-
de Souza RF, Lovato da Silva CH, Nasser M, et al: Interventions for the dibular Pract 13:81-88, 1995.
management of temporomandibular joint osteoarthritis, Cochrane Machon V, Rehorova M, Sedy J, et al: Platelet-rich plasma in temporo-
Database Syst Rev 2012(4):CD007261, 2012. mandibular joint osteoarthritis therapy: a 3-month follow-up pilot
Delpachitra SN, Dimitroulis G: Osteoarthritis of the temporomandibu- study, J Arthritis 2:1-4, 2013.
lar joint: a review of aetiology and pathogenesis, Br J Oral Maxillofac Mazzonetto R, Spagnoli DB: Long-term evaluation of arthroscopic dis-
Surg 60(4):387-396, 2022. cectomy of the temporomandibular joint using the holmium YAG
Dimitroulis G: A review of 56 cases of chronic closed lock treated with laser, J Oral Maxillofac Surg 59:1018-1023, 2001.
temporomandibular joint arthroscopy, J Oral Maxillofac Surg 60: McKenna SJ: Discectomy for the treatment of internal derangements of
519-524, 2002. the temporomandibular joint, J Oral Maxillofac Surg 59:1051-1056,
Dimitroulis G: The use of dermis grafts after discectomy for internal 2001.
derangement of the temporomandibular joint, J Oral Maxillofac Surg Milam SB: Chronic temporomandibular joint arthralgia, Oral Maxillofac
63:173-178, 2005. Surg Clin North Am 12:5-26, 2000.
Dolwick MF: Disc preservation surgery for the treatment of internal Nitzan DW, Price A: The use of arthrocentesis for the treatment of
derangements of the temporomandibular joint, J Oral Maxillofac Surg osteoarthritic temporomandibular joints, J Oral Maxillofac Surg 59:
59:1047-1050, 2001. 1154-1159, 2001.
Edwards SP, Feinber SE: The temporalis muscle flap in contemporary Park J, Keller EE, Reid KI: Surgical management of advanced degenera-
oral and maxillofacial surgery, Oral Maxillofac Surg Clin North Am 15: tive arthritis of temporomandibular joint with mental fossa-eminence
513-535, 2003. hemijoint replacement prosthesis: an 8-year retrospective pilot study,
Emschoff R, Rudisch A: Are internal derangement and osteoarthrosis J Oral Maxillofac Surg 62:320-328, 2004.
linked to changes in clinical outcome measures of arthrocentesis of Reston JT, Turkelson CM: Meta-analysis of surgical treatments for tem-
the temporomandibular joint? J Oral Maxillofac Surg 61:1162-1167, poromandibular articular disorders, J Oral Maxillofac Surg 61:3-10,
2003. 2003.
Emschoff R, Rudisch A: Determining predictor variables for treatment Stegenga B: Osteoarthritis of the temporomandibular joint organ and its
outcomes of arthrocentesis and hydraulic distention of the temporo- relationship to disc displacement, J Orofac Pain 15:193-205, 2001.
mandibular joint, J Oral Maxillofac Surg 62:816-823, 2004. Tucker MR, Spagnoli DB: Autogenous dermal and auricular cartilage
Eriksson L, Westesson PL: Discectomy as an effective treatment grafts for temporomandibular joint repair, Atlas Oral Maxillofac Surg
for painful temporomandibular joint internal derangement: a 5-year Clin North Am 4:75-92, 1996.
clinical and radiographic follow-up, J Oral Maxillofac Surg 59: Umeda H, Kaban LB, Pogrel MA, et al: Long-term viability of the tem-
750-758, 2001. poralis muscle/fascia flap used for temporomandibular joint recon-
Eriksson L, Westesson PL: Long-term evaluation of meniscectomy of the struction, J Oral Maxillofac Surg 51:530-533, 1993.
temporomandibular joint, J Oral Maxillofac Surg 43:263-269, 1985. White RD: Arthroscopic lysis and lavage as the preferred treatment for
Feinberg SE: Use of local tissues for temporomandibular joint surgery internal derangement of the temporomandibular joint, J Oral Maxil-
disc replacement, Atlas Oral Maxillofac Surg Clin North Am 4:51-74, lofac Surg 59:313-316, 2001.
1996. Xie Y, Zhao K, Ye G, et al: Effectiveness of intra-articular injections of
Fricton JR, Look JO, Schiffman E, et al: Long-term study of temporo- sodium hyaluronate, corticosteroids, platelet-rich plasma on tem-
mandibular joint surgery with alloplastic implants compared with poromandibular joint osteoarthritis: a systematic review and network
nonimplant surgery and nonsurgical rehabilitation for painful tem- meta-analysis of randomized controlled trials, J Evid Base Dent Pract
poromandibular joint disc displacement, J Oral Maxillofac Surg 22(3):101720, 2022.
60:1400-1411, 2002. Yun PY, Kim YK: The role of facial trauma as a possible etiologic factor
Guarda-Nardini L, Piccotti F, Mogno G, et al: Age-related differences in in temporomandibular joint disorder, J Oral Maxillofac Surg 63:
temporomandibular disorder diagnoses, J Craniomandibular Pract 1576-1583, 2005.
30:103-109, 2012. Zingg M, Iizuka T, Geering AH, et al: Degenerative temporomandibular
Hawkins A, Mercuri LG, Miloro M: Are rib grafts still used for temporo- joint disease: surgical treatment and long-term results, J Oral Maxil-
mandibular joint reconstruction? J Oral Maxillofac Surg 78:195-202, lofac Surg 52:1149-1158, 1994.
2020.

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71
Temporomandibular Joint Ankylosis
SI N A H A S H EM I and DAV ID J . P S U T K A

CC Examination
A 62-year-old male presents to your office with a complaint of a The patient appears well and is in no apparent distress.
limited mouth opening for the past several years. He is orthognathic in appearance and has balanced facial
Mandibular hypomobility can be caused by disorders that are proportions. There is no pain to palpation of his joints or his
intra- or extraarticular (pseudoankylosis). Intraarticular disorders masticatory muscles. Palpation of the joints does not reveal any
are further classified based on the type of tissue involved (fibrous, underlying masses. There is a severe limitation in his ROM with
bone, or mixed). There is no gender predilection in temporoman- a maximal incisal opening of 4 mm and a hard-end feel. The
dibular joint (TMJ) ankylosis. There is, however, a bimodal age neurosensory examination results are normal.
distribution. Whereas growing patients most often develop anky- The intraoral examination is quite limited because of the severely
losis because of an exaggerated healing response to trauma, older restricted mouth opening. There are signs of poor oral hygiene,
adults typically develop ankylosis after longstanding degenerative including caries, retained roots, and plaque and calculus build-up.
joint pathologies or iatrogenic procedures.
Imaging
HPI
The panoramic radiograph is an invaluable screening tool, par-
The patient was involved in a motor vehicle crash a couple of years ticularly in patients with TMJ dysfunction. It is quick and inex-
ago during which he suffered multiple facial fractures. He under- pensive and provides a gross overview of the joint anatomy. Large
went open reduction and internal fixation of his panfacial frac- sclerotic lesions, advanced degenerative changes, and ankylotic
tures, including his parasymphysis. He also had bilateral condylar bone masses can all be readily seen on a panoramic radiograph.
fractures that were treated with closed reduction. Shortly after Existing hardware and malunions of facial bones can also cor-
surgery, he was never able to regain his premorbid mouth open- roborate a history of trauma.
ing. He reports his range of motion (ROM) continued to slowly For a more thorough appreciation of the bony architectural
decrease over the next couple of years until he was no longer able changes, a medical-grade computed tomography (CT) scan with
to open his mouth. His limited ROM has led to difficulties eat- 1-mm thickness of slices is the study of choice. Contrast is not neces-
ing, speaking, and maintaining oral hygiene. In growing patients, sary if a neoplastic or infectious process has been ruled out. Although
ankylosis can also lead to facial asymmetry because the normal magnetic resonance imaging may be useful in diagnosing a fibrous
mandibular growth is perturbed. ankylosis, it provides no additional information in bony ankylosis.
The development of ankylosis can often be insidious with slow In our patient, the panoramic radiograph reveals significant
but progressive and relentless limitations in ROM. pathology in both joints, which we can presume to be the result of
bony ankylosis from bilateral condylar head fractures (Fig. 71.1).
PMHX/PDHX/Medications/Allergies/SH/FH The CT images reveal the true extent of the joint destruction.
There is an absent joint space with fusion of the mandibular condyle
The patient has well-controlled hypertension but otherwise has a to the glenoid fossa. The medial extent of bone can represent an old
noncontributory medical history. malunion of a condylar head fracture or heterotopic bone (Fig. 71.2).
In the setting of trauma, patients may often be very young and Given the increased risk of injuring vital structures when op-
without any underlying comorbidities. erating in an area of aberrant anatomy, a CT angiogram was also
Patients with degenerative joint diseases and systemic arthriti- ordered to evaluate the relationship of the ankylotic bone masses
des may often develop ankylosis because of their disease progres- with surrounding vascular structures. This knowledge can be in-
sion or iatrogenic surgical insults. They can present with associated valuable when planning surgery (Fig. 71.3).
myofascial pain disorders, as well as signs and symptoms in other
joints affected by their disease process. Infection is also a very com- Labs
mon etiological factor in the development of ankylosis, and any
septic joint arthritis would need to be treated aggressively to reduce The patient underwent routine preoperative laboratory work, in-
the incidence of this complication. cluding a complete blood count and a basic metabolic panel.

363
t.me/Dr_Mouayyad_AlbtousH
364 S E C TI O N Temporomandibular Joint Disorders

Right

• Fig. 71.1 Panoramic radiograph revealing malunion of bilateral condylar

head fractures and irregular bone architecture.

Left
A
• Fig. 71.2 Coronal view of a computed tomography scan demonstrating
complete bony ankylosis. The remnants of the condylar processes are
fused to the base of the skull.

Additional laboratory work and investigations are dictated by

underlying comorbidities and often at the discretion of the preop-
erative clinic after a full history and physical examination.
In the event of a systemic arthritis, a referral to a rheumatolo-
gist would be prudent for a thorough evaluation at time of con-
sultation.

Assessment
The patient was diagnosed with a complete bony ankylosis of his
bilateral TMJs.
In fibrous ankylosis, the joint space is occupied by a dense fi- B
brous scar that ultimately replaces the articular disk. Bony anky-
losis develops from longstanding fibrous ankylosis and is more • Fig. 71.3 A and B, Three-dimensional reconstruction of a computed
destructive. The most common cause is trauma. It is theorized tomography angiogram. The proposed condylar resection margin is bright
that an intraarticular hematoma, along with scarring and excessive red. Branches of the external carotid artery, in dark red, are seen in inti-
bone formation, leads to progressively limited mandibular ROM. mate relationship with the surgical site.
This manifest itself as an initial loss of translation, then eventual
rotation, and finally a severe restriction in opening after the con-
dyle fuses to the glenoid fossa. Other causes of ankylosis include should be considered if the ROM remains restricted after the gap
infectious arthritis, systemic autoimmune arthritides, and iatro- arthroplasty and ankylosis release.
genic surgical procedures. Reconstruction of the TMJ differs in a growing patient versus
an adult. In a growing patient, distraction osteogenesis or costo-
Treatment chondral grafts (CCGs) are the currently acceptable treatment
options. The CCG is the autogenous graft of choice for recon-
The treatment objectives in the patients with ankylosis are to re- struction of the condyle because of its similarity in shape and
store mouth opening and to prevent or reduce the risk of reanky- potential for continual growth. Alloplastic joint reconstruction is
losis. In growing patients, one faces the additional challenge of a matter of controversy because of lack of growth. As a result, one
attempting to restoring symmetric mandibular growth. would have to consider either replacement of the joint or orthog-
Treatment is begun by performing a gap arthroplasty, which nathic surgery as the patient continues to grow.
includes resection of the ankylotic bone and creation of a critical In adults, custom-made alloplastic joints are the gold standard.
sized defect of 2 cm to reduce the risk of reankylosis. An ipsilateral Historically, these were done in two stages. Gap arthroplasty,
coronoidectomy is always performed, and a contralateral one postoperative CT scanning, and creation of a stereolithic model

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 CHAPTER 71 Temporomandibular Joint Ankylosis 365

A B
• Fig. 71.4 Virtual surgical planning. A, Condylar cutting guide. B, Fossa cutting guide.

for joint fabrication used to be the workflow. Now with improve-

ments in virtual planning and the accuracy of surgical templates
and guides, treatment can almost always be performed in Name: B03
one stage. During single-stage surgery, you need to prepare the
glenoid fossa and ramus of the mandible to receive the custom
components. This is performed using cutting guides and tem-
plates (Fig. 71.4).

Complications
The complications relevant to total joint replacements apply to
ankylosis surgery but with a higher incidence because of distorted
anatomy. Intraoperative bleeding, cerebrospinal fluid leak, and
intracranial misadventures are particularly of concern when re-
secting large ankylotic bony segments. The vasculature surround-
ing the condylar neck can be visualized with CT angiography.
Preoperative embolization may be performed if there any branches
of the maxillary artery deemed to be at risk during surgery.
This is coordinated with interventional radiology before surgery
(Fig. 71.5). Intraoperative bleeding can often be managed by pres-
sure and direct vessel ligation. Proximal control at the external
carotid artery may be unreliable because of collateral flow. In cases
of persistent arterial bleeding, selective embolization is preferred.
Facial nerve injury, infection, and dehiscence are also concerns
when the surgical site is significantly scarred. This is often the case
in a multiply operated joint of an ankylosis patient.
With costochondral graft reconstruction, there is a concern for
unpredictable growth. Overgrowth has been shown to occur when • Fig. 71.5 Angiography and embolization of the left internal maxillary ar-
transplanting a cartilaginous cap in excess of 2 to 3 mm. As with tery with coils.
all autogenous grafts, complications of the donor site should be
considered. Morbidity from a costochondral graft donor site nota-
bly includes pleural tear, pneumothorax, and chronic chest pain. bone. Quality of life will invariably suffer because of disabling
When reconstructing with alloplastic materials, one needs to limitations in mastication, speech, maintenance of oral hygiene,
consider material wear, hardware failure, and foreign body reac- and perturbed growth. Ankylosis of the TMJ often arises second-
tions. Fortunately, these are quite rare with the current second- ary to trauma, infection, or inflammatory arthropathy or from
generation custom prostheses. A prosthetic joint infection, though iatrogenic surgical procedures. There are several classifications
also rare, can be devastating. systems of TMJ ankylosis. It is often simpler to categorize based
Finally, reankylosis and heterotopic ossification of an alloplas- on tissue involved (fibrous, bony, or mixed) and based on site
tic joint is always a concern, and this can manifest as relapse in (intra- or extraarticular).
ROM and result in failed outcomes. The goals of surgery are to improve ROM and reduce the risk
of reankylosis. In a growing patient, one must also consider the
Discussion challenging objective of preserving symmetric mandibular growth.
Treatments options include releasing the ankylosis with a gap ar-
Temporomandibular joint ankylosis occurs when the normal joint throplasty alone or immediate reconstruction. Historically, inter-
is progressively destroyed and replaced with dense fibrous tissue or positional grafts such as dermis, muscle, cartilage, and fascia were

t.me/Dr_Mouayyad_AlbtousH
366 S E C TI O N Temporomandibular Joint Disorders

used after gap arthroplasty with variable results. Immediate recon-

struction has shown superior results compared with gap arthro-
plasty alone.
In a growing patient, a costochondral graft is the autogenous
material of choice because of the growth potential. Aside from
unpredictable growth, healing and integration is another concern
for autogenous grafts that rely on the vascular bed for nourish-
ment. It has been shown that capillaries can penetrate up to 180
to 220 microns of tissue. However, scar surrounding previously
operated bone averages 440 microns in thickness. Distraction
osteogenesis is another acceptable method of reconstruction in
skeletally immature patients. A distractor is applied to a vertical
ramus osteotomy, which is sequentially activated until appropriate
neocondylar position is reached. As with all distraction cases, a
fibrocartilaginous cap forms on the transport segment, which is
theoretically ideal because it mimics normal condylar anatomy.
Patient compliance, poor vector control, and scarring are impor-
tant drawbacks to consider. Custom-made alloplastic joints
remain the gold standard for total joint reconstruction in adult
patients. Fortunately, material wear and hardware failure are un-
common. The lack of growth precludes their use in children.
Certain innovations merit discussion. Virtual surgical plan-
ning and computer-aided manufacturing have revolutionized
most aspects of our specialty, and TMJ surgery is no exception.
The use of cutting and positioning guides has significantly facili-
tated the ankylosis release and surgical site preparation to receive
the custom alloplastic implants. The accuracy of the virtual plan
has significantly improved over the past several years. In fact, most
ankylosis cases are no longer performed as two-stage surgeries,
and patients no longer need to be wired shut after ankylosis re-
lease for CT scanning and device reconstruction. One of the • Fig. 71.6 Navigation-assisted surgery used in a pediatric ankylosis case.
limitations of the virtual plan is the inability to replicate the ex-
tent of medial fossa preparation because of the two-dimensional
nature of the surgical guides. There are several ways to navigate
this. One can use the stereolithographic model and crudely mark
the saw or bur according to the medial extent of the fossa. Com-
puter-aided planning and intraoperative navigation have signifi-
cantly advanced the safety of skull base surgery. Large amounts of
ankylotic bone can be incrementally removed in a controlled and
safe manner using the multiplanar CT images that have been
registered to the patient (Fig. 71.6).
To reduce the risk of reankylosis, certain adjuvant treatments
have been proposed. Autogenous fat grafting around the articula-
tion reduces the deadspace and potential for hematoma formation
and organization into heterotopic bone. Postoperative indometh-
acin has been described in the orthopedic literature to reduce risks
• Fig. 71.7 Postoperative panoramic radiograph with a prosthesis in
of heterotopic bone formation as well. Postoperative radiation is place. Fossa prostheses are radiolucent, and only screws are visible.
often performed to target multipotent stem cells from developing
into osteoblasts. Regimens typically vary from 10 to 20 Gy SH
and can be given in one or multiple fractions early in the postop- and treatment planning, the successful management of patients
erative period. Finally, one cannot understate the importance of with TMJ ankylosis can have a profound effect on their quality of
postoperative physiotherapy in early joint mobilization and re- life (Figs. 71.7 and 71.8).
ducing relapse from scar contracture and fibrosis. Physiotherapy
is a long-term commitment that must be diligently explained to ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
patients to improve their compliance. Through careful diagnosis complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 71 Temporomandibular Joint Ankylosis 367

A B
• Fig. 71.8 Five-year follow-up demonstrating (A) good facial nerve function and (B) 40 mm of maximal
incisal opening.

t.me/Dr_Mouayyad_AlbtousH
 367.e1

Bibliography Malis DD, Xia JJ, Gateno J, et al: New protocol for 1-stage treatment of
temporomandibular joint ankylosis using surgical navigation, J Oral
Maxillofac Surg 65(9):1843-1848, 2007. doi:10.1016/j.joms.2005.
Al-Moraissi EA, El-Sharkawy TM, Mounair RM, et al: A systematic re- 11.080.
view and meta-analysis of the clinical outcomes for various surgical Movahed R, Mercuri LG: Management of temporomandibular joint
modalities in the management of temporomandibular joint ankyloses, ankyloses, Oral Maxillofac Surg Clin North Am 27(1):27-35, 2015.
Int J Oral Maxillofac Surg 44(4):470-482, 2015. doi:10.1016/j. doi:10.1016/j.coms.2014.09.003.
ijom.2014.10.017. Padgett EC, Robinson DW, Stephenson KL: Ankylosis of the temporo-
He D, Yang C, Chen M, et al: Traumatic temporomandibular joint an- mandibular joint. Surgery 24(2):426-437, 1948.
kylosis: our classification and treatment experience, J Oral Maxillofac Pearce CS, Cooper C, Speculand B: One stage management of ankylosis
Surg 69(6):1600-1607, 2011. doi:10.1016/j.joms.2010.07.070. of the temporomandibular joint with a custom-made total joint re-
Heiland M, Habermann CR, Schmelzle R: Indications and limitations of placement system, Br J Oral Maxillofac Surg 47(7):530-534, 2009.
intraoperative navigation in maxillofacial surgery, J Oral Maxillofac doi:10.1016/j.bjoms.2009.04.024.
Surg 62(9):1059-1063, 2004. doi:10.1016/j.joms.2004.02.013. Schmelzeisen R, Gellrich NC, Schramm A, et al: Navigation-guided
Kaban LB, Bouchard C, Troulis MJ: A protocol for management of resection of temporomandibular joint ankylosis promotes safety in
temporomandibular joint ankylosis in children. J Oral Maxillofac skull base surgery, J Oral Maxillofac Surg 60(11):1275-1283, 2002.
Surg 67(9):1966-1978, 2009. doi:10.1016/j.joms.2009.03.071. doi:10.1053/joms.2002.35724.
Kaban LB, Perrott DH, Fisher K: A protocol for management of Sweeney K, Handa S, August M, et al: Are there identifiable risk factors
temporomandibular joint ankyloses, J Oral Maxillofac Surg 48(11): associated with heterotopic ossification of the temporomandibular
1145-1152, 1990. joint? J Oral Maxillofac Surg 80(8):1318-1330, 2022. doi:10.1016/j.
Katsnelson A, Markiewicz MR, Keith DA, et al: Operative management joms.2022.04.020.
of temporomandibular joint ankylosis: a systematic review and meta- Topazian RG: Etiology of ankylosis of temporomandibular joint: analysis
analysis, J Oral Maxillofac Surg 70(3):531-536, 2012. doi:10.1016/j. of 44 cases, J Oral Surg Anesth Hosp Dent Serv 22:227-233, 1964.
joms.2011.10.003.

t.me/Dr_Mouayyad_AlbtousH
72
Squamous Cell Carcinoma
K A U SH I K H . S H A R M A a n d D E E PA K K A D E M A N I

CC oral cavity tumors in males and 61% of those in females. Chewing

tobacco is associated with an increased risk of oral SCC. Alcohol
A 55-year-old African American male presents to your office and use alone and in conjunction with tobacco use has been shown to
states, “There is something wrong with my tongue, and my den- pose an increased risk of oral SCC. In studies controlled for smok-
tist said I need to have it checked.” (African Americans have a ing, those who consumed moderate to heavy amounts of alcohol
higher incidence of squamous cell carcinoma [SCC] and double were found to have a three to nine times greater risk of the devel-
the mortality rates.) opment of SCC. When alcohol and smoking are combined, alco-
hol is considered to be a promoter and a possible co-carcinogen
HPI to tobacco, with some studies showing a 100-fold increased risk.

The patient recently visited his general dentist for evaluation of Examination
his ill-fitting upper dentures. Upon examination, a red and white,
fungating, nontender, ulcerated mass of the right lateral border of The examination of a patient with the diagnosis of SCC should
his tongue was noted (SCC until proved otherwise). The patient entail a complete head and neck examination to search for neck
was otherwise asymptomatic. (Early mucosal lesions of oral cancer metastasis (the most common areas of distant metastasis are the
are usually asymptomatic; painful ulcers are more suggestive of an lungs); synchronous primary tumors; or in cases of presenting
inflammatory or infectious cause.) Within 2 weeks, he had an neck disease, occult primary tumors. Particular attention is given
incisional biopsy of the lesion by a local oral surgeon, with a sub- to the status of the lymph nodes and the size of the presenting
sequent diagnosis of an invasive SCC. lesion. Previous studies have shown that on initial examination of
The biopsy report from the previous surgeon was requested a known primary tumor, there is a 3% to 7% incidence of a syn-
and reviewed. (It is important to confirm the diagnosis before chronous tumor in the upper aerodigestive tract. A nasopharyn-
definitive treatment.) The histopathology report described a loss golaryngoscopic (NPL) examination is indicated to evaluate the
of normal maturation of the epithelial cells, with invasion of ab- subepiglottic and supraepiglottic regions, posterior oropharynx,
normal cells beyond the basement membrane into the underlying larynx, and nasopharynx.
subcutaneous tissues and muscle layers (indicative of invasive tu- General. The patient is a well-developed and well-nourished
mor). Stranding and islands of keratin-like material are also African American male who appears his stated age, with no signs
noted. (Keratin is indicative of greater cellular differentiation.) of cachexia (seen with advanced disease).
The abnormal cells appeared pleomorphic (having many different Maxillofacial. There is a 3.5-cm red and white, fungating mass
shapes) with an increased nuclear-to-cytoplasmic ratio and occa- on the right lateral border of the tongue with central ulceration. (A
sional mitotic figures (signs of cellular malignant transformation). nonhealing ulcer in the oral cavity is considered to be SCC until
Generalized inflammatory infiltration was noted at the deepest proved otherwise; Fig. 72.1.) There is no pain or bleeding noted
portion of the specimen. The diagnosis of a grade III (see Discus- on palpation of the lesion. (Although ulcers from SCC may occa-
sion) invasive SCC was made. sionally bleed, they are usually painless.) Some patients may also
complain of ear pain if the lesions are deep and involve the lingual
PMHX/PDHX/Medications/Allergies/SH/FH nerve. When ear pain is present, perineural invasion cannot be
ruled out until final pathology. Examination of the remaining oral
The patient has a 45-pack-year history of tobacco use. In addi- cavity, including the buccal mucosa, hard and soft palate, parotid
tion, he regularly consumes alcoholic beverages on weekends and and submandibular glands, oropharynx, and nasopharynx, reveals
occasionally on weekdays. (Tobacco and alcohol are both risk no other abnormalities. Nasopharyngolaryngoscopy reveals no
factors for the development of oral SCC; see Discussion.) He does abnormal tissues in the posterior oropharynx, subglottic or supra-
not receive routine medical or dental treatment. (Lack of routine glottic regions, or nasopharynx. (NPL should be performed as part
health care can delay early detection of oral SCC.) of the head and neck evaluation of tongue SCC.)
The strong association between SCC and tobacco use is well Neck. No cervical or submandibular lymphadenopathy is
established. The risk of SCC developing in a smoker is approxi- noted. (Cancers of the tongue usually metastasize to the level I
mately five to nine times greater than in a nonsmoker. It is also and II nodes.) There is no pain on palpation of the neck. (Lymph-
postulated that smoking is responsible for approximately 90% of adenopathy from cancer is usually painless.)

370
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 72 Squamous Cell Carcinoma 371

lesion. No other abnormal uptake in the neck or chest was noted.

The panoramic and chest radiographs revealed no abnormalities.

Labs
A complete metabolic panel (CMP), complete blood count
(CBC), and coagulation profile (prothrombin time [PT], partial
thromboplastin time, and international normalized ratio) are
mandatory laboratory studies in the patients with cancer because
of metabolic, electrolyte, and nutritional derangements that may
accompany malignant disease. Liver function tests are obtained as
part of the CMP and are important screening tests for liver me-
tastasis or alcohol dependence. Other laboratory studies can be
ordered based on the patient’s medical history.
In the current patient, the CBC, CMP, liver function test re-
• Fig. 72.1 An ulcerating fungating mass on the right lateral border of the sults, and coagulation studies were within normal limits.
tongue, diagnosed as squamous cell carcinoma.
Assessment
T2, N0, M0 (tumor .2 cm but ,4 cm, with no positive nodes and
The presence of occult neck disease in the N0 neck is related no distant metastasis) stage II, oral SCC of the right lateral border of
to the tumor’s stage, size, and depth of invasion; perineural inva- the tongue with a Broders’ histologic grade of III.
sion; and histologic grade. Lesions larger than 4 mm in depth,
along with a high-grade histology, have a greater than 20% risk of Treatment
neck disease in the N0 neck.
Treatment of patients with SCC of the tongue begins with a com-
Imaging plete history and physical examination, including NPL. This is
followed by appropriate tests, including CBC with differentials,
The initial imaging modalities for the evaluation of patients with electrolytes, liver function tests, chest radiographs, and CT with
SCC begin with a panoramic radiograph. This is a useful screen- contrast. The role of PET scanning for occult metastasis continues
ing tool to evaluate for the presence of bony infiltration associated to evolve.
with the tumor. It also provides valuable information regarding The treatment of SCC is site specific; surgical ablation
the long-term prognosis of the remaining dentition because some with minimum 1.0- to 1.5-cm margins is the main modality of
patients may require extraction of carious or periodontally in- treatment (Fig. 72.2). Most oral cavity tumors are approached
volved teeth before radiotherapy. transorally; however, some tumors may need to be accessed via
A computed tomography (CT) scan of the head and neck is a transfacial or transcervical approach. Sometimes when the tu-
the commonly used imaging study of choice to delineate the le- mor is located in the dentoalveolar process of the mandible, the
sion and assess the neck for cervical lymphadenopathy. (Nodes inferior border can be preserved (marginal mandibulectomy),
larger than 1.5 cm, with central necrosis, an ovoid shape, and fat depending on the degree of infiltration. However, when the can-
stranding are indicative of nodal metastasis.) Additional tests, cellous portion of the mandible is invaded, segmental resection is
such as magnetic resonance imaging and ultrasonography, can be required to maintain oncologic safety.
used to assess the status of the cervical nodes.
Anteroposterior and lateral chest radiographs are used to screen
for underlying pulmonary disease and evaluate for pulmonary
metastasis because the lungs are the most common areas of metas-
tasis for this tumor. Positron emission tomography (PET) scans are
becoming a common modality for the evaluation of distant metas-
tasis. This technology uses an 18F-fluorodeoxyglucose (FDG)
marker to examine sites of increased glucose uptake, which are
seen with metabolically active cancer cells. This imaging modality
is commonly used to rule out distant disease, and it is also helpful
for clinically staging the tumor. Several studies have demonstrated
that a standardized uptake value (SUV) of greater than 3 correlates
with hypermetabolism suggestive of a pathologic process. Clinical
staging is helpful because a treatment plan can be worked up for
the patient and adjuvant modalities recommended.
In the current patient, axial and coronal CT images of the head
and neck, with and without contrast, revealed a 3.5-cm, well-
circumscribed lesion of the right lateral border of the tongue
musculature. No evidence of cervical lymphadenopathy was
noted. The PET scan performed with 18F-FDG showed a hyper- • Fig. 72.2 Tongue squamous cell carcinoma shown with a dotted line
metabolic area in the right tongue coinciding with the clinical and 1.5-cm margin shown with a solid line.

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372 S E C TI O N Oral Cancer

A common procedure that accompanies the removal of the

tumor is the removal of the fibrofatty contents of the neck, for
treatment of cervical lymphatic metastases and for complete stag-
ing of the cancerous process (see the section on neck dissections
later in this chapter).
Reconstruction and rehabilitation. Depending on the defect,
the reconstructive surgery can be divided into soft tissue or bony
reconstruction (or both). Closing the defect primarily is ideal if it
can be accomplished. Soft tissue surgical procedures include
closure by secondary intention, skin grafts, local flaps, or microvas-
cular free flaps. Simultaneous bony reconstruction can be accom-
plished using vascularized free flaps from the iliac crest, scapula, or
fibula when needed. In select cases for SCC involving the maxilla,
an obturator can provide temporary or definitive rehabilitation for
the ablative defect depending on the patient’s wishes. When large
ablative and reconstructive procedures are performed, they can be
performed simultaneously (see Chapter 12). Depending on the
amount of healing and dysfunction anticipated, a percutaneous • Fig. 72.3 Tongue squamous cell carcinoma in close proximity to the
endoscopic gastrostomy tube and elective tracheostomy can be midline.
performed to secure the airway and aid in the nutritional support
of the patient during the postoperative period.
Radiation therapy. Radiation therapy can be used as a pri-
mary or an adjuvant therapy. Primary radiotherapy is usually re-
served for patients with significant comorbidities or when the
primary tumor or the patient is not amenable to surgery. This is
not a primary indication for early-stage SCC because of the as-
sociated morbidity, including dysphagia and xerostomia. Another
significant risk is the development of metachronous lesions after
radiation therapy.
Postoperative radiation therapy is commonly used as a part of
the comprehensive treatment. The indications for its use include
positive or near margins, significant perineural or perivascular
invasion, bone involvement, multiple nodal involvement, extra-
capsular spread, or stage III or stage IV disease. Typically, about
6000 cGy in divided doses is administered, and treatment is initi-
ated soon after healing from the initial surgery is complete.
Surgery combined with radiation therapy and chemotherapy has
increased the 5-year survival rates for stage III and stage IV can-
cers by 10%.
In the current patient, a right partial glossectomy via a tran-
soral approach was performed with 1.5-cm margins. The status of
the margins was evaluated using frozen section microscopy, which
demonstrated negative margins. An ipsilateral supraomohyoid
neck dissection (levels I–III) was completed for staging, which
revealed no positive lymph nodes. The tongue defect was recon-
structed with a radial forearm free flap, anastomosing with the
facial artery and vein. An elective tracheostomy was performed.
After complete healing, the patient was followed closely for signs
of recurrence. (A total of 85% of recurrences occur in the first
3 years after initial treatment.) • Fig. 72.4 Bilateral supraomohyoid neck dissection for squamous cell
carcinoma involving the tongue midline.
Occasionally, a cancerous lesion can present within 1 cm of
midline or at the midline, which can drain to ipsilateral or con-
tralateral lymph node groups (or both groups) (Fig. 72.3). This is Intraoperative Complications
of great importance when planning for elective neck dissection to
determine pathological staging of neck disease. In this clinical The main intraoperative concerns associated with oncologic abla-
situation, the possibility of bilateral neck dissection should be tive and reconstructive surgery include control of hemorrhage and
discussed with the patient well in advance (Fig. 72.4). anesthetic complications. Damage to adjacent structures, such as
the lingual nerve and Wharton’s duct, is possible with ablative
Complications procedures of the tongue and floor of the mouth. When simulta-
neous neck dissection is performed, additional complications may
Complications are best categorized as intraoperative, postopera- be seen, such as nerve palsies (facial and spinal accessory nerves),
tive (within 1 month), and long-term (after 1 month). vascular injury to the carotid artery or internal jugular vein and,

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 CHAPTER 72 Squamous Cell Carcinoma 373

more rarely, pneumothorax, air embolism, and formation of a

chylous fistula (especially on the left side).

Postoperative Complications
Postoperative complications include wound infection, hematoma,
skin necrosis, flap failure, orocutaneous fistula, poor speech, and
swallowing dysfunction. Poor healing can also be noted in pa-
tients with alcoholism because their prealbumin status is usually
low. Complications after bony reconstruction include malunion,
nonunion, contour irregularities, osteonecrosis, osteomyelitis,
osteoradionecrosis, and hardware failure.

Long-Term Complications
The gravest long-term complications are recurrence of the pri-
mary tumor and death (85% of recurrences occur in the first
3 years). The lifetime risk of development of a second primary
tumor is 2% to 3% per year, and the 5-year survival rate is 56%
for all tumor stages. Routine diagnostic tests are performed based
on the clinical suspicion of recurrence. Imaging studies can be
difficult to assess in the postoperative setting because of the dif-
ficulty of separating recurrent tumors from postoperative ana-
tomic changes. Recurrent disease usually occurs at the surgical
wound margin. Other complications include lingual nerve hypo-
esthesia, duct obstruction, and flap failure. Dysphagia, xerosto- • Fig. 72.5 Squamous cell carcinoma of the right retromolar area in a dif-
mia, mucositis, and the risk of osteoradionecrosis are associated ferent patient from the one shown in Fig. 72.1.
with radiation therapy. The most common causes of death in
patients with oral cancer are related to locoregional disease, dis-
tant metastasis, or cardiopulmonary failure. Metastases of SCC associated with an increased risk for developing SCC. The quid
tend to involve the lung (most common site), bones, liver, and consists of a betel leaf wrapped around a mixture of areca nut and
brain. slaked lime, commonly in combination with tobacco. The slaked
lime releases an alkaloid from the areca nut, causing a feeling of eu-
Discussion phoria. Chronic use of the quid can lead to a debilitating condition
known as submucous fibrosis, which is a premalignant condition.
Squamous cell carcinoma accounts for roughly 90% of neoplastic Human papillomavirus (HPV) types 16 and 18 have been
cases in the head and neck. In 2022, approximately 54,000 new cases shown to increase the risk of SCC. Data from recent studies show
of oral cavity and oropharynx cancers were estimated to be diagnosed that HPV 16 and 18 increase the ratio of SCC by approximately
in the United States. Of these, approximately 11,230 people will suc- three- to fivefold. Tonsillar SCC has the highest rate of HPV in-
cumb to their disease. The annual incidence in the United States is fection, with approximately 50% testing positive. Patients with
around 11 cases per 100,000 adult males and females. The incidence these HPV-positive oropharyngeal tumors are usually treated with
rate is highest in individuals aged 75 to 84 years. Unfortunately, 60% chemoradiation. HPV-related SCC can be prevented by 9-valent
of oral or pharyngeal cancers are moderately advanced (regional HPV vaccine (Gardasil-9). It is a non-infectious recombinant vac-
stage) or metastatic at the time of diagnosis, which decreases the cine prepared from the purified virus-like particles of the major
5-year survival rate because of advanced stages (stages III and IV). capsid protein of HPV types 6, 11, 16, 18, 31, 33, 45, 52, and
The 5-year survival rate is 67%. African Americans are reported to 58. This vaccine also provides protection again cervical cancer in
have significantly lower survival rates, approaching 35%. Roughly females.
two-thirds of these cases can be prevented with cessation of known Other known risk factors include chronic sun exposure, lead-
risk factors (tobacco and alcohol). ing to cutaneous SCC of the lip. Several studies have suggested
From an epidemiologic and clinicopathologic standpoint, car- that oral lichen planus, particularly the erosive form, is associated
cinomas in the head and neck region can be divided into three with an increased risk for SCC. Severe iron deficiency presenting
anatomic areas: as Plummer-Vinson syndrome is associated with an increased risk
1. Carcinomas arising in the oral cavity, which includes the for pharyngeal and esophageal SCC. Previous radiation exposure
tongue, gingiva, floor of the mouth, hard palate, buccal mu- is linked to an increased risk for developing SCC.
cosa, and retromolar area Premalignant conditions. Several well-known entities patho-
2. Carcinomas of the lip vermilion logically have a distinct association with SCC: leukoplakia, eryth-
3. Carcinomas of the oropharynx, including the base of the roplakia, and lichen planus.
tongue, lingual tonsil, soft palate, and uvula Leukoplakia is a white patch or plaque that cannot be charac-
Fig. 72.5 shows a different patient with a large fungating SCC terized clinically or pathologically as any other disease. Erythro-
of the right retromolar area. plakia is defined as a red lesion of the oral cavity that cannot be
In addition to alcohol and tobacco, the use of betel quid, classified clinically or pathologically as any other lesion (see the
or paan, which is popular in India and southeast Asia, has been section on oral leukoplakia in Chapter 7).

t.me/Dr_Mouayyad_AlbtousH
374 S E C TI O N Oral Cancer

Oral lichen planus has been a subject of controversy in the TABLE Oral Squamous Cell Carcinoma Survival Rates
literature concerning its possible role as a premalignant condition. 72.1 by Stage
Several studies have shown that the transformation rate of oral
lichen planus to SCC is approximately 0.04% to 1.74%. Year 1 Year 2 Year 3 Year 4 Year 5
Early oral SCC usually presents as one of the premalignant con- (%) (%) (%) (%) (%)
ditions discussed: a white, red, or mixed red and white lesion. As Stage I 93.9 84.4 77.5 73.0 68.1
the lesion matures, it can become centrally ulcerated and the bor-
ders become less distinct. The surface can become exophytic with Stage II 88.1 72.7 64.2 58.6 52.9
papillary projections or endophytic with raised, rolled borders. Stage III 77.5 60.9 52.5 46.0 41.3
The tongue is the most common site of SCC (30%) followed
Stage IV 60.3 40.6 33.5 29.3 26.5
closely by the floor of the mouth (28%). These sites are at the
higher risk, probably because of carcinogens that pool with saliva Modified from the National Cancer Institute, US National Institutes of Health: Surveillance
in these areas, contributing to a greater exposure. The thin, non- epidemiology and end results (SEER). Available at http://seer.cancer.gov/publicdata/access.
html. Accessed January 2024.
keratinized layer of epithelium in these areas may contribute to
the greater susceptibility. The other areas of prevalence, in de-
scending order, are the upper and lower alveolar ridges (including
the hard palate), retromolar trigone, buccal mucosa, and lips.
Broders’ classification system is an index of malignancy based decades. The key to survival is early diagnosis of SCC by the oral
on the fact that less differentiation (differentiation is defined as health provider and a prompt referral to an oral and maxillofacial
the degree of keratinization) is proportionally related to greater surgeon for definitive management. Even today, a thorough clini-
malignancy of the tumor. The classification is as follows: cal examination remains the gold standard for oral cancer screen-
• Grade I: more than 75% differentiated cells ing, and all patients should be offered oral cancer screening on an
• Grade II: 25% to 75% differentiated cells annual basis.
• Grade III: fewer than 25% differentiated cells
• Grade IV: anaplastic with no cell differentiation Acknowledgment
Histopathologic factors correlating with a poorer outcome in-
clude depth of invasion, perineural invasion, and extracapsular The authors and publisher wish to acknowledge Dr. David C.
spread. Swiderski for his contribution on this topic to the previous edition.
The 5-year survival rate remains about 50% and is related to
the stage at diagnosis (Table 72.1). Unfortunately, there has been ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
only a modest improvement in survival over the past several complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 374.e1

Bibliography Reichart PA, Philipsen HP: Oral erythroplakia: a review, Oral Oncol
41:551-561, 2005.
Schmidt BL, Dierks EJ, Homer L, et al: Tobacco smoking history and
Braakhuis BJM, Tabor MP, Kummer JA, et al: A genetic explanation of presentation of oral squamous cell carcinoma, J Oral Maxillofac Surg
Slaughter’s concept of field cancerization: evidence and clinical impli- 62:1005-1058, 2004.
cations, Cancer Res 63:1727-1730, 2003. Schwartz LH, Ozsahin M, Zhang GN, et al: Synchronous and metachro-
Broders AC: Carcinomas of the mouth: types and degrees of malignancy, nous head and neck carcinomas, Cancer 74:1933-1938, 1994.
Am J Roentgenol Radium Ther Nucl Med 17:90-93, 1927. Shafer WG, Waldron CA: Erythroplakia of the oral cavity, Cancer
Funk FF, Karnell LH, Robinson RA, et al: Presentation, treatment, and 36:1021-1028, 1975.
outcome of oral cavity cancer: a national cancer data base report, Smith GI, O’Brien CJ, Clark J, et al: Management of the neck in patients
Head Neck 24:165-180, 2002. with T1 and T2 cancer in the mouth, Br J Oral Maxillofac Surg
Hillbertz NS, Hirsch JM, Jalouli J, et al: Viral and molecular aspects of 42:494-500, 2004.
oral cancer, Anticancer Res 32:4201-4212, 2012. Syrjanen S: Human papillomavirus (HPV) in head and neck cancer,
Kademani D, Bell RB, Bagheri SC, et al: Prognostic factors for intraoral J Clin Virol 32(suppl 1):S59-S66, 2005.
squamous cell carcinoma: the influence of histologic grade, J Oral Todd R, Donoff RB, Wong DTW: The molecular biology of oral carci-
Maxillofac Surg 63:1599-1605, 2005. nogenesis: toward a tumor progression model, J Oral Maxillofac Surg
Marur S, D’Souza G, Westra WH, et al: HPV-associated head and neck 55:613-623, 1997.
cancer: a virus-related cancer epidemic, Lancet Oncol 11:781-789, 2010. Van der Meij EHDDS, Schepman KP, Van der Waal I: The possible
McClure SA, Mohaved R, Salama A, et al: Maxillofacial metastases: a premalignant character of oral lichen planus and oral lichenoid le-
retrospective review of one institution’s 15-year experience, J Oral sions: a prospective study, Oral Surg Oral Med Oral Pathol Oral Radiol
Maxillofac Surg 16(2):181-188, 2012. Endod 96:164-171, 2003.
Neville BW, Day TA: Oral cancer and precancerous lesions, CA Cancer Waldron CA, Shafer WG: Leukoplakia revisited: a clinicopathological
J Clin 52:195-215, 2002. study of 3,256 oral leukoplakias, Cancer 36:1386-1392, 1975.
Oliver AJ, Helfrick JF, Gard D: Primary oral squamous cell carcinoma, Wooglar JA: Histological distribution of cervical lymph node metastases
J Oral Maxillofac Surg 54:949-954, 1996. from intraoral/oropharyngeal squamous cell carcinomas, Br J Oral
Oral Cavity and Nasopharyngeal Cancers Screening (PDQ®)–Health Maxillofac Surg 37:175-180, 1999.
Professional Version. National Cancer Institute. Available at: https://
www.cancer.gov/types/head-and-neck/hp/oral-screening-pdq.

t.me/Dr_Mouayyad_AlbtousH
73
Verrucous Carcinoma
AL E X AF S H AR , D E E PAK K A D E M A N I , K E TAN PAT EL , and A N T H O N Y M O RL A N DT

CC Intraoral. The patient has significant occlusal wear on his teeth,

enamel staining (secondary to smokeless tobacco use), and moder-
A 68- year-old male farmer is referred to you. He complains, “I’m ate generalized periodontal disease. There is a heterogeneous,
worried about this growth on my cheek. It just won’t seem to go multifocal growth that involves the right buccal mucosa and right
away.” (Verrucous carcinoma is more commonly seen in the older mandibular gingiva (the most common site of verrucous carci-
adult male population, those older than 60 years of age.) noma is the buccal mucosa), measuring 4 cm 3 5 cm (Fig. 73.1).
On the posterior buccal mucosa, the lesion is a cauliflower, exo-
HPI phytic mass. On the anterior buccal mucosa, the lesion has leuko-
plakia with surrounding erythema, as well an exophytic pink mass
The patient reports a 6-month history of a rough, corrugated area inferior to this leukoplakia. On the right mandibular gingiva, there
on his right buccal mucosa and mandibular gingiva. He was seen is a cauliflower exophytic growth measuring 8 mm 3 8 mm (can
by his dentist and was referred to you for evaluation of possible be seen on final specimen on Fig. 73.2). The entire buccal mucosa
“oral cancer.” (Verrucous carcinoma cannot be distinguished is firm to palpation.
clinically from squamous cell carcinoma [SCC].) The area has not
been painful but has recently become more irritated. (Pain is not Imaging
characteristically seen with neoplastic processes.) He has been in-
advertently chewing on the area, with occasional bleeding. He A panoramic radiograph should be obtained to screen for any
denies any weight loss or constitutional symptoms. (These may be bony erosion or infiltration and to evaluate the dentition.
seen with metastatic disease.) Although verrucous carcinoma has a low tendency to metastasize,
it does represent a malignancy; therefore, formal oncologic stag-
PMHX/PDHX/Medications/Allergies/SH/FH ing should be considered. A routine oncologic workup includes
an assessment of the extent of locoregional disease using clinical
The patient has a positive history of chronic obstructive pulmo- and radiographic modalities (panoramic radiograph, computed
nary disease (COPD; secondary to chronic tobacco use). He sees tomography [CT] scan of the head and neck, nasopharyngeal
his local dentist only when he develops a problem. (He does not laryngoscopy, and chest radiograph or CT). The likelihood of
have routine oral cancer screening.) He has used smokeless to- distant disease is remote and can be addressed based on system-
bacco for 30 years and consumes three or four alcoholic beverages driven findings.
per week. In the current patient, a panoramic radiograph demonstrated
Many patients with verrucous carcinoma are reported to chew normal bony anatomy of the jaws. The maxillary sinuses appear
tobacco, but this association is not consistent. Both tobacco use and clear and have no evidence of widening of the periodontal liga-
chronic alcohol consumption are risk factors for the development ments or localized resorption of teeth (signs of infiltrative disease
of SCC. The association with verrucous carcinoma is uncertain. processes). A contrast-enhanced CT scan (contrast enhances visu-
alization of soft tissue) of the head and neck was obtained. This
Examination showed a mass of the right buccal mucosa. There was no evidence
of infiltration or extension of the lesion, and no enlarged lymph
General. The patient is a thin, older adult White male who ap- nodes (signs of metastatic disease) were noted. Because of the risk
pears older than his stated age; this is most apparent by his sun- of occult malignancy, nasopharyngoscopy was performed. No
damaged skin and extensive facial rhytids. (Chronic tobacco and abnormalities were detected. An anteroposterior chest radiograph
sun exposure both contribute to early signs of aging secondary to revealed mild cardiomegaly and lung hyperinflation (secondary to
changes in collagen synthesis.) COPD) but no focal lung lesions indicative of metastatic disease.
Maxillofacial. The patient has deeply tanned skin with many
rhytids (secondary to prolonged sun exposure). There are no skin Labs
lesions in the sun-exposed areas (it is important to look for early
signs of basal cell carcinoma and actinic keratosis), and there is no Routine laboratory tests are indicated in the routine workup of
facial or cervical lymphadenopathy. (Enlarged lymph nodes would verrucous carcinoma as dictated by the medical history. A hemo-
be suggestive of a malignant disease process.) globin or hematocrit level may be obtained before the removal of

375
t.me/Dr_Mouayyad_AlbtousH
376 S E C TI O N Oral Cancer

larger lesions. Liver function tests are typically not required be-
cause the risk of liver metastasis is extremely low.

Differential Diagnosis
Based on the history and clinical examination, verrucous carci-
noma can be confused with SCC, as well as a number of white
lesions. These different lesions may represent a spectrum of simi-
lar diseases. Proliferative verrucous leukoplakia is a diagnosis for
lesions that begin as simple hyperkeratosis and spread to other
sites, become multifocal, and progress slowly through a spectrum
of dysplasia to frank invasive carcinoma. Histologically, the associ-
ated dense inflammatory infiltrate may contribute to the occa-
sional misdiagnosis as pseudoepitheliomatous hyperplasia or
chronic hyperplastic candidiasis. Small lesions can resemble focal
epithelial hyperplasia (Heck disease).

Biopsy
When a diagnosis of verrucous carcinoma is considered, a full-
thickness biopsy sample, down to the periosteum or submucosa,
must be taken to minimize the possibility of misdiagnosis.
Appropriate treatment relies on a good biopsy technique, with at-
tention to including the base of the lesion as part of the specimen.
The key in differentiating between benign and malignant lesions is
to take a biopsy sample that is both deep (full thickness) and large
enough to allow examination of the relationship between the tu-
mor and the underlying connective tissue. On occasion, multiple
• Fig. 73.1 Multifocal verrucous carcinoma of the right buccal mucosa. biopsies may be necessary to diagnose verrucous carcinoma.

Assessment
This is a 68-year-old male with COPD presenting with a multifo-
cal cT3N0 verrucous carcinoma of the right buccal mucosa. For
the current patient, under local anesthesia, a full-thickness wedge
biopsy sample, including normal tissue, was taken from center of
the cauliflower lesion on the posterior buccal mucosa. The tissue
was sent for permanent hematoxylin and eosin staining, which
showed a thick surface layer of orthokeratinized squamous epithe-
lium with occasional parakeratosis. There were exaggerated, blunt
rete pegs extending into the lamina propria, with an intact,
well-polarized basal layer and a “pushing border” appearance. The
suprabasilar cells were well differentiated. Lymphocytic inflamma-
tion was seen throughout the lamina propria with a high degree
of keratinization and minimal pleomorphism.

Treatment
Surgical resection is the mainstay of management of verrucous
carcinoma of the oral cavity. For treatment planning purposes,
preexisting comorbidities; the site, grade, and stage of the tumor;
and the effectiveness of the particular therapy and its associated
complications should be taken into account.
Because of the superficial, cohesive growth pattern and sharply
demarcated margins of this lesion, a number of authors recom-
mend surgical excision as the treatment of choice. Surgery involves
wide excision of the primary lesion and surrounding tissues,
including bone and muscle when invasion is suspected. Wide sur-
gical excision with 0.5- to 1-cm margins is the recommended
treatment for verrucous carcinoma. With adequately treated tu-
• Fig. 73.2 The final specimen after wide local excision of right buccal mors, the recurrence rate is low. Neck dissections can be performed
mucosa and rim mandibulectomy was performed. for clinically N1 necks. However, verrucous carcinoma rarely

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 CHAPTER 73 Verrucous Carcinoma 377

exhibits regional or distant metastasis, and enlarged lymph nodes, (compared with slightly greater than 50% for SCC). Radiation
if present on initial examination, tend to be reactive in nature. can be used as adjuvant therapy for close or positive margins or
Postoperative radiation therapy can be performed for close or unresectable lesions; however, long-term survival rates drop to
positive margins. However, recent studies in oral cavity verrucous about 57.6%.
carcinoma show no clear survival benefit with postoperative ra- The most common site of verrucous carcinoma is the oral cav-
diation therapy. Palliative radiation may be used in unresectable ity. Verrucous carcinoma most commonly involves the buccal
tumors or in patients not amenable to surgical excision because of mucosa, the mandibular gingiva alveolar ridge, or the tongue. It
comorbidities. Surgery alone with negative margins appears to typically presents as a nonulcerated, slow-growing, exophytic,
show optimal survival benefit for patients with oral verrucous “papulonodular” or “warty,” fungating gray or white mass. Less
carcinoma. Patients should be aware of the risks of mucositis, frequently, the roughened, pebbly surface can be inconspicuous,
xerostomia, radiation caries, and osteoradionecrosis of the jaws. and the tumor can present as a flattened white lesion. It can vary
For the current patient, general anesthesia was induced, and in size from a small patch to a confluent, extensive mass. Verru-
nasal endotracheal intubation was performed. The lesion was ex- cous carcinoma can superficially invade the soft tissues and under-
cised with wide margins (0.5–1 cm) of uninvolved surrounding lying bone structures, becoming fixed to the periosteum. Distant
tissue. A rim mandibulectomy was also performed, which included metastasis is exceedingly rare.
a rim of the right mandibular bone as well as teeth #28 and #29. The etiology of verrucous carcinoma remains unclear, but to-
The final specimen measured 3.5 cm 3 5 cm (see Fig. 73.2). The bacco is thought to play a significant role for lesions of the aerodi-
depth of the specimen measured less than 2 mm relative to the gestive tract. Tobacco smoking and excess alcohol are known risk
surrounding normal mucosa, which included excision to factors for the development of SCC of the mouth, and they may
the level of the buccinator fascia. After complete hemostasis play a role in the pathogenesis of verrucous carcinoma. Similari-
was obtained, the wound bed was covered with a 0.015-inch, split- ties between the morphologic features of verrucous carcinoma
thickness skin graft harvested from the thigh. On the final pathol- and virally infected epithelial lesions suggest a possible etiologic
ogy, the tumor did not invade the bone. Lymphovascular invasion link with human papillomavirus (HPV) infection. HPV types 6,
and perineural invasion not identified. The final stage of the speci- 11, 16, and 18 have been detected to varying degrees in verrucous
men was pT3Nx (multifocal) verrucous carcinoma. carcinoma of the oral cavity.
The hallmark of this tumor is the discrepancy between the
Complications histologic pattern and the clinical behavior. Microscopically,
verrucous carcinoma appears as a papillary or verrucous, low-
The prognosis is excellent after adequate excision. Complications grade (i.e., well-differentiated) SCC. Verrucous carcinomas typi-
relate mainly to local destructive effects caused by the tumor itself cally present clinically as exophytic lesions; they can also present
and its surgical removal. Large lesions can be locally destructive, with a mixed or an endophytic growth pattern. Squamous cells
with invasion or erosion of adjacent tissue and bone. Regional display minimal or no dysplasia, with infrequent mitoses local-
and distant metastasis is exceedingly rare, and clinically, N1 ized to the invading (pushing) front. There is an overlying hyper-
necks are typically reactive on final pathology. Focal areas of inva- orthokeratosis or parakeratosis, resulting in keratin-filled clefts of
sive SCC are sometimes found within an excised specimen. Those the surface epithelium with prominent, bulbous rete processes
with hybrid features (verrucoid SCC) should be treated similar to extending to a uniform distance into the underlying connective
conventional SCC. tissue; this creates a “pushing border” rather than an infiltrating
quality at the base of this tumor. The basement membrane is
Discussion intact, with little evidence of connective tissue invasion. An in-
tense, mixed inflammatory infiltrate may surround and blend
The terms verrucous carcinoma of Ackerman and oral florid papil- with the tumor, sometimes obscuring the epithelium–connective
lomatosis have been used to describe verrucous carcinomas occur- tissue interface.
ring within the aerodigestive tract. This is an uncommon tumor; As mentioned, verrucous carcinoma is an uncommon tumor
it is diagnosed in 1 to 3 individuals per 1 million people each year that can be seen in the oral cavity. Excision of the tumor should
and accounts for 2% to 9% of oral cancers. Most patients with be followed by frequent follow-up evaluations for recurrence and
verrucous carcinoma are older than age 50 years. (The average for new-onset SCCs of the upper aerodigestive tract.
age at the time of diagnosis is 65 years.) Males are affected more
often than females. Verrucous carcinoma is typically associated ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
with a favorable prognosis, with 5-year survival rates up to 85% complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 377.e1

Bibliography Jyothirmayi R, Sankaranarayanan R, Varghese C, et al: Radiotherapy in

the treatment of verrucous carcinoma of the oral cavity, Oral Oncol
33(2):124-128, 1997.
Addante R, McKenna S: Verrucous carcinoma, Oral Maxillofac Surg Clin Koch B, Trask D, Hoffman HT, et al: National survey of head and neck
North Am 18:513-519, 2006. verrucous carcinoma: patterns of presentation, care and outcome,
Alonso JE, Kuan EC, Arshi A, et al: A population-based analysis of ver- Cancer 92(1):110-120, 2001.
rucous carcinoma of the oral cavity, Laryngoscope 128(2):393-397, Mirbod S, Ahing S: Lesions of the oral cavity. II. Malignant lesions, J Can
2018. Dent Assoc 66:308-311, 2000.
Batsakis JG, Suarez P, El-Naggar AK: Proliferative verrucous leukoplakia Naik AN, Silverman DA, Rygalski CJ, et al: Postoperative radiation
and its related lesions, Oral Oncol 35:354-359, 1999. therapy in oral cavity verrucous carcinoma, Laryngoscope 132(10):
Bouquot JE: Oral verrucous carcinoma: incidence in two US popula- 1953-1961, 2022.
tions, Oral Surg Oral Med Oral Pathol Oral Radiol Endod 86(3): Paleri V, Orvidas LJ, Wight RG, et al: Verrucous carcinoma of the paranasal
318-324, 1998. sinuses: a case report and clinical update, Head Neck 26(2):184-189, 2004.
Charles S: The man behind the eponym: Lauren V. Ackerman and ver- Schwartz RA: Verrucous carcinoma of the skin and mucosa, J Am Acad
rucous carcinoma of Ackerman, Am J Dermatopathol 26(4):334-341, Dermatol 32(1):1-21, 1995.
2004. Walvekar R, Chaukar DA, Deshpande MS, et al: Verrucous carcinoma of
Jordan RC: Verrucous carcinoma of the mouth, J Can Dent Assoc 61(9): the oral cavity: a clinical and pathological study of 101 cases, Oral
797-801, 1995. Oncol 45:47-51, 2009.

t.me/Dr_Mouayyad_AlbtousH
74
Malignant Salivary Gland Tumors
J AM E S M U R P H Y, M O HAMME D Q A I S I , a n d K E TA N PAT E L

CC nerves are intact (low-grade mucoepidermoid carcinoma typically

does not display perineural invasion).
The patient is a 64-year-old female referred for evaluation of a Intraoral. A 2-cm 3 2-cm submucosal swelling is present on
mass on the right posterior hard palate. (Mucoepidermoid carci- the right posterior hard palate (Fig. 74.1). The mass is firm, non-
noma occurs across a wide age range and has a slight female pre- mobile, nonpulsatile, and nontender to palpation (highly sugges-
dilection. Adenoid cystic carcinoma [ACC] has a relatively equal tive of a neoplastic process). The overlying mucosa is pink (may
male-to-female distribution and is most commonly seen in the present with a bluish or reddish color) and nonulcerated. The
older adult population.) greater and lesser palatine nerves are intact. The dentition is in
good repair, and all teeth are vital without pain on percussion.
HPI There are no other intraoral lesions or masses.
Neck. There is no lymphadenopathy (regional lymph node
The patient first noticed a lump on her hard palate approximately metastasis is uncommon, especially for low-grade lesions, but may
6 months earlier. (The parotid gland is the most common site for occur with high-grade lesions or advanced disease).
mucoepidermoid carcinoma; minor salivary glands, especially
from the palate, are the second most common.) The patient is Imaging
asymptomatic, although the mass has been slowly increasing in
size. (Mucoepidermoid carcinoma usually presents as progres- The workup for a biopsy-proved mucoepidermoid carcinoma in-
sively enlarging, asymptomatic swelling.) She denies pain, fever, volves a complete head and neck physical examination, CT scan
chills, night sweats, nausea, vomiting, weight loss, and other of the head and neck (with intravenous [IV] contrast) for delinea-
constitutional symptoms. She also denies any history of dental tion of the primary tumors and regional metastasis, a panoramic
pain or sinus congestion. (ACCs are more common in the sub- radiograph (initial screening examination), and a chest radiograph
mandibular gland and lower lips. Late-stage ACCs can present for evaluation of pulmonary metastasis. Newer imaging modali-
with progressive anesthesia on the lip because of the propensity ties, such as positron emission tomography (PET) scanning, have
for perineural invasion.) become powerful tools for delineation of local and distant disease.
Most PET studies are performed using the glucose analog 18F-
PMHX/PDHX/Medications/Allergies/SH/FH fluorodeoxyglucose (18F-FDG), which has been shown to accu-
mulate in areas of higher metabolic activity. This is especially
The patient denies tobacco and alcohol use. important in ACCs because these tumors have a predilection for
Although exposure to ionizing radiation has been implicated as distant metastasis.
a cause of salivary gland cancer, the etiology of most salivary gland In the current patient, no abnormalities of the dentition or
cancers cannot be determined. Occupations that may be associated surrounding bony structures were identified on the panoramic
with an increased risk for salivary gland cancers include rubber radiograph. Axial and coronal views from the CT scan of the head
product manufacturing, asbestos mining, plumbing, and some and neck performed with IV contrast (for improved delineation
types of woodworking. Tobacco and alcohol consumption do not of soft tissue) demonstrated a 2-cm 3 1-cm enhancing soft tissue
seem to have a causal relationship with salivary gland tumors. mass of the right posterior hard palate that did not appear to in-
volve the underlying bone. No cervical lymphadenopathy was
Examination noted. The chest radiograph was normal.

General. The patient is a well-developed and well-nourished Labs

White female who appears her stated age and is in no apparent
distress. She is not cachexic. (Cachexia may be a sign of advanced For the biopsy procedure, routine laboratory studies are not indi-
disease.) cated in an otherwise healthy patient. A complete blood count,
Maxillofacial. The face is symmetrical and without any extra- electrolyte studies, and coagulation studies may be performed to
oral swelling. The patient has no proptosis (maxillary sinus malig- establish a baseline before the definitive surgery. Liver function
nancies can invade both the palate and orbit). The infraorbital tests are not routinely obtained because liver metastasis is rare.

378
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 CHAPTER 74 Malignant Salivary Gland Tumors 379

• Fig. 74.1 Submucosal swelling on the right posterior hard palate. (From • Fig. 74.2 Histopathology image showing an abundance of mucus cells
Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 6, in a low-grade mucoepidermoid carcinoma.
St. Louis, 2014, Saunders.)

Differential Diagnosis
The differential diagnosis in the case of a submucosal mass of the
posterior hard palate should include benign (pleomorphic ade-
noma, monomorphic adenoma, canicular adenoma) and malig-
nant minor salivary gland tumors (mucoepidermoid carcinoma,
ACC, polymorphous low-grade adenocarcinoma, acinic cell carci-
noma, and adenocarcinoma). Lesions of infectious etiology should
be considered but are unlikely given the presentation. Sarcomas
can also occur on the palate and should be considered in the dif-
ferential diagnosis. An incisional biopsy is indicated for the cur-
rent patient.

Biopsy • Fig. 74.3 Adenoid cystic carcinoma showing perineural invasion.

Mucoepidermoid carcinoma is graded on a scale of I to III

(low, intermediate, and high grade, respectively); features of Assessment
high-grade tumors include nuclear atypia, necrosis, perineural
spread, mitoses, bony invasion, lymphatic and vascular inva- T1, N0, M0 (a tumor #2 cm in diameter, with no lymphadenopa-
sion, intracystic component, and tumor front invading in small thy and no evidence of distant metastases) low-grade mucoepidermoid
nests and islands. The grading system for mucoepidermoid carcinoma of the right posterior hard palate.
carcinoma is subjectively assessed based on the degree of epi-
dermoid versus mucinous cellular components. High-grade Treatment
tumors have a relatively higher proportion of epidermoid cells
(squamous and intermediate cells) and few mucus-producing After a biopsy-proven diagnosis of low-grade mucoepidermoid
cells, whereas low-grade tumors have a high proportion of mu- carcinoma has been made, the lesion is definitively treated by
cus cells (Fig. 74.2). wide local excision with 1-cm margins. High-grade lesions may
In ACC, three major forms are recognized histopathologically: require more extensive resection, with surgical management of the
the cribriform, tubular, and solid variants (Fig. 74.3). Micro- neck, to limit the potential for locoregional recurrence.
scopically, ACC is composed of small cells arranged in groups that For the current patient, the treatment of choice was a right
form glandular spaces filled with mucoid material or a hyaline partial maxillectomy with a split-thickness skin graft and immedi-
plug. The cribriform variant is most common, and the solid vari- ate placement of a prosthetic obturator (see Discussion). Adjuvant
ant has the worst prognosis. radiation therapy is not indicated for low-grade lesions that are
In the current patient, an incisional biopsy of the central por- completely excised.
tion of the palatal mass was performed under local anesthesia. The patient was placed under general anesthesia and under-
Histopathology of the specimen confirmed a low-grade mucoepi- went a formal right partial maxillectomy, with 1-cm, tumor-free
dermoid carcinoma (high proportion of mucus cells with minimal margins, via a transoral approach. (A Weber-Ferguson incision
cellular atypia). It is important to obtain a tissue sample from the may be indicated for larger tumors that require a more extensive
center of the lesion in cases of suspected salivary gland neoplasms. ablative surgery.) A split-thickness skin graft (0.015 inch) was
A biopsy from the periphery may result in a nondiagnostic speci- harvested from the right thigh and used to line the ablative defect.
men because of inadequate depth. This was bolstered using Xeroform gauze packing (Coe-Soft [GC

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380 S E C TI O N Oral Cancer

America] denture liner can also be used) and a preformed surgical getting tissue for histopathological diagnosis. It is recommended
stent, which was secured to the maxilla with a midpalatal screw. that the biopsy be taken from the center of the mass. A punch
The stent was removed after 2 weeks, and an impression was taken biopsy facilitates this nicely.
for fabrication of a temporary maxillary obturator. Imaging is a prerequisite for the workup of all head and neck
malignancies, salivary gland malignancies being no different. A
Complications neck computed tomography (CT) scan with contrast to evaluate
the primary lesion and for any regional lymphadenopathy is fa-
Complications associated with a partial maxillectomy include vored by most as the initial imaging. This is typically done with a
bleeding because of vascular injury of the terminal branches of the CT chest in line with National Comprehensive Cancer Network
internal maxillary artery (greater and lesser palatine vessels) or the guidelines. These initial imaging modalities can be combined with
internal maxillary artery itself. magnetic resonance imaging (MRI) using institutionally deter-
Hemorrhage can be controlled with direct pressure, hemostatic mined protocol such as skull base protocol to evaluate for possible
agents, electrocautery, or vessel ligation. Uncontrollable arterial radiologic evidence of perineural invasion. This is of particular
bleeding may require angiography and embolization of the feed- relevance in ACC because of its well-documented neurotropism.
ing vessels to obtain proximal control. The use of a maxillary stent MRI is favored for evaluating soft tissues with CT generally being
helps promote hemostasis and improve patient comfort and favored for the evaluation of bone invasion.
speech in the healing period. The majority of salivary gland malignancies are treated with
Local recurrence or regional metastases, although uncommon, surgical resection followed by any indicated adjuvant therapy.
is a major concern (see Discussion). Complications associated This is certainly the mainstay of treatment for the three malignant
with the rehabilitation and reconstruction of the defect can also salivary gland tumors this chapter focuses on. Even though the
have a significant impact on the patient’s quality of life. presentation of these malignant salivary gland carcinomas can be
similar, there is some variance in their management, which is
Discussion discussed later. Long-term follow-up is crucial to monitor for re-
currence. This is of particular relevance with respect to ACC be-
Malignancies of the salivary glands are relatively rare, making up cause it tends to have good 5- and 10-year survival rates but a poor
approximately 6% to 8% of all head and neck cancers, which 20-year survival rate because hematogenous spread to the lungs is
equates to 2000 to 2500 cases in the United States each year. As can almost inevitable with this disease process. Often distant lung
be seen from reviewing the evolution of the World Health Organi- metastasis can be present at diagnosis, but surgical resection of the
zation’s (WHO’s) classification of malignant salivary gland tumors, primary mass is generally recommended even in this scenario.
there is quite a significant number of tumors added with each itera-
tion. This has gained pace recently with advances in molecular biol- Mucoepidermoid Carcinoma
ogy. Regardless, mucoepidermoid carcinoma, ACC, and acinic cell
carcinoma remain mainstays and are among the most frequent Mucoepidermoid carcinoma arises from the glandular cells of the
malignant salivary gland carcinomas diagnosed. There is geograph- salivary glands and is characterized by the presence of three types
ical variability in which salivary gland malignancy is the most com- of cells: mucous, intermediate, and epidermoid cells. Mucoepi-
mon with ACC often quoted as being the most common in Euro- dermoid carcinoma is further classified into three subtypes based
pean countries but mucoepidermoid carcinoma typically being on the ratio of these cell types: low, intermediate, and high grade.
regarded as the most common in the United States. The presenta- Low-grade mucoepidermoid carcinoma is the most common sub-
tion of the salivary gland tumors being discussed in this chapter is type and is characterized by a low number of intermediate and
often similar and may include a swelling in the neck or face, pain epidermoid cells. High-grade mucoepidermoid carcinoma is char-
or numbness in the face, difficulty swallowing or speaking, and a acterized by a high number of intermediate and epidermoid cells.
change in voice. These cancers may also cause facial deformities, The majority of mucoepidermoid carcinomas occur in the major
difficulty breathing, and weight loss. Salivary gland tumors not only salivary glands and the parotid in particular. An unusual variant
affect the major salivary glands but can also affect all the upper of mucoepidermoid carcinoma is when it presents in an intraos-
aerodigestive tract, including the oral cavity and pharynx. seous location. This is thought to result from malignant transfor-
Salivary gland malignancies can affect both the major and mation of tissue within an odontogenic cyst. Molecular biology
minor salivary glands. Benign masses of the salivary glands are has shown that the majority of mucoepidermoid carcinomas have
more common; however, managing a salivary gland malignancy in MAML2 rearrangement. This finding is particularly useful when
the fashion of a benign lesion will likely lead to initial undertreat- the rare intraosseous mucoepidermoid carcinoma is encountered
ment, which will likely affect the patient’s prognosis. Therefore, because traditional histopathological analysis can find it difficult
when a mass of the salivary glands is noted, an appropriate to differentiate it from glandular odontogenic cysts. Clearly, the
workup is crucial. Of the utmost importance when a patient pres- management of these entities is different, and evaluation of
ents with a mass of the major salivary glands that is consistent MAML2 rearrangement has been shown to be very helpful in
with a neoplastic process, a fine-needle aspiration (FNA) is rec- these cases.
ommended. If the FNA is nondiagnostic or does not correlate Within pediatric salivary gland malignancies, mucoepider-
with clinical findings, either a repeat FNA or a core biopsy is moid carcinoma accounts for the majority, and the parotid is the
recommended. There is a theoretical risk that a core biopsy may most frequent site of occurrence. Most pediatric cases present in
result in seeding of malignant cells along the tract used to obtain the second decade of life; however, if it presents in the first decade,
the core biopsy, but practically, this has not been shown to be an it is more likely to be high grade and associated with a poorer
issue. An open biopsy of a neoplastic process of the major salivary prognosis. The etiopathogenesis of pediatric mucoepidermoid
glands is frowned upon. With regard to the minor salivary glands, carcinoma, like that in adults, is unknown. Epstein-Barr virus and
an open incisional biopsy is generally the preferred route of exposure to radiation are frequently suggested, and there is some

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 CHAPTER 74 Malignant Salivary Gland Tumors 381

weak evidence to support this but the exact etiology is currently subtype is characterized by cells arranged in tubes or cords, the
unknown. No prospective or randomized trials exist to help deter- solid subtype is characterized by a solid mass of cells without any
mine the best therapeutic strategy to adopt in the management of discernible glandular structures. ACC arises from inner ductal
pediatric mucoepidermoid carcinoma much less the rarer intra- epithelial and outer myoepithelial cells of the intercalated ducts.
oral variant. Therefore, data are limited to case series and indi- With respect to the cribriform and tubular varieties, both pro-
vidual case reports. genitor cell types tend to be present, but the solid variety tends to
Most agree that primary surgical management is the best strat- lose the myoepithelial cells, which appears to confer the solid
egy. Surgical resection of the primary mass is indicated for all variant with a more aggressive biology. Molecular biology has re-
grades of mucoepidermoid carcinoma. This entails a superficial vealed that ACC frequently has chromosome 6:9 translocation,
parotidectomy for those involving the superficial parotid with resulting in an MYB:NFIB gene fusion with overexpression of
facial nerve preservation. The management of the neck varies with MYB oncoprotein.
grade. For low-grade malignancies, surgical resection of the pri- The most common location of ACC is at the junction of the
mary is generally all that is performed. Most manage intermedi- hard and soft palate from a minor salivary gland. The parotid
ate-grade mucoepidermoid carcinomas the same as low-grade gland is the second most common location, although other major
ones. When the primary site is the submandibular gland, a lim- salivary glands may be involved (Fig. 74.5). Neural invasion is
ited level 1B neck dissection is generally performed for low- and common and can be seen even in early-stage tumors. This peri-
intermediate-grade mucoepidermoid carcinomas. If there is radio- neural invasion can result in metastasis to the central nervous
logically enlarged cervical lymph nodes in low- or intermediate- system. The prevailing attitude that regional metastatic disease to
grade tumors, then consideration can be given to FNA of these the cervical lymph nodes is rare has been challenged. Recent evi-
lymph nodes to determine if a neck dissection is merited. A neck dence suggests it may be close to 20%, which would be supportive
dissection is generally indicated in high-grade mucoepidermoid of neck dissection. Regional lymphadenopathy is an indicator of
carcinomas. High-grade tumors and perineural invasion are non- poor prognosis with ACC. Previously a conundrum existed that a
controllable factors that have been associated with recurrence of significant proportion of patients with ACC required adjuvant
mucoepidermoid carcinoma along with positive surgical resection radiation given its propensity for perineural invasion and the rela-
margins. There is some controversy with regard to the manage- tively high rate of close or positive margins. The current National
ment of mucoepidermoid carcinoma of the palate. Some authors Comprehensive Cancer Network guidelines recommend adjuvant
have advocated for resection of the soft tissue and the underlying radiation for all patients with ACC regardless of the absence of
bone regardless of the histologic grade or stage. On the other intermediate- or high-risk factors. This is because of the literature
hand, other authors have shown that less invasive treatment is has shown there is a significantly reduced risk of local recurrence
sufficient for low-grade tumors. Caccamese et al. managed low- with postoperative adjuvant radiation even in the absence of tra-
grade mucoepidermoid carcinoma with wide local excision and ditional features that would indicate adjuvant therapy. As a con-
stripping the periosteum off the palatal bone, which served as the tinuum of this, most institutions tend to avoid neck dissection
deep margin. The ability to remove low-grade mucoepidermoid unless there is strong evidence to suggest regional metastasis pre-
carcinoma of the palate without removing palatal bone without operatively. This is not a clear-cut issue and can generate a healthy
recurrence was emphasized in a larger study (Fig. 74.4). Both of discussion among tumor board members. Elective neck dissection
these studies advocating a less aggressive approach stated that if is generally recommended when the primary ACC is a T3 or T4,
there is radiologic evidence of bone erosion or invasion, palatal and it involves the major salivary glands in large part because a
bone should be removed. neck incision will already be required to treat such tumors. For
Most studies agree that adjuvant therapy is rarely indicated for tumors involving minor salivary glands and specifically the palate,
low-grade mucoepidermoid carcinoma. Future directions in the a partial maxillectomy is indicated. Some authors have advocated
treatment of low-grade mucoepidermoid carcinoma will probably for tracing the greater palatine nerve all the way up to the skull
be based on knowledge gained from molecular studies. A correla- base as part of the surgical resection. If the nerve is not amenable
tion between mucoepidermoid carcinoma prognosis and prolif- to surgical resection, coverage with radiation therapy all the way
eration markers PCNA and Ki-67 has been demonstrated. This to skull base is usually planned. Distant metastases with this en-
knowledge has yet to translate into a treatment algorithm, but as tity have traditionally treated with chemotherapeutic agents such
research continues, more directed therapy with less aggressive as cisplatin, cyclophosphamide, doxorubicin, and 5-fluorouracil.
surgery is likely to result. Adjuvant therapy for high-grade muco- Results have been poor. Efforts at more targeted therapy have
epidermoid carcinoma is directed by histopathologic findings af- been unpredictable to date.
ter surgical resection. Perineural invasion, regional lymph node Histopathologic diagnosis of perineural invasion is an unfavor-
involvement, high-grade tumors, positive margins, and extraglan- able prognostic finding. ACC has a relatively high rate of local
dular extension are generally considered indications for adjuvant recurrence even with widely negative surgical margins. Approxi-
radiation. mately 40% of patients have locoregional recurrence, and 60%
develop distant metastasis, predominantly to the lung, despite
Adenoid Cystic Carcinoma appropriate and what would be considered successful manage-
ment of the primary malignancy. Despite advances in surgical
Adenoid cystic carcinoma arises from the glandular cells of the methods and molecular biology, these have yet to pay dividends
salivary gland or other head and neck tissues. It is characterized by because ACC tends to be a slow and relentlessly invasive malig-
slow-growing, locally aggressive behavior and a relatively high rate nancy with a good 5-year survival rate but poor 20-year survival
of recurrence after treatment. ACC is further classified into three rate. Unfortunately, ACC tends to be resistant to immunotherapy
subtypes: cribriform, tubular, and solid. The cribriform subtype is because of its low tumor immunogenicity and lack of pro-
the most common and is characterized by glandlike structures grammed death–ligand 1 expression. The search for targeted
with holes (cribriform) in the tumor cells. Whereas the tubular therapy continues.

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382 S E C TI O N Oral Cancer

A B

C D

E
• Fig. 74.4 A, Biopsy-proven low-grade mucoepidermoid carcinoma of the right hard palate. B, Excised
specimen with orientation sutures. The lesion was excised with a 1-cm margin, taking the periosteum as
the deep margin. C, Preoperative computed tomography imaging did not demonstrate any bony erosion
of the hard palate. D, Wound allowed to heal by secondary intention. A temporary maxillary stent is worn
by the patient for the first 7 to 14 days to allow for patient comfort during the healing phase. E, Six months
after surgery, demonstrating healed palatal mucosa.

Acinic Cell Carcinoma cells, and the histopathologic diagnosis tends to be relatively
straightforward in these cases. When acinic cell carcinoma is com-
Acinic cell carcinoma is traditionally regarded as the third most posed of nonserous cells, histopathologic diagnosis is difficult
common salivary gland malignancy. Histopathological diagnosis even for experienced histopathologists. Molecular biology, like
of acinic cell carcinoma can be difficult. The WHO defines it as other salivary gland malignancies, is helping in this regard. A
“a malignant epithelial neoplasm of salivary glands which is char- significant proportion of previously diagnosed acinic cell carcino-
acterized by cytoplasmic zymogen secretory granules. Salivary mas when reviewed were reclassified as secretory carcinoma (pre-
ductal cells are also a component of this neoplasm.” It tends to viously classified as mammary analog secretory carcinoma)
present over a relatively wide age range of patients. Most acinic because of the finding of a rearrangement of ETV6 gene locus
cell carcinomas are seen to be composed of largely serous-like with a translocation t(12;15)(p13;q25), which is a fusion of the

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 CHAPTER 74 Malignant Salivary Gland Tumors 383

A B

C D
• Fig. 74.5 A, Axial cut computed tomography scan demonstrating a large biopsy-proven adenoid cystic
carcinoma involving the left floor of mouth, likely arising from the sublingual gland or other minor salivary
glands. B, Coronal cut demonstrating the left floor-of-mouth submandibular mass. C, Specimen, resected
via trans oral and transcervical approach with overlying adherent floor of mouth mucosa. D, Left floor-of-
mouth reconstruction with a radial forearm free flap.

ETV6 gene on chromosome 12 and the NTRK3 gene on chromo- adjuvant radiation therapy. Acinic cell carcinoma is considered to
some 15. One author found that most nonparotid acinic cell be chemoresistant because of its slow growth rate. The survival
carcinomas were incorrectly diagnosed when reviewed and ana- rate tends to be good, but long-term follow-up is required because
lyzed for the ETV6-NTRK3 translocation. late recurrences decades later can occur.
Epidemiologic data show acinic cell carcinoma occurs in the
parotid gland in the vast majority of cases. When acinic cell car- Conclusion
cinoma is found to involve the minor salivary glands, it tends not
to involve the palate, instead favoring involvement of the minor Salivary gland tumors are a diverse group of malignancies, and
salivary glands in the buccal mucosa and upper lip. Similar to given that they form a smaller proportion of head and neck malig-
histopathology, cytologic diagnosis of acinic cell carcinoma is ex- nancies compared with other carcinomas, randomized controlled
tremely difficult. The final diagnosis of acinic cell carcinoma is trials are lacking. As an entity, they have experienced some changes
usually made after it is resected. Histopathologically, acinar, inter- in nomenclature and management as techniques such as molecular
calated ductal, vacuolated, clear, microcystic, papillary-cystic, and biology have elucidated etiopathogenesis and the potential for new
follicular growth patterns have been described. These tend not to targeted therapies. With the exception of rare case reports of suc-
have any prognostic significance. In contradiction to this, facial cessful targeted therapy, it still remains elusive for the majority of
nerve involvement, positive surgical resection margins, greater salivary gland tumors. Surgery followed by any indicated adjuvant
than two mitoses per 10 high-power fields, tumor necrosis, peri- therapy continues to be the management of choice.
neural or vascular invasion, and spread beyond the frequently seen
tumor capsule are poor prognostic indicators (Fig. 74.6). Regional Acknowledgment
metastasis to the neck is generally regarded as uncommon and as
a result neck dissection is rarely indicated, but this is controver- The authors and publisher wish to acknowledge Dr. David Rallis
sial. The role of radiation therapy in the management of acinic cell and Dr. David C. Swiderski for their contribution on this topic to
carcinoma is not clearly defined, but by default, similar to other the previous edition.
salivary gland malignancies, patients with close or positive
margins, perineural invasion, evidence supporting lymph node ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
metastasis, and tumors with a high mitotic rate may benefit from complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
384 S E C TI O N Oral Cancer

A B

C D
• Fig. 74.6 A, Axial cut computed tomography scan demonstrating enhancing mass involving the right
superficial lobe of the parotid. B, Intraoperative photograph of superficial parotidectomy via a modified
Blair approach. C, Specimen of the superficial lobe of the parotid. D, Neck closure.

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 384.e1

Bibliography Eversole LR, Rovin S, Sabes WR: Mucoepidermoid carcinoma of minor

salivary glands: report of 17 cases with follow up, J Oral Surg 30:107-112,
1972.
Al-Zaher N, Obeid A, Al-Salam S, et al: Acinic cell carcinoma of the Fordice J, Kershaw C, El-Naggar A, et al: Adenoid cystic carcinoma of
salivary glands: a literature review, Hematol Oncol Stem Cell Ther the head and neck: predictors of morbidity and mortality, Arch Oto-
2:259-264, 2009. laryngol Head Neck Surg 125:149-152, 1999.
American Cancer Society: Key Statistics About Salivary Gland Cancer. Goode R, Auclair P, Ellis G: Mucoepidermoid carcinoma of the major
https://www.cancer.org/cancer/salivary-gland-cancer/about/what-is- salivary glands: clinical and histopathological analysis of 234 cases
key-statistics.html. (Accessed 2 January 2023). with evaluation and grading criteria, Cancer 82(7):1217-1224, 1997.
Amit M, Binenbaum Y, Sharma K, et al: Incidence of cervical lymph Grasl S, Janik S, Grasl MC, et al: Nodal metastases in acinic cell carci-
node metastasis and its association with outcomes in patients with noma of the parotid gland, J Clin Med 8(9):1315, 2019.
adenoid cystic carcinoma. An international collaborative study, Head Guzzo M, Andreola S, Sirizzotti G, et al: Mucoepidermoid carcinoma
Neck 37:1032-1037, 2015. of the salivary glands: clinicopathologic review of 108 patients treated
Beckhardt RN, Weber RS, Zane R, et al: Minor salivary gland tumors of at the National Cancer Institute of Milan, Ann Surg Oncol 9(7):
the palate: clinical and pathologic correlates of outcome, Laryngoscope 688-695, 2002.
105:1155-1160, 1995. Hicks, JA, Flaitz C: Mucoepidermoid carcinoma of the salivary glands in
Bishop JA, Yonescu R, Batista D, et al: Most nonparotid “acinic cell children and adolescents: assessment of proliferation markers, Oral
carcinomas” represent mammary analog secretory carcinomas, Am J Oncol 36:454-460, 2000.
Surg Pathol 37:1053-1057, 2013. Hosokawa Y, Shirato H, Kagei K, et al: Role of radiotherapy for muco-
Boahene DK, Olsen KD, Lewis JE, et al: Mucoepidermoid carcinoma of epidermoid carcinoma of the salivary gland, Oral Oncol 35:105-111,
the parotid gland: the Mayo Clinic experience, Arch Otolaryngol Head 1999.
Neck Surg 130(7):849-856, 2004. Kirschnick LB, Silveira FM, Schuch LF, et al: Clinicopathological analy-
Boliere C, Murphy J, Qaisi M, et al: Mammary analogue secretory carci- sis of oral and maxillofacial acinic cell carcinoma: a systematic review,
noma of the palate: case report and review of the literature, Case Rep J Oral Pathol Med 50:741-749, 2021.
Dent 2019:741630, 2019. Lee SK, Kwon MS, Lee YS, et al: Prognostic value of expression of
Bradley P, McClelland L, Mehta D: Pediatric salivary gland epithelial molecular markers in adenoid cystic cancer of the salivary glands
neoplasms, J Otorhinolaryngol Relat Spec 69:137-145, 2007. compared with lymph node metastasis: a retrospective study, World J
Bradley PJ: Adenoid cystic carcinoma evaluation and management: prog- Surg Onc 10:266-275, 2012.
ress with optimism! Curr Opin Otolaryngol Head Neck Surg 25:147- Li Quan, Zhang Xin-Rui, Liu Xue-Kui, et al: Long-term treatment out-
153, 2017. come of minor salivary gland carcinoma of the hard palate, Oral
Brandwein MS, Ivanov K, Wallace DI, et al: Mucoepidermoid carci- Oncol 48:456-462, 2012.
noma: a clinicopathologic study of 80 patients with special reference Lorini L, Ardighieri L, Bozzola A, et al: Prognosis and management of
to histological grading, Am J Surg Pathol 25(7):835-845, 2001. recurrent and/or metastatic head and neck adenoid cystic carcinoma,
Caccamese JF Jr, Ord RA: Pediatric mucoepidermoid carcinoma of the Oral Oncol 115:105213, 2021.
palate, Int J Oral Maxillofac Surg 31:136-139, 2002. Merna C, Kita A, Wester J, et al: Intraosseous mucoepidermoid carci-
Carlson ER, Schimmele SR: The management of minor salivary gland noma: outcome review, Laryngoscope 128:1083-1092, 2018.
tumors of the oral cavity, Atlas Oral Maxillofacial Surg Clin North Am Mullins JE, Ogle O, Cottrell DA, et al: Painless mass in the parotid re-
6(1):75-98, 1998. gion, J Oral Maxillofac Surg 58(3):316-319, 2000.
Cavaliere M, De Luca P, Scarpa A, et al: Acinic cell carcinoma of the Nightingale J: Adenoid cystic carcinoma: a review of clinical features,
parotid gland: from pathogenesis to management: a literature review, treatment targets and advances in improving the immune response to
Eur Arch Otorhinolaryngol 277:2673-2679, 2020. monoclonal antibody therapy, Biochim Biophys Acta Rev Cancer 1875:
Choi SH, Yang AJ, Yoon SO, et al. Role of postoperative radiotherapy in 188523, 2021.
resected adenoid cystic carcinoma of the head and neck, Radiat Oncol Olsen KD, Devine KD, Weiland LH: Mucoepidermoid carcinoma of the
17(1):197, 2022. oral cavity, Arch Otolaryngol Head Neck Surg 89:783-791, 1981.
Cipriani NA, Lusardi JJ, McElherne J, et al: Mucoepidermoid carci- Ord R, Salama A: Is it necessary to resect bone for low-grade mucoepi-
noma: a comparison of histologic grading systems and relationship to dermoid carcinoma of the palate? Br J Oral Maxillofac Surg 50(8):
MAML2 rearrangement and prognosis, Am J Surg Pathol 43:885-897, 712-714, 2012.
2019. Ord RA, Carlson ER: Pediatric salivary gland malignancies, Oral Maxil-
Coca-Pelaz A, Rodrigo JP, Bradley PJ, et al: Adenoid cystic carcinoma of lofac Surg Clin N Am 28:83-89, 2016.
the head and neck—an update, Oral Oncol 51:652-661, 2015. Plambeck K, Friedrich RE, Schmelzle R: Mucoepidermoid carcinoma of
Conley J, Tinsley PP Jr: Treatment and prognosis of mucoepidermoid salivary gland origin: classification, clinical-pathological correlation,
carcinoma in the pediatric age group, Arch Otolaryngol 111:32-324, treatment results and long-term follow-up in 55 patients, J Cranio-
1985. maxillofac Surg 24:133-139, 1996.
Devaraju R, Gantala R, Aitha H, et al: Mucoepidermoid carcinoma, BMJ Pogrel MA: The management of salivary gland tumors of the palate,
Case Rep 2014:bcr-2013-202776, 2014. J Oral Maxillofac Surg 52:454-459, 1994.
Dillon PM, Chakraborty S, Moskaluk CA, et al: Adenoid cystic carci- Rapidis A, Givalos N, Gakiopoulou H, et al: Mucoepidermoid carci-
noma: a review of recent advances, molecular targets, and clinical noma of the salivary glands. Review of the literature and clinico-
trials, Head Neck 38:620-627, 2016. pathological analysis of 18 patients, Oral Oncol 43:130-136, 2007.
Ellington CL, Goodman M, Kono SA, et al: Adenoid cystic carcinoma of Rapidis AD, Givolas N, Gakiopoulou H, et al: Adenoid cystic carcinoma
the head and neck: incidence and survival trends based on 1973-2007 of the head and neck: clinicopathological analysis of 23 patients and
surveillance, epidemiology, and end results data, Cancer 118(18): review of the literature, Oral Oncol 41:428-435, 2005.
4444-4451, 2012. Ryan JT, El-Naggar AK, Huh W, et al: Primacy of surgery in the manage-
El-Naggar AK, Chan JKC, Takata T, et al: The fourth edition of the head ment of mucoepidermoid carcinoma in children, Head Neck 33:
and neck World Health Organization blue book: editors’ perspectives, 1769-1773, 2011.
Hum Pathol 66:10-12, 2017.

t.me/Dr_Mouayyad_AlbtousH
384.e2

Sama S, Komiya T, Guddati AK: Advances in the treatment of mucoepi- Sultan I, Rodriguez-Galindo C, Al-Sharabati S: Salivary gland carcino-
dermoid carcinoma, World J Oncol 13:1-7, 2022. mas in children and adolescents: a population based study with com-
Scherl C, Kato MG, Erkul E, et al: Outcomes and prognostic factors for parison to adult cases, Head Neck 33:1476-1481, 2011.
parotid acinic cell carcinoma: a National Cancer Database study of Vander Poorten V, Triantafyllou A, Thompson LD, et al: Salivary acinic
2362 cases, Oral Oncol 82:53-60, 2018. cell carcinoma: reappraisal and update, Eur Arch Otorhinolaryngol
Schramm VL, Imola MJ: Management of nasopharyngeal salivary gland 273:3511-3531, 2016.
malignancy, Laryngoscope 111(9):1533-1544, 2001.

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75
Neck Dissections
S C O T T T. C L A I B O R N E a n d D E E PAK K A D E M A N I

CC nodes feel firm but not fixed. (Fixed nodes could be a sign of ex-
tracapsular spread.)
A 60-year-old White male presents to your office. He states, “I Nasopharyngoscopy reveals no abnormal tissues in the poste-
have been told I have a squamous cell carcinoma on my tongue.” rior oropharynx, subglottic or supraglottic region, or nasophar-
ynx. (Nasopharyngoscopy should be performed as part of the
HPI head and neck evaluation of tongue SCC.)

The patient noticed a spot on his tongue about a month ago. He Imaging
reports that the lesion is painful, with radiating pain to the ear
(this is a typical symptom of tongue carcinoma). He was initially The initial imaging modality for evaluation of a patient with SCC
seen by his general dentist and then referred to an oral and maxil- is a panoramic radiograph. This is a useful screening tool to evalu-
lofacial surgeon for a biopsy. The biopsy results described a squa- ate for bony infiltration associated with the tumor. It also provides
mous cell carcinoma (SCC). valuable information regarding the long-term prognosis of the
remaining dentition because some patients may require extraction
PMHX/PDHX/Medications/Allergies/FH of carious or periodontally involved teeth before radiotherapy.
A computed tomography (CT) scan of the head and neck is
The patient has a 45-year history of tobacco use. He also reports the commonly used imaging study of choice to delineate the le-
consumption of alcohol. (An association between tobacco and sion and assess the neck for cervical lymphadenopathy (nodes
alcohol consumption and the development of SCC has been well .1.5 cm, with central necrosis, an ovoid shape, and fat stranding
established.) The patient does not report any other significant are indicative of nodal metastasis). Additional tests, such as mag-
medical problems. netic resonance imaging and ultrasonography, can be used to as-
sess the status of the cervical nodes.
Examination Positron emission tomography (PET) scans are indicated for
the evaluation of distant metastasis. This technology uses a 18F-
The examination of the patient with a diagnosis of SCC should fluorodeoxyglucose (FDG) marker to examine sites of increased
include a complete head and neck examination. A neck examina- glucose uptake that are seen with metabolically active cancer cells.
tion is very important to evaluate for neck metastasis. Studies have In addition to helping to rule out distant disease, PET aids in
shown that on initial examination of a known primary tumor, clinical staging of the cancer. Clinical staging is helpful because a
there is a 3% to 7% incidence of a synchronous tumor in the up- treatment plan can be worked up for the patient and adjuvant
per aerodigestive tract, especially in smokers. A nasopharyngo- modalities recommended.
scopic examination is indicated to evaluate the subepiglottic and The current patient’s axial and coronal CT scans of the head
supraepiglottic regions, posterior oropharynx, and nasopharynx. and neck, with and without contrast, revealed a 4-cm, well-
General. The patient is a well-developed and well-nourished circumscribed lesion of the left lateral border of the tongue mus-
male who appears his stated age, with no signs of cachexia. culature. Some adenopathy was noted in the submental region
Maxillofacial. The left tongue has a tumor, measuring bilaterally and in the left submandibular region. (Usually nodes
approximately 4 cm 3 2 cm, that feels endophytic and ulcerated. are oval in shape; however, in patients with cancer who have
On palpation, it seems to have possibly crossed the midline lymph node involvement, the nodes are more circular. Nodes
(Fig. 75.1). The rest of the oral cavity is free of lesions. The patient .1 cm in diameter should raise suspicion of metastatic disease.
also has multiple necrotic teeth that are grossly carious. (Some Central necrosis is another factor that correlates with a poorer
patients may also complain of ear pain if the lesions are deep and outcome.) The PET scan performed with 18F-FDG showed
involve the lingual nerve. When ear pain is present, perineural a hypermetabolic area in the left tongue, coinciding with the
invasion cannot be ruled out until a final pathology evaluation.) clinical lesion, with a standard uptake value (SUV) of 17. (Some
Examination of the rest of the oral cavity, including the buccal studies suggest a correlation between a higher SUV and more ag-
mucosa, hard and soft palate, parotid, oropharynx, and nasophar- gressive tumors.) Also noted were a single right level IB node, a
ynx, reveals no other abnormalities. Adenopathy is palpable in the single left level IB node, several left level IIA nodes, and a left level
submental and the left submandibular regions of the neck. The III node, all demonstrating associated FDG uptake. The largest

385
t.me/Dr_Mouayyad_AlbtousH
386 S E C TI O N Oral Cancer

• Fig. 75.1 Clinical view showing a squamous cell carcinoma of the left
lateral tongue and multiple necrotic teeth.

node was a 1-cm 3 1-cm level IIA lymph node demonstrating a

maximum SUV of 5.4 (Fig. 75.2). An SUV of greater than 3 has
been shown to correlate with the increased metabolic activity as-
sociated with some pathologic conditions; however, clinical cor- A
relation must be completed.
In the current patient, the panoramic film showed that the
condyles were seated on the fossa, with no bony invasion. In ad-
dition, several necrotic teeth with considerable periapical pathol-
ogy were noted on the film.

Labs
A complete metabolic panel (CMP), complete blood count
(CBC), and coagulation profile (prothrombin time, partial
thromboplastin time, and international normalized ratio) are
mandatory laboratory studies in the patients with cancer because
of metabolic, electrolyte, and nutritional derangements that may
accompany malignant disease. Liver function tests are obtained as
part of the CMP and are important screening tests for liver me-
tastasis and alcoholism. Other laboratory studies can be ordered
based on the patient’s medical history. B
In the current patient, the CBC, CMP, liver function test re-
sults, and coagulation studies were within normal limits. • Fig. 75.2 A, Full body positron emission tomography (PET) scan show-
ing some uptake in the nodes in the left neck in levels II and III. B, Head
PET scan showing the primary tumor and an associated positive lymph
Assessment node in level II.

T2N2cM0 (tumor .2 cm, with multiple bilateral nodes with no depending on the degree of infiltration. However, when the can-
distant metastasis), stage IV, oral SCC of the left lateral border of the cellous portion of the mandible is invaded, segmental resection is
tongue with a Broder’s histologic grade of III. required to maintain oncologic safety.
In the current case, several approaches were possible, including
Treatment a transoral approach, a pull-through approach, a lip split man-
dibulotomy, and transoral robotic surgery, to obtain a cuff of
The treatment of patients with SCC is site specific; surgical abla- normal tissue for the posterior tongue base margin. A transoral
tion with minimum 1- to 1.5-cm margins is the main modality of approach was used to excise the primary tumor. A common pro-
treatment. Most oral cavity tumors are approached intraorally; cedure that accompanies the removal of the tumor is neck dissec-
however, some tumors may need to be accessed extraorally via a tion, or removal of the fibrofatty contents of the neck; this is done
transfacial approach. When the tumor is located in the mandible, for treatment of cervical lymphatic metastases and for complete
the inferior border can be preserved (marginal mandibulectomy), staging of the cancerous process. In the current patient, selective

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 CHAPTER 75 Neck Dissections 387

neck dissection was performed on the right (levels I–III) and left Subplatysmal flaps were then raised to the level of the inferior
(levels I–V) sides. Bilateral neck dissection was performed because border of the mandible superiorly and the omohyoid muscle infe-
the tumor had crossed the midline and because the results of the riorly (Fig. 75.4). (This inferiorly based flap can be extended to
PET scan were positive bilaterally. Vessel preservation was per- just above the clavicle if further dissection to level IV is required.
formed for a vascular free flap anastomosis (radial free forearm Care should be exercised to preserve the greater auricular nerve.
flap) to the facial artery and to the internal jugular vein. The external jugular vein should be skeletonized, ligated, and
The neck dissection procedure can be completed in many dif- divided.) The superficial layer of the deep cervical fascia was dis-
ferent ways. For the current patient, the following technique was sected approximately 1.5 cm below the inferior border of the
used, because it is the preferred method at our institution. mandible to protect the marginal branch of the facial nerve. The
capsule of the submandibular gland was dissected, and a subcap-
Selective Neck Dissection (Levels I–III) sular dissection was initiated superiorly to the inferior border of
the mandible. Bovie electrocauterization was used to dissect the
After the patient had been prepped and draped, a surgical marker fascia to the anterior belly of the digastric muscle in the submen-
was used to delineate the incision site. Several variations of neck tal triangle; this was continued posteriorly to the submandibular
dissection incisions have been used historically (Fig. 75.3). In this gland. (The lateral limit of the dissection is the midline diatheses
case, a straight-line neck incision was used, with the incision situ- or the contralateral anterior belly of the digastric muscle.) The
ated in a resting skin tension line midway between the angle of submandibular gland was then retracted inferiorly into the neck
the mandible and clavicle, extending just slightly anterior to the and circumferentially dissected along the contents of level I. The
auricle to the midline. (Any skin crease in the neck can be used, common facial vein and artery were identified and ligated as they
as long as it is 2 cm below the inferior border of the mandible traversed the posterior aspects of the gland. Anteriorly, they were
to avoid damage to the marginal mandibular branch of cranial again identified and ligated. (They are typically encountered on
nerve [CN] VII.) A #10 knife blade was used to create an incision the medial side of the submandibular gland, thereby mobilizing
through the skin and subcutaneous tissue to visualize the pla- the gland.) An Army Navy retractor was placed beneath the my-
tysma; this was sharply dissected with a Bovie electrocautery. lohyoid muscle to retract it superiorly. (The lingual nerve typically

A B C

D E F

G H
• Fig. 75.3 Variations of neck dissection incisions that have been used historically. A, Latyshevsky and
Freund incision. B, Freund incision. C, Crile incision. D, Martin incision. E, Babcock and Conley incision.
F, MacFee incision. G, Incision used for unilateral supraomohyoid neck dissection. H, Incision used for
bilateral supraomohyoid neck dissection. (From Rothrock JC: Alexander’s care of the patient in surgery,
ed 14, St. Louis, 2011, Mosby.)

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388 S E C TI O N Oral Cancer

• Fig. 75.4 Clinical view showing the superior and inferior subplatysmal
flaps. • Fig. 75.5 Clinical view showing the neck after removal of all the fibrofatty
tissues from levels I through III.

is visualized with the parasympathetic rami to the submandibular

gland. The rami are transected with care to protect the lingual antibiotic ointment is applied. Extubation should be performed
nerve.) The submandibular duct was then identified, skeletonized, with minimal agitation while pressure is held to the surgical site
and divided. (The entire contents of level I should be pedicled to prevent the formation of a postoperative hematoma.
inferiorly on the digastric muscle. The fascia overlying the anterior
border of the sternocleidomastoid (SCM) superiorly from the Complications
level of the digastric muscle inferiorly to the omohyoid muscle is
then separated from the muscle with Bovie electrocauterization.) Complications of neck dissection are categorized as intraoperative,
When the inferior surface of the SCM was dissected, the spinal postoperative (within 1 month), and long term (after 1 month).
accessory nerve was identified approximately 1 cm above Erb’s
point and skeletonized. (When a clearance of level IIb is desired, Intraoperative Complications
the fascia above the CN XI is dissected deep to the level of the
levator scapulae and splenius capitis. This fascia packet is then The main intraoperative concerns associated with oncologic abla-
brought inferiorly beneath the nerve. The cervical roots form the tive and reconstructive surgery include the control of hemorrhage
posterior limit of the dissection, and fascia should be removed and anesthetic complications. When simultaneous neck dissec-
superficial to the nerve rootlets. Dissection deeper than the cervi- tion is performed, additional possible complications include
cal roots should be avoided to prevent injury to the transverse nerve palsies (facial, lingual, spinal accessory nerves, and hypo-
cervical vessels and preserve the prevertebral fascia, which overlies glossal nerves); vascular injury to the carotid artery or internal
the phrenic nerve and brachial plexus.) The fascia over the carotid jugular vein; and, rarely, pneumothorax, air embolism, and for-
sheath was then dissected over. (After the white roll is identified mation of a chylous fistula.
on the anterior border of the internal jugular vein, a #15 blade can
be used to skeletonize the fascia from the vein sharply.) The Postoperative Complications
branches of the internal jugular vein were identified on the ante-
rior border and were skeletonized, ligated, and divided. (After this Postoperative complications include wound infection, hematoma,
has been done, the fascia from the jugular sheath is advanced su- skin necrosis, orocutaneous fistula, poor speech, and swallowing
perficially from the posterior belly of the digastric muscle and the dysfunction.
omohyoid muscle inferiorly to the level of the level I dissection,
which is pedicled on the digastric muscle. As the dissection con- Long-Term Complications
tinues, the anterior jugular veins are identified and ligated. The
specimens can now be removed from the patient and orientated The gravest long-term complications are recurrence of the pri-
by level.) Fig. 75.5 shows the neck after removal of the fibrofatty mary tumor and death (85% of recurrences occur in the first 3
tissues from levels I through III. years). Other complications include lingual nerve hypoesthesia
After the surgical field has been rendered hemostatic, the Val- and duct obstruction. Dysphagia, xerostomia, mucositis, and the
salva maneuver can be performed to ensure that there is no evi- risk of osteoradionecrosis are associated with radiation therapy.
dence of chyle leakage or pneumothorax. A flat #10 Blake drain The most common causes of death in patients with oral cancer are
is placed and secured. Closure is then performed with 3-0 Vicryl related to locoregional disease, distant metastasis, or cardiopulmo-
suture for approximation of the platysma muscle. Skin closure nary failure. Metastases of SCC tend to involve the lung, bones,
can be completed with either 5-0 Prolene sutures or staples, and liver, and brain.

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 75 Neck Dissections 389

Discussion with gross extracapsular spread and infiltration of the spinal acces-
sory nerve, SCM muscle, or internal jugular vein.
Neck dissection was originally based on Halstead’s principles of en
bloc removal of lymph nodes in the neck for the management of
patients with head and neck tumors. The term neck dissection has
Modified Radical Neck Dissection
evolved to encompass several different operations that may be This procedure involves the removal of lymph nodes from levels I
selected based on the nature of the disease. Neck dissection was through V but requires the preservation of one or more of the non-
first described in the late 19th century by von Langenbeck, Bill- lymphatic structures that are included in a radical neck dissection
roth, von Volkmann, and Kocher, who developed and reported (e.g., spinal accessory nerve, internal jugular vein, or SCM muscle).
the early cases of different types of neck dissection. The first report
of a neck dissection published in the literature was by Crile in
1906, and several modifications were subsequently made.
Selective Neck Dissection
The neck is divided into anatomic regions for purposes of neck This is an umbrella term encompassing several procedures in
dissection. The system most widely used today was adopted at the which neck nodes of certain (“selected”) levels are removed and
Memorial Sloan-Kettering Cancer Center. Researchers at that other areas are preserved.
institution have defined seven regions, denoted as levels I through
VII (Fig. 75.6 and Box 75.1).
Several types of neck dissections have been described in the
Supraomohyoid Neck Dissection
literature. This is the selective removal of levels I through III. Its main indica-
tion is for the N0 neck in cases of oral cavity SCC with a 20% or
Radical Neck Dissection greater chance of occult neck disease. The guiding parameters in-
clude an aggressive, high-grade tumor (characterized histopatho-
This is the standard procedure for the removal of the entire cervi- logically); invasion of greater than 3 mm (if discussing oral SCC);
cal lymphatic chain from the unilateral neck, encompassing levels and perineural invasion. The procedure is performed on the ipsi-
I through V, the spinal accessory nerve, the internal jugular vein, lateral side from the primary tumor, except in the case of primary
and the SCM muscle. Indications for this surgery include ad- tumors arising from midline structures such as the floor of the
vanced neck disease with multiple-level positive lymph nodes mouth, because such tumors are known to metastasize bilaterally.

Midline

Mandible

Anterior belly of the

digastric muscle
IB
Posterior belly of the
IIB IA digastric muscle

IIA Sternocleidomastoid
muscle (cut)
VI
Hyoid bone

Thyroid cartilage
III
Internal jugular vein

Cricoid cartilage

VA
Trapezius muscle

IV Omohyoid
VB

Clavicle

VII
Sternocleidomastoid
muscle (cut)
• Fig. 75.6 The levels of the neck for oncologic surgery.

t.me/Dr_Mouayyad_AlbtousH
390 S E C TI O N Oral Cancer

• BOX 75.1 Seven Levels of the Neck

• Level I: submental and submandibular. Contains the submental and sub- are deep to the sternal head of the SCM are categorized as IVa, and those
mandibular triangles, which are bounded by the posterior belly of the di- deep to the clavicular are categorized as IVb.
gastric muscle, the midline, the body of the mandible superiorly, and the • Level V: posterior triangle. Contains the lymph nodes in the posterior tri-
hyoid bone inferiorly. Level I can be further subdivided into Ia (submental angle bounded by the anterior border of the trapezius muscle posteriorly,
triangle) and Ib (submandibular triangle). the posterior border of the SCM muscle anteriorly, and the clavicle inferiorly.
• Level II: upper jugular. Contains the upper jugular lymph nodes and This area may be further classified into the upper, middle, and lower levels,
extends from the skull base superiorly to the hyoid bone inferiorly. The corresponding to the superior and inferior planes that define levels II, III,
anterior landmarks are the midline strap muscles; posteriorly, this level is and IV.
bounded by the anterior border of the trapezius muscle. The spinal acces- • Level VI: prelaryngeal (delphian), pretracheal, and paratracheal. Con-
sory nerve (XI) travels obliquely across this area and can be used to subdi- tains the lymph nodes of the anterior central compartment from the hyoid
vide this area into IIa (anteriorly) and IIb (posteriorly). bone superiorly to the suprasternal notch inferiorly. On each side, the lateral
• Level III: midjugular. Contains the middle jugular lymph nodes from the boundary is formed by the medial border of the carotid sheath.
hyoid bone superiorly to the level of the lower border of the cricoid carti- • Level VII: upper mediastinal. Contains the lymph nodes inferior to the
lage inferiorly. suprasternal notch in the superior mediastinum.
• Level IV: lower jugular. Contains the lower jugular lymph nodes from the
SCM, Sternocleidomastoid.
level of the cricoid cartilage superiorly to the clavicle inferiorly. Nodes that

Anterior Compartment Neck Dissection Extended Neck Dissection

This is the selective removal of level VI nodes. The primary indica- This procedure includes removal of structures not routinely in-
tions for this procedure are primary tumors of the thyroid gland, volved with radical neck dissection. Such structures can include
hypopharynx, cervical trachea, cervical esophagus, and subglottic retropharyngeal lymph nodes and the hypoglossal nerve, prever-
larynx. tebral musculature, or carotid artery. This surgery is indicated for
advanced neck disease involving difficulty obtaining negative
Posterolateral Neck Dissection margins.

This is the removal of lymph nodes II through V. The procedure ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
is indicated for scalp and auricular tumors. complete set of bibliography.

Lateral Neck Dissection

This is the selective removal of levels II through IV. The main
indication for this surgery is primary cancer of the oropharynx,
hypopharynx, and larynx.

t.me/Dr_Mouayyad_AlbtousH
 390.e1

Bibliography Martin H, Del Valle B, Ehrlich H, et al: Neck dissection, Cancer

4(3):441-499, 1951.
Medina JE: A rational classification of neck dissections, Otolaryngol Head
Crile G: Excision of cancer of the head and neck, with special reference Neck Surg 100:169-176, 1989.
to the plan of dissection based on 132 operations, JAMA 47:1780- Rinaldo A, Ferlito A, Silver CE: Early history of neck dissection, Eur Arch
1785, 1906. Otorhinolaryngol 265(12):1535-1538, 2008.
Gavilan J, Gavilan C, Herranz J: Functional neck dissection: three de- Shah JP: Patterns of lymph node metastases from squamous carcinomas
cades of controversy, Ann Otol Rhinol Laryngol 101(4):339-341, of the upper aerodigestive tract, Am J Surg 160(4):405-409, 1990.
1992. Smith GI, O’Brien CJ, Clark J, et al: Management of the neck in patients
Kerawala CP, Heliotos M: Prevention of complications in neck dissec- with T1 and T2 cancer in the mouth, Br J Oral Maxillofac Surg
tion, Head Neck Oncol 1:35, 2009. 42:494-500, 2004.
Lindberg R: Distribution of cervical lymph node metastases from squa- Wooglar JA: Histological distribution of cervical lymph node metastases
mous cell carcinoma of the upper respiratory and digestive tracts, from intraoral/oropharyngeal squamous cell carcinomas, Br J Oral
Cancer 29:1446-1449, 1972. Maxillae Surg 37:175-180, 1999.

t.me/Dr_Mouayyad_AlbtousH
76
Posterior Mandibular Augmentation
W IL L I A M S T U ART M c K E NZ I E a n d PATR I C K J . LOU IS

CC Imaging
A 69-year-old White male presents for evaluation for dental im- Panoramic radiograph reveals no pathologic findings of the si-
plants. He states, “I am interested in getting implants.” nuses, maxilla, temporomandibular joints, or mandible. There is
pneumatization of bilateral maxillary sinuses and generalized
HPI periodontal disease with periapical radiolucency at teeth #18,
#28, and #31.
The patient was referred by his general dentist for extraction of
periodontally involved teeth and evaluation for implant place- Labs
ment. He reports that he has difficulty chewing his food because
of discomfort and mobility of several of his posterior teeth. No labs are indicated at this time.

PMHX/PSHX/Medications/Allergies/SH/FH Assessment
The patient reports hypercholesterolemia, prostatic hypertrophy, White male, 69 years old, with a history of hypercholesterolemia,
gastroesophageal reflux disease (GERD), chronic neck pain, and prostatic hypertrophy, GERD, chronic neck pain, and chronic rhinitis
chronic rhinitis and sinusitis. His current medications include and sinusitis presents for an evaluation for dental implant placement
aspirin 81 mg, fenofibrate, alfuzosin, and omeprazole. The past after extraction of periodontally involved teeth. The physical examina-
surgical history includes a hernia repair. The patient reports aller- tion reveals vertical insufficiency of the right mandibular and bilat-
gies to tramadol and hydrocodone. He also reports a history of eral maxillary posterior alveolar ridges in addition to a horizontal
cigarette smoking but quit 10 years ago. He denies alcohol and alveolar deficiency of the right mandibular posterior alveolar ridge
illicit drug use. The family history is negative for heart disease, (Fig. 76.1).
diabetes, and head and neck malignancy.
Treatment
Examination
Alveolar deficiencies of the posterior mandible present unique
General. The patient is a well-nourished, well-developed 69-year- surgical challenges. Defects must be accurately assessed for the
old White male in no apparent distress. horizontal and vertical deficiencies of bone and the amount of
Vital signs. Blood pressure is 156/87 mm Hg, heart rate is keratinized tissue available to support the final prosthesis. A host
69 bpm, respiratory rate is 16 breaths per minute, and tempera- of reconstructive techniques and materials must be considered
ture is 37°C. and the most appropriate method selected to maximize the indi-
Maxillofacial. Normocephalic. The skin is dry and intact, pu- vidual patient’s outcome (Fig. 76.2). The success of endosteal
pils equal, round, and reactive to light and accommodation. There implant restorations and prostheses has made augmentation of
is no scleral icterus. Visual acuity is grossly intact. External audi- the posterior mandible a necessary skill for oral and maxillofacial
tory canals clear bilaterally. Tympanic membranes are intact, and surgeons. The use of titanium mesh, autogenous bone, allogeneic
the nares are patent. Cranial nerves II through XII are grossly in- or xenogeneic bone, and inlay bone grafting is discussed later.
tact bilaterally. The neck is supple and without lymphadenopathy.
Intraoral. The mucosa is moist and pink. No ulcers, masses, Horizontal Defects
or discolorations of the oral cavity are noted. Teeth #3, #11
through #15, #19, #20, and #30 are absent. Generalized peri- A horizontal defect is defined as an inadequate buccolingual di-
odontal disease is noted with root exposure on teeth #2, #4, #18, mension of bone with an adequate superoinferior dimension.
#21, #28, and #30. A buccal horizontal defect is present at teeth Horizontal defects most commonly occur on the facial aspect of
#19, #20, and #30. the mandible. Generally, implants 5 mm in diameter are placed in

393
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394 S E C TI O N Reconstructive Oral and Maxillofacial Surgery

A B
• Fig. 76.1 A, Initial panoramic radiograph showing generalized periodontal disease and insufficient height
of bilateral maxillary and right mandibular posterior alveolar ridges for implant placement. B, Right poste-
rior mandible showing severe periodontal disease and buccal horizontal defects at the posterior area.

the molar region; this requires 7 to 8 mm of horizontal bone to the graft. Multiple sites of decortication are created on the defect
ensure 1 to 1.5 mm of bone buccal and lingual to the implant. site with a small round bur to promote neovascularization of the
graft. The graft is secured with one or two resorbable or titanium
Block Grafts screws. Particulate bone is packed into any gaps, and the site is
covered with a resorbable or nonresorbable membrane. Tension-
The autogenous block graft has been widely used for horizontal free closure is obtained using a periosteal releasing incision if
defects. The harvest site of the cortical bone depends largely necessary.
on the length of bone required. For smaller defects, harvest from
the mandibular symphysis or mandibular ramus allows for easy Particulate Bone
access with low long-term morbidity. However, temporary V3
paresthesia has been reported in 10% to 50% of symphysis grafts Particulate bone graft material is available from a wide array of
and 0 to 5% of ramus grafts. For larger defects, distant harvest sources, including autografts (from the patient), allografts (from a
sites of bone are necessary. The calvarial graft, taken from the pari- human donor), xenografts (from an animal donor), and alloplas-
etal bone, provides dense cortical bone that is resistant to resorp- tic material (synthetic material). Autogenous particulate bone
tion. Harvesting a split-thickness graft from this region provides an may be harvested from intraoral sites, including cortical shaving
approximately 3-mm-thick segment of bone, and the harvest site from the symphysis, ramus, or zygoma, and cancellous bone can
has few complications. The ilium may also be used; however, the be harvested from the ilium or tibia. Autogenous bone is often
cortical bone is thinner and less resistant to resorption because of combined with banked particulate bone; this increases the volume
the endochondral origin of the ilium compared with the intra- of graft material while maintaining the osteogenic and osteoin-
membranous origin of the parietal bone. However, a large amount ductive properties of the autogenous bone. The choice of graft
of bone may be harvested from the iliac crest. The main complica- material depends on the amount of particulate bone needed, os-
tions of iliac crest bone grafts include gait disturbances, paresthe- teoinductive versus osteoconductive properties, and the desires of
sia, hematoma or seroma, and fracture of the hip. the patient. Whether the graft is mineralized or demineralized
The use of block allografts has been presented in case series. determines the type of membrane required for graft stabilization.
Nissen and colleagues placed 29 cancellous block allografts in 21 In general, mineralized particulate bone is able to better withstand
patients with posterior mandibular atrophy; the graft failure rate the forces exerted on the surgical site during healing, requiring
was 20.7%, and the implant survival rate in the remaining grafts only a nonrigid membrane at the time of graft placement. Demin-
was 95.2% at 37-month follow-up. However, long-term out- eralized bone, however, requires a rigid membrane during the
comes for allogeneic block grafts from prospective, randomized healing phase. Titanium mesh is well suited to protecting demin-
clinical trials are lacking. A systematic review by Waasdorp and eralized bone and can tolerate exposure to the oral cavity without
Reynolds found only nine articles that met inclusion criteria, and a significant rate of graft failure. The titanium mesh is contoured
eight of the articles were case reports or case series. The authors and adapted to the alveolar ridge and secured with titanium
concluded that although the case reports demonstrated potential screws.
for allogeneic block grafts for alveolar ridge augmentation, there
is insufficient evidence to establish treatment efficacy with regard Procedure
to graft stability and long-term implant survival. A crestal or vestibular incision is used to expose the defect.
Decortication of the defect is performed using a small round
Procedure bur. The particulate graft is placed. If a nonrigid membrane
The defect site is exposed using a crestal incision. The defect is is used, the edges are trimmed and tucked underneath the
then measured for the size of the graft needed. The appropriate- flaps. If a rigid membrane is used, the membrane is contoured,
sized block graft is harvested from the donor site and is contoured packed with particulate bone, and then secured with screws to
to approximate the defect. The facial surface of the defect site is prevent movement. Tension-free closure is obtained using a
also contoured to allow for maximum surface area contact with periosteal releasing incision if necessary. The vestibular incision

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 CHAPTER 76 Posterior Mandibular Augmentation 395

A B

C D L

E
• Fig. 76.2 A, Panoramic radiograph showing titanium mesh placement for posterior ridge augmentation.
A mixture of autogenous bone from a right mandibular torus, hydroxyapatite, and platelet-rich plasma
was used under the mesh. B, Titanium mesh after 6 months of healing, with pseudomembrane intact.
C, Implant placement at teeth #28, #29, and #30 after titanium mesh removal. D, Final panoramic radio-
graph showing right mandibular implants with restoration. The patient also underwent bilateral maxillary
sinus lifts, right maxillary ridge split osteotomy, and implant placement at teeth #3, #5, #11, #12, #14, #18,
and #20. E, Postoperative photograph showing restored posterior mandibular implants in function 8 years
after placement.

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396 S E C TI O N Reconstructive Oral and Maxillofacial Surgery

usually allows for tension-free closure without release of the graft and anorganic bovine inlay) versus short implant place-
periosteum. ment without augmentation. The meta-analysis showed an in-
creased implant failure rate (borderline significance; P 5 .06)
Inlay Bone Graft and a statistically significant increase in the complication rate in
the augmented group. The additional time, cost (e.g., general
First described by Simion and colleagues in 1992, the alveolar anesthesia, hospitalization), and patient discomfort are also
split osteotomy technique for horizontal bone defects and subse- important factors. However, the long-term outcomes of short
quent implant placement has shown predictable results. The sur- implants in the posterior mandible have not been adequately
gery is usually performed in a two-stage fashion in the mandible evaluated to date.
because of the dense cortical buccal plate. At least 3 mm of hori-
zontal width is preferred for a controlled fracture; however, widths Block Grafts
as narrow as 2 mm have been reported. The goal of the technique
is to produce a vascularized bone flap through controlled fracture The use of onlay autogenous grafting for vertical augmentation
of the buccal plate. The gap produced by the fracture at the sec- has been widely described in the literature. One of the shortcom-
ond stage can then be grafted with block or particulate bone, or ings of the onlay graft is resorption of the graft during healing.
implants can be placed along with a particulate graft. A mem- Studies using intraoral (symphysis, ramus, or both) and posterior
brane is generally used to protect the graft and implants during iliac crest have reported 17% to 41% resorption of the onlay graft
healing. at 4 to 6 months.
Procedure Procedure
The initial surgery requires a full-thickness flap to expose the buc- Autogenous block grafts for vertical augmentation can be har-
cal cortical plate. A crestal incision with releasing incisions away vested in a fashion identical to that previously described.
from the planned corticotomy sites is used. Crestal, apical, and A crestal incision is made, and the block is adapted to the alveo-
two vertical corticotomies are performed and connected to create lar defect and secured with titanium screws. Gaps are packed
an outline of the intended bone flap. A piezoelectric drill is often with particulate bone, and a membrane is placed. The incision
used to preserve bone. The mucosal flap is then sutured. Stage 2 is sutured over the graft after periosteal release for tension-free
is performed after approximately 4 weeks; with this interval, the closure.
periosteal blood supply to the bone is restored, but callus is still
present at the corticotomy sites. The crestal incision is made along Particulate Bone
the crestal corticotomy, with care taken to reflect as little perios-
teum as possible. Osteotomes are used to gently outfracture the Particulate bone grafting for vertical deficiency has been shown to
bone flap. The bone graft or implants (or both) can then be be effective when used with a rigid membrane or titanium mesh.
placed. Primary closure can be attempted using a periosteal releas- The use of titanium mesh has been shown to be effective in the
ing incision, but primary closure is often difficult, requiring the reconstruction of alveolar ridge defects regardless of the particu-
use of a membrane. If implants are not placed, 4 to 6 months of late bone source. The titanium mesh acts as a permanent, rigid
healing is allowed before implant placement. barrier that is biocompatible and easily molded to the desired
shape. Several studies have demonstrated successful vertical aug-
Vertical Defects mentation (maxilla and mandible) using titanium mesh, with
average vertical gains of 3.71 to 14 mm and implant success rates
Vertical defects of the posterior mandible refer to inadequate in the grafted area of 93% to 100%. Exposure of the titanium
height of alveolar bone in relation to the inferior alveolar nerve. mesh during the healing phase is commonly reported, with a rate
Vertical defects can be challenging to treat because of a small ranging from 5% to 52%. However, the rates of infection and
surface area of crestal mandibular bone for onlay grafting, diffi- graft failure remain low compared with other nonresorbable bar-
culty with exposure of the graft because of tension of the soft riers. Watzinger and colleagues demonstrated that the timing of
tissue after augmentation, and resorption of graft material. Tech- the mesh exposure is critical to the final outcome. If exposure
niques described include onlay grafting, particulate bone grafts, occurred within 4 to 6 weeks of the grafting procedure, graft take
inlay grafts, and distraction osteogenesis. was poor. However, if exposure occurred after 4 to 6 weeks, these
In 2009, Esposito and colleagues performed a Cochrane sys- sites had outcomes similar to those for grafts that did not have
tematic review of randomized controlled trials (RCTs) for hori- exposure. Most areas of late exposure of titanium mesh (after 4–
zontal and vertical ridge augmentation. Of the 13 trials that met 6 weeks) can be managed with local wound care; removal is re-
the inclusion criteria, 10, enrolling 218 patients, addressed ver- quired only if signs of infection are present.
tical ridge augmentation. Analysis of the trials found that verti-
cal augmentation resulted in a high complication rate (20%– Procedure
60%) and graft failure rates of 10% to 15%. Interestingly, two The technique for particulate bone grafting was described previ-
split-mouth trials compared alloplastic grafting (anorganic ously in the section on particulate bone grafting for horizontal
bovine bone and Regenaform, respectively) with autogenous deficiency.
bone grafting (iliac crest and particulate bone) and showed no
statistical difference in outcomes. Although both studies had Inlay Graft
small sample sizes (10 and 5 patients), the reduction in operative
time, cost, and patient discomfort certainly justify further inves- Inlay grafting, or “sandwich” osteotomy, provides the advantage
tigation. The review also included a meta-analysis of two RCTs of having a pedicled segment of alveolar bone overlying the graft
examining mandibular ridge augmentation (iliac crest inlay material. Felice and colleagues demonstrated significantly less

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 CHAPTER 76 Posterior Mandibular Augmentation 397

bone resorption of the inlay graft compared with onlay grafting of least 3 mm tall to tolerate the placement of titanium screws with-
anterior iliac crest bone, in 20 patients. In another study by Felice, out fracturing. The bone graft is placed, and the transported and
no statistical difference in outcomes was found for inlay grafts basal mandibular segments are plated with titanium miniplates
with anorganic bovine bone (Geistlich Bio-Oss, Geistlich Pharma and screws, thus stabilizing the graft. Gaps are filled with particu-
North America), compared with iliac crest bone, for vertical aug- late bone, and the vestibular incision is closed. A healing period
mentation in the posterior mandible. The disadvantages of inlay of 3 to 4 months is allowed before the hardware is removed and
grafting are the inability to address horizontal defects with the implants are placed.
procedure and limitation of the amount of vertical augmentation
by the lingual soft tissue pedicle to the mobilized alveolar seg- Discussion
ment. Additionally, there must be at least 4 mm of bone above the
mandibular canal to preserve viability of the mobilized segment With the growing popularity of implant restorations, mandibu-
while avoiding damage to the nerve. lar ridge augmentation has become a necessary skill for oral and
maxillofacial surgeons. The posterior mandible can be a par-
Procedure ticularly difficult area to successfully augment because of the
A vestibular incision is made, and a subperiosteal flap is raised to unique anatomy of the area. A thorough understanding of
expose the buccal surface of the alveolar ridge. The crestal and surgical techniques and bone grafting options is vital to maxi-
lingual tissue is not reflected. A reciprocating saw or piezoelectric mizing the final functional and esthetic outcomes for the pa-
handpiece is used to create the horizontal and two vertical oblique tient (Fig. 76.3).
osteotomies, with care taken not to damage the lingual tissue. The
horizontal osteotomy should be at least 2 mm superior to the ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
mandibular canal, and the alveolar segment should ideally be at complete set of bibliography.

A B

C D L

• Fig. 76.3 A, A 59-year-old White male with left posterior mandibular vertical deficiency. B, Completion
of osteotomy for inlay graft (sandwich osteotomy technique). C, Mobilization of the mandibular alveolar
segment. A block of allograft bone was used without fixation for the interpositional graft. D, Postoperative
panoramic radiograph with block graft in place, showing adequate height for implant placement in left
posterior mandible.

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 397.e1

Bibliography Louis P: Bone grafting the mandible, Oral Maxillofac Surg Clin North Am
23:209-227, 2011.
Mertens C, Decker C, Seeberger R, et al: Early bone resorption after
Bell RB, Blakey GH, White RP, et al: Stages reconstruction of the se- vertical bone augmentation: a comparison of calvarial and iliac grafts,
verely atrophic mandible with autogenous bone graft and endosteal Clin Oral Implants Res 24(7):820-825, 2013.
implants, J Oral Maxillofac Surg 60:1135, 2002. Nissen J, Ghelfan O, Mardinger O, et al: Efficacy of cancellous block
Chiapasco M, Abati S, Romeo E, et al: Clinical outcome of autogenous allograft augmentation prior to implant placement in the posterior
bone blocks or guided bone regeneration with e-PTFE membranes atrophic mandible, Clin Implant Dent Relat Res 13(4):279-285, 2011.
for the reconstruction of narrow edentulous ridges, Clin Oral Im- Pieri F, Corinaldesi G, Fini M, et al: Alveolar ridge augmentation with
plants Res 10(4):278-288, 1999. titanium mesh and a combination of autogenous bone and anorganic
Clavero J, Lundgren S: Ramus or chin grafts for maxillary sinus inlay and bovine bone: a 2-year prospective study, J Periodontol 79:2093-2103,
local onlay augmentation: comparison of donor site morbidity and 2008.
complications, Clin Implant Dent Relat Res 5(3):154-160, 2003. Proussaefs P, Lozada J, Kleinman A, et al: The use of ramus autogenous
Cordaro L, Amade DS, Cordaro M: Clinical results of alveolar ridge block grafts for vertical alveolar ridge augmentation and implant
augmentation with mandibular block bone grafts in partially edentu- placement: a pilot study, Int J Oral Maxillofac Implants 17:238, 2002.
lous patients prior to implant placement, Clin Oral Implants Res Proussaefs P, Lozada J: The use of intraorally harvested autogenous block
13:103, 2002. grafts for vertical alveolar ridge augmentation: a human study, Int
Corinaldesi G, Pieri F, Sapigni L, et al: Evaluation of survival and success J Periodontics Restorative Dent 25:351, 2005.
rates of dental implants placed at the time of or after alveolar ridge Roccuzzo M, Ramieri G, Bunino M, et al: Autogenous bone graft alone
augmentation with an autogenous mandibular bone graft and tita- or associated with titanium mesh for vertical alveolar ridge augmenta-
nium mesh: a 3- to 8-year retrospective study, Int J Oral Maxillofac tion: a controlled clinical trial, Clin Oral Implants Res 18:286-294,
Implants 24:1119-1128, 2009. 2007.
Esposito M, Grusovin MG, Felice P, et al: The efficacy of horizontal and Roccuzzo M, Ramieri G, Spada MC, et al: Vertical alveolar ridge aug-
vertical bone augmentation procedures for dental implants: a Co- mentation by means of a titanium mesh and autogenous bone grafts,
chrane systematic review, Eur J Oral Implantol 2(3):167-184, 2009. Clin Oral Implants Res 15:73-81, 2004.
Felice P, Marchetti C, Iezzi G, et al: Vertical ridge augmentation of the Simion M, Baldoni M, Zaffe D: Jawbone enlargement using immediate
atrophic posterior mandible with interpositional bloc grafts: bone implant placement associated with a split-crest technique and guided
from the iliac crest vs bovine anorganic bone—clinical and histologi- tissue regeneration, Int J Periodontics Restorative Dent 12:462-473,
cal results up to one year after loading from a randomized-controlled 1992.
clinical trial, Clin Oral Implants Res 20:1386-1393, 2009. Tolstunov L, Hicke B: Horizontal augmentation through the ridge-split
Felice P, Pistilli R, Lizio G, et al: Inlay versus onlay iliac bone grafting in procedure: a predictable surgical modality in implant reconstruction,
atrophic posterior mandible: a prospective controlled clinical trial for J Oral Implantol 39(1):59-68, 2013.
the comparison of two techniques, Clin Implant Dent Relat Res Waasdorp J, Reynolds MA: Allogeneic bone onlay grafts for alveolar
11(Suppl 1):e69-e82, 2009. ridge augmentation: a systematic review, Int J Oral Maxillofac Im-
Her S: Titanium mesh as an alternative to a membrane for ridge augmen- plants 25(3):525-531, 2010.
tation, J Oral Maxillofac Surg 70:803-810, 2012. Watzinger F, Luksch J, Millesi W, et al: Guided bone regeneration with
Louis P, Gutta R, Said-Al Naief N, et al: Reconstruction of the maxilla titanium membranes: a clinical study, Br J Oral Maxillofac Surg 38:
and mandible with particulate bone graft and titanium mesh for im- 312-315, 2000.
plant placement, J Oral Maxillofac Surg 66:235-245, 2008.

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77
Radial Forearm Free Flap
M AR C U S A . C OUE Y, A S H I S H PAT E L , a n d J O N AT H A N S H UM

CC and radial arteries. The ulnar artery supplies the superficial palmar
branch, and the radial artery supplies the deep palmar branch.
A 40-year-old edentulous male is referred by his general dentist (Communication between the superficial and deep systems allows
for evaluation of a tongue mass. The patient states, “My tongue perfusion of the hand if there is interruption of one of the two
hurts.” main arteries to the hand, such as with the radial forearm free flap
harvest.) Allen’s test determines the perfusion of the hand by
HPI simulating complete interruption of the radial artery. This is to
ensure that the hand remains viable upon harvesting of the radial
The patient was referred to an oral and maxillofacial surgeon for forearm free flap. The test is performed by elevating the intended
evaluation of an ulcerative tongue lesion. The patient first noticed hand and digitally occluding both the ulnar and the radial arter-
the lesion 8 months ago, and only for the past 2 months has the ies. The patient is asked to clench and release a fist to cause
pain become worse. His general dentist had noted a large ulcer- blanching of the hand. Next, the pressure over the ulnar artery is
ative lesion involving the right posterior lateral tongue. An inci- released, and the capillary refill of the hand is evaluated. A wide
sional biopsy of the tongue mass was performed, resulting in the range of values for hand reperfusion have been noted, ranging
diagnosis of a poorly differentiated, invasive squamous cell carci- from 3 to 15 seconds. Additional techniques to qualify hand per-
noma (SCC). fusion include the use of pulse oximetry (placed on the first fin-
ger) or Doppler assessment in conjunction with the modified
PMHX/PDHX/Medications/Allergies/SH/FH Allen’s test. If hand perfusion is predominately based from the
radial artery, use of the contralateral forearm or of an ulnar fascio-
The patient has hypertension, gastroesophageal reflux disease, and cutaneous free flap should be considered.
high cholesterol. He is currently taking simvastatin, hydrochloro-
thiazide, and Pepcid OTC. The patient also has a 60-pack-year Imaging
history of cigarette smoking and has indulged in alcohol regularly
for more than 20 years (risk factors for oral cancer). The family In general, if the patient has a normal result on the modified Al-
history is noncontributory. len’s test, no imaging is necessary before radial forearm free flap
harvest.
Examination The workup of SCC of the tongue includes at a minimum
computed tomography (CT) scanning of the head and neck with
General. The patient is a slim, pleasant white male who appears intravenous contrast (for improved delineation of soft tissue) and
his stated age. a chest radiograph (see Chapter 72).
Intraoral. The patient is edentulous and has a prominent ul- In the current patient, axial and coronal CT scans demon-
ceration at the right posterior lateral tongue that measures 3 cm strated a 3-cm 3 2-cm 3 1.5-cm mass with poorly defined mar-
in length and 2 cm in width. The red and white lesion is tender gins in the area of the tongue. No cervical lymphadenopathy was
and has a necrotic center with firm, everted edges along its periph- noted. The results of the chest radiograph were within normal
ery (Fig. 77.1). The tongue is freely mobile. There appears to be limits.
no extension into the floor of the mouth.
Neck. There is no palpable lymphadenopathy. Labs
Flexible fiberoptic laryngoscopy. The lesion does not extend
into the base of tongue; the bilateral tonsillar pillars, epiglottis, Routine laboratory studies, such as a complete blood count, elec-
valleculae, arytenoids, piriform sinuses, and glottis are without trolyte studies, and coagulation studies, may be obtained to estab-
obvious lesions. lish a baseline preoperatively. Liver function tests are obtained as
Extremity. Peripheral pulses are 21 for all extremities, and part of the complete metabolic panel and are important screening
there is no cyanosis, clubbing, or edema. Bilateral modified Allen’s tests for liver metastasis.
tests reveal good collateral circulation to the hands. Before major ablative surgery and reconstruction, several labora-
Modified Allen’s test is used to assess the circulatory blood flow tory tests with implications for wound healing may be considered.
of the hand. The main blood supply to the hand is via the ulnar In patients for whom malnutrition is suspected, a prealbumin level

398
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 CHAPTER 77 Radial Forearm Free Flap 399

can be helpful in determining the need for preoperative nutritional randomized clinical trials. Furthermore, coronary stenting re-
support (e.g., percutaneous endoscopic gastrostomy tube). In pa- quires dual antiplatelet therapy (DAPT), and early discontinua-
tients with a history of thyroid dysfunction or radiation to the head tion of DAPT greatly increases the risk of stent thrombosis
and neck, a thyroid-stimulating hormone level with reflex thyroxine and should be avoided if possible. In most cases, given the
level should be obtained because hypothyroidism can have pro- nonelective and time-sensitive nature of oral cancer treatment,
found negative effects on wound healing. Patients with or at risk for extensive cardiac workup should not delay surgery and should
diabetes should have their hemoglobin A1c evaluated, with optimi- be deferred if the results are not expected to change periopera-
zation of glucose levels before surgery. tive management.
Patients with impaired functional status should have an elec- For the current patient, the results of all the laboratory studies
trocardiography and cardiac risk assessment, and an echocardio- mentioned were within normal limits.
gram may be helpful in determining baseline cardiac function.
Stress tests before nonelective surgery are controversial; although Assessment
stress tests have a high negative predictive value for major car-
diac adverse events, the positive predictive value is low, and the cT2N0M0, stage II (greatest clinical tumor dimension is between 2
results are unlikely to change the perioperative management. and 4 cm, depth of invasion .5 to ,10 mm, with no regional nodal
Prophylactic coronary artery revascularization before noncardiac metastasis and no distant metastasis on clinical or radiologic investi-
surgery has not improved short- or long-term survival in large gation) SCC of the right lateral tongue.

Treatment
Primary surgery is generally accepted as the standard of care for
patients with oral SCC. Primary radiation with or without che-
motherapy has been used for organ preservation, but most reports
suggest lower survival or increased adverse effects such as osteora-
dionecrosis. Most patients are managed surgically, with radiation
with or without chemotherapy reserved for adjuvant therapy de-
pending on the risk factors determined on the final pathologic
assessment. Occasionally, patients who are not suitable candidates
for surgery because of unresectable disease or medical comorbidi-
ties are considered for primary radiation therapy.
Access to the lesion is considered first. In the current patient,
the resection can be completed via a transoral approach. For larger
oral SCCs of the oral cavity, it is not uncommon to gain access via
a lip split mandibulotomy or “pull-through” approach (Fig. 77.2).
• Fig. 77.1 Squamous cell carcinoma of the right lateral and ventral Along with resection of the tumor, reconstruction of the defect is
tongue. planned preoperatively.

A B

• Fig.77.2 Access surgery for tongue resection. A, Lip split mandibulotomy approach. An osteotomy is
completed through the symphysis of the mandible. A subtotal glossectomy was completed with the re-
maining tongue retracted with a towel clamp. B, Pull-through approach. A hemiglossectomy and floor-of-
mouth compartment resection was completed through a combined transoral and transcervical approach.

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400 S E C TI O N Reconstructive Oral and Maxillofacial Surgery

The concept of the reconstructive ladder is useful to describe The radial forearm fasciocutaneous flap is the soft tissue flap of
reconstructive methods in order of complexity; however, it is not choice for reconstructing small- to medium-sized oral and oro-
used to determine the best method for reconstructing any particu- pharyngeal defects. Based on the radial artery and cephalic vein or
lar defect. In cases in which the defect will be relatively small or venae comitantes, it consists of thin, pliable skin and a very long
scarring is not expected to cause substantial morbidity, less com- pedicle, which make it well suited for use in the oral cavity. It can
plex options such as secondary intention, primary closure, or local be designed to include tendons, muscle, or a segment of bone up
flaps can be considered. Larger defects that will impair form or to 12 cm in length, making it also useful for composite maxillary
function or those that result in communication between the and mandibular defects.
mouth and the neck generally require more robust reconstructive For the current patient, the radial forearm free flap was selected
methods such as pedicled regional flaps or microvascular free to provide bulk and to prevent restriction in tongue mobility that
flaps. In the current patient, the surgical defect after resection would affect speech and swallowing functions. The patient was
would result in a significant loss of tissue because oncologic clear- placed under general anesthesia and underwent a tracheostomy to
ance generally incorporates at least a 1-cm margin. The recon- secure his airway. A marking pen was used to delineate the
structive surgeon should also consider that intraoperative findings planned resection edges, and a paper template was used to ap-
or frozen section results may lead to a more extensive resection. proximate the size and shape of the resection. A right hemiglos-
With respect to tongue defects, reconstruction should consider sectomy was performed, and the margins of the resection were
preserving the patient’s functions of speech and swallow. The confirmed to be adequate with frozen sections (Fig. 77.3A and B).
anterior tongue, and particularly the tongue tip, are critical for A right selective neck dissection was performed, with care at-
articulation and for propelling a food bolus posteriorly; the pos- tention to preserving vessels for microvascular reconstruction
terior tongue is largely involved with swallowing. Primary closure (Fig. 77.3C).
is an acceptable means of reconstruction if closure will not restrict Simultaneous harvest of the radial forearm free flap was per-
tongue mobility (e.g., cases with minimal floor of mouth involve- formed on the nondominant hand. The template was used to
ment). When a glossectomy leaves more than 33% to 50% of the approximate the area of skin needed for the fasciocutaneous flap
tongue, emphasis should be placed on maintaining mobility of harvest. The highest concentration of perforators along the radial
the remaining tongue through the use of a thin, pliable flap, such artery are in the proximal half of the distal third of the forearm.
as a radial or an ulnar fasciocutaneous free flap. When the defect In cases requiring a very large surface area, the skin of the entire
leaves less than 33% to 50% of the original tongue, reconstruc- volar forearm can feasibly be harvested, extending from the ante-
tion shifts to the restoration of bulk to direct secretions toward cubital fossae to the flexor crease of the wrist. The skin and sub-
the oropharynx and to provide contact of the neotongue with the cutaneous tissue are thinner in the distal forearm than in the
palate for deglutition. For greater tissue bulk, the anterior lateral proximal portion of the forearm. Also of note, the area of the
thigh free flap is an effective choice for reconstruction. distal forearm is thinner in males than in females.

A B C D

E F G H
• Fig. 77.3 A, Right tongue defect after right hemiglossectomy. B, Right hemiglossectomy specimen.
C, After completion of the supraomohyoid neck dissection. The sternocleidomastoid muscle is retracted
posteriorly, revealing the internal jugular vein and common facial vein. The facial artery has been clipped
and is seen overlying the posterior belly of the digastric D, A skin flap is raised on the distal volar surface
of the forearm. Note the radial pedicle distally (marked by a vessel loop), and the cephalic vein travelling
toward the antecubital fossae. E, Radial forearm free flap fully elevated on its vascular pedicle. F, Artery
and veins within the antecubital fossae marked by red and blue vessel loops, respectively. G, Inset of the
radial forearm fasciocutaneous free flap. H, Healed forearm flap over 1 year postsurgery.

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 77 Radial Forearm Free Flap 401

Clinical landmarks that assist in the harvest of a radial forearm the process of thrombosis in the lumen of the vessels. Inherent to
free flap include the distal extent of the flap within a flexor crease the anatomy of blood vessels, arteries generally have a thicker
of the wrist; the antecubital fossae; and the brachioradialis, flexor media, whereas veins have thinner vessel walls; hence, anastomosis
carpi radialis, and palmaris longus. In this case, the flap outline was for the artery is commonly completed with sutures, and the veins
centered over the region of the vascular pedicle located between are coupled together because their thin walls make them amena-
the brachioradialis and flexor carpi radialis, and the distal extent of ble to coupling.) Adequate perfusion of the flap was confirmed
the flap was marked at 3 cm from the distalmost wrist crease. clinically by assessment of color, texture, capillary refill, and tem-
The surgery began with placement of a tourniquet proximal to perature. (Doppler probes are also regularly used to assess blood
the elbow and exsanguination of the arm using an Esmarch ban- flow through the free flap.)
dage. The tourniquet was inflated to 250 mm Hg for 60 minutes Closure of the donor site was completed in a layered fashion,
to facilitate bloodless dissection. An incision was made along the with dermal sutures followed by staples for the skin. The skin
distal margin of the planned flap to expose and identify the vas- paddle donor site can be closed primarily if it is small, and tech-
cular pedicle, cephalic vein, and superficial branch of the radial niques have been described for using local flaps (e.g., Z-plasty) to
nerve. (After identification of the vascular pedicle, a confirmatory facilitate closure. Most defects are repaired with either a split-
Allen’s test can be performed with a bulldog clamp, the tourniquet thickness skin graft, full-thickness skin graft, or skin substitute
let down, and perfusion checked in the hand.) A suprafascial dis- material (allograft or xenograft). Unlike microvascular flaps, these
section was completed to the extent of the planned flap, with care grafts are dependent on nutrition from the recipient bed via plas-
taken to incorporate the vascular pedicle and to travel along the matic imbibition for 48 to 72 hours until capillary ingrowth oc-
brachioradialis and flexor carpi radialis and to incorporate the curs. During the initial wound healing phase, it is necessary to
cephalic vein (Fig. 77.3D). Suprafascial dissection maintains a bolster the graft on the recipient bed to provide stability for
layer of antebrachial fascia over the flexor tendons for improved the healing process. The split-thickness skin graft incorporates the
skin graft take. This suprafascial plane is only broken around the epidermis and a portion of the dermis. Its advantages include the
pedicle to incorporate the radial artery and its vena comitantes ability to cover large areas with a higher rate of successful graft
into the flap. At the proximal margin of the flap, the vascular take. However, split-thickness skin grafts are less esthetic, are sus-
pedicle was dissected free to the antebrachial fossae, preserving ceptible to more contracture, and require an additional donor site.
communicating branches between the superficial (cephalic vein) Full-thickness skin grafts incorporate all layers of the epidermis
and deep (venae comitantes) venous systems (Fig. 77.3E and F). and dermis and provide a more esthetic result with less late wound
Along the medial aspect of the skin flap, care is taken to avoid contracture. The donor site for the full-thickness skin graft can
injury to the ulnar artery during dissection (deep between the also be closed primarily, and the graft can be harvested from in-
flexor digitorum superficialis and flexor carpi ulnaris muscles). conspicuous areas of the body, such as the supraclavicular area,
After complete dissection of the flap, the tourniquet is released, volar forearm, or the medial aspect of the upper arm.
and perfusion of the flap is assessed. In the current patient, the harvested split-thickness skin graft was
The radial artery was ligated and divided distal to the takeoff bolstered with a negative-pressure wound therapy system (“wound
of the recurrent radial artery; if additional pedicle length is vac”), and the wrist was immobilized for 5 to 7 days with a volar
needed, the recurrent radial artery can be divided, and the entire splint to prevent shearing of the skin graft. The flap remained viable
length of the radial artery can be harvested up to its takeoff from at the recipient site and healed without complications.
the brachial artery (branching point of the brachial to the radial
and ulnar arteries). The cephalic vein and venae comitantes were Complications
ligated and divided, and the flap was transferred to the head and
neck for inset (Fig. 77.3G). The surgical complication rate among patients undergoing micro-
Blunt dissection was used to create tunnel of at least three vascular reconstruction after head and neck surgery is 19% to
fingerbreadths of width to connect the defect with the ipsilateral 22%. The majority of these surgical complications are related to
neck, medial to the right mandibular body. The pedicle was then the reconstruction itself and manifest as flap loss (total or partial
delivered through this tunnel into the neck through a 1-inch loss) and wound healing complications at either the donor or re-
Penrose drain. Excess skin paddle was removed as needed to cipient site. Preoperative risk factors that have been described to
achieve the desired bulk, and the flap was sutured circumferen- contribute to the incidence of surgical complications include
tially to the resection defect before the microvascular vessel anas- American Society of Anesthesiologists status of III or IV, low
tomosis. The term ischemia time of the flap refers to the time from preoperative hemoglobin, prolonged operative time (longer than
ligation of the vascular supply at the harvest site to the moment 10 hours), and prior radiation or surgery. Factors specific for free
that arterial flow is reestablished. Free flap reconstructions have a flap failure have been associated with the surgeon’s experience,
limited tolerance to tissue ischemia, and the period of ischemia flap selection, and the patient’s nutritional status. Free flap success
tolerance varies with the type of tissues incorporated into the flap. rates have improved significantly since this technique moved into
Skin and fascia are the most resistant to ischemia; they have a mainstream use. Initial free flap survival rates, during the first
tolerance period of 4 to 6 hours before irreversible cellular injury decade of popularity in the 1980s, ranged from 85% to 89%;
occurs that could jeopardize the viability of the free flap. Muscle recent studies have demonstrated a success rates greater than 95%.
is generally the most sensitive to ischemia time; it has a tolerance Specifically, the radial forearm free flap is very reliable, with flap
period of less than 3 hours. survival rates of 96% to 100% in multiple studies.
The arterial anastomosis was performed in an end-to-end fash- The main disadvantage of the radial forearm fasciocutaneous
ion with the facial artery using 9-0 nylon sutures in an interrupted free flap is the morbidity associated with the donor site. Inherent
fashion, and the venous anastomosis was performed in an end-to- to the harvest of the graft is the manipulation of the superficial
side fashion into the internal jugular vein. (During the microvas- branch of the radial nerve because this nerve is closely associated
cular anastomosis, heparinized saline [100 U/mL] is used to mute with the cephalic vein. The superficial branch of the radial nerve

t.me/Dr_Mouayyad_AlbtousH
402 S E C TI O N Reconstructive Oral and Maxillofacial Surgery

provides sensory input for the dorsal surface of the thumb and the
second and third digits. Abnormal sensation (hypoesthesia, hyp-
esthesia, or paresthesia) in the donor hand occurred in 82% of
patients at 3 months after surgery; however, this improved to 26%
during a mean follow-up period of 14 months.
Wound healing accounts for most of the complications associ-
ated with the donor site. Subfascial radial forearm fasciocutaneous
free flap harvests demonstrated a higher incidence of skin graft
loss, ranging from 16% to 28%; in this same subgroup, tendon
exposure and delayed healing accounted for 13% to 28% and 22%
to 28%, respectively. When a suprafascial dissection is chosen, a A B
thin layer of investing fascia remains over the tendons of the fore-
arm, and this serves as a better foundation for the skin graft. To • Fig. 77.4 Example of maxillectomy defect reconstruction with radial
ensure tendon coverage, this fascia can be pulled over the tendons forearm free flap and zygomatic implants. A, Resection defect via a tran-
soral approach. Two zygomatic implants in place. B, Defect coverage with
and sutured to the pronator quadratus muscle with resorbable su-
radial forearm free flap.
ture. Skin graft losses in suprafascial donor sites are reported to be
4% to 6%. The incidence of skin graft loss has been associated
with the likelihood of decreased grip strength. It is reported that fascia and supplies perforating vessels that pass through to form
subjective grip strength was significantly decreased in 5% to 10% subfascial, intrafascial, and suprafascial vascular plexuses. These
of patients who demonstrated partial skin graft failure. networks establish the extensive subcutaneous vascular plexuses
Use of the radial forearm flap as an osteocutaneous flap can be that supply the skin. The fascia provides a degree of additional
associated with the risk of radial fracture; if bone is harvested with protection to the pedicle and overall integrity of the flap.
the flap, less than half of the thickness of the radius should be Multiple variations of this flap can be developed from the in-
removed. The length of bone is limited by the attachments of the corporation of accessible anatomic structures. Additional bulk can
pronator teres muscle proximally and the brachioradialis muscle be obtained from the brachioradialis muscle, tendon can be ob-
distally, on average 10 to 12 cm. If bone is harvested with the flap, tained from the palmaris longus, innervation can be obtained
prophylactic plating over the span of the defect is recommended through the antebrachial cutaneous nerve, and bone can be ob-
to decrease the likelihood of radius fracture. Prior studies in which tained through harvest of the radius.
the radius was not plated after harvesting reported a fracture inci- There are two distinct venous systems that provide venous
dence of 15% to 67%. drainage for the free forearm—the deep system and the superficial
system. The deep supply is composed of the paired venae comi-
Discussion tantes, which run in the intermuscular septum along with the
radial artery. The superficial venous supply consists chiefly of the
Since the original description of the radial forearm fasciocutane- cephalic vein. A study of 492 head and neck free flap procedures
ous free flap, the technique has evolved into a versatile and reliable performed at the University of Toronto compared two-vein anas-
flap for head and neck reconstruction. First described by Yang in tomosis with single-vein anastomosis and demonstrated an im-
1979 and popularized in oral cavity reconstruction by Soutar and proved success rate for the former (98.6% vs 93.6%). When only
colleagues in 1983, this flap continues to be a workhorse for soft a single vein is used for reconstruction, there are no differences in
tissue reconstruction. Although the forearm is a commonly cho- using the superficial over the deep venous system as the sole out-
sen because of its pliability, pedicle length, ease of harvest, and flow for the flap.
reliability, there are numerous alternatives, including the lateral The radius is situated lateral to the ulna and articulates with
arm flap, ulnar flap, and anterior lateral thigh perforator flap. the humerus and ulna proximally and with the ulna, scaphoid,
There are many applications for the radial forearm free flap in and lunate bones distally. It averages 23 cm in length, and in cross
head and neck reconstruction. As demonstrated in this case pre- section, the radial shaft appears triangular. Functionally, the ra-
sentation, tongue reconstruction with the radial forearm free flap dius plays a minor role in the stability of the elbow; however, at
is a common indication. Use of this type of flap has been described the radiocarpal joint, it is an integral structure of the wrist. The
for reconstructing the ablative defects of the soft palate and man- proximal head of the radius allows the hand to pronate, and the
dible, restoring soft tissue deficiencies, and repairing tracheo- distal head plays a role in hand flexion, extension, adduction, and
esophageal fistulas. Dual skin flaps have been used to reconstruct abduction.
through-and-through defects in the cheek and lip, and with two- The brachioradialis functions to flex the arm at the elbow and
stage procedures, prefabricated grafts can be prepared for recon- for pronation and supination of the forearm. Its origin is at the
struction of complex structures such as the nose (Fig. 77.4). lateral supracondylar ridge of the humerus, and it attaches to the
The surgical anatomy of the radial forearm flap is consistent distal styloid process of the radius by way of the brachioradialis
and readily assessed. As previously mentioned, the viability of a tendon. It is located in the posterior compartment of the forearm
donor site is based on the results of Allen’s test. The blood supply and is innervated by the radial nerve. In reconstruction, the bra-
is based on the radial artery, which is consistently located between chioradialis can be used to provide bulk, such as in a total glos-
the brachioradialis and flexor carpi radialis. On average, the sectomy defect.
length of the radial artery, from the antecubital fossa to the wrist, The skin available to be harvested on the forearm is defined by
is 18 to 20 cm, and the vessel has a diameter of 2 to 2.5 mm. the radial artery angiosome. It extends from the flexor crease of
It is relatively superficial, and dissection is completed within a the wrist to the antecubital fossa and from the medial third of the
subfascial plane guided by the brachioradialis and flexor carpi ra- ventral surface of the forearm to the lateral third of the dorsal
dialis. The radial artery is intimately associated with the overlying surface of the forearm. If an innervated flap is considered, the

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 77 Radial Forearm Free Flap 403

somatosome of the lateral antebrachial cutaneous nerve is used to can replace missing tissue without significantly restricting the
guide the location of skin flap harvesting. The somatosome of the mobility of the tongue. Studies that compared free flap recon-
lateral antebrachial cutaneous nerve extends from the midline of structions to prior methods for tongue reconstruction (e.g., the
the ventral forearm to the lateral third of the dorsal surface of the pectoralis major pedicled flap) showed that patients with free flaps
forearm. had more intelligible speech. Furthermore, in a limited resection
Innervated tongue flaps are accomplished by neurorrhaphy of in which primary closure was performed, patients had equal or
the lateral antebrachial cutaneous nerve to a recipient nerve. Sen- better function in terms of speech and swallowing functions. The
sation recovery of the innervated radial forearm flap was noted to reconstruction for a glossectomy defect that leaves less than 33%
be predictable in patients who did not receive postoperative radio- of the tongue base focuses on the replacement of bulk to direct
therapy and when neurorrhaphy was completed to the lingual or secretions toward the oropharynx and to provide contact of the
inferior alveolar nerve. Comparisons between reconstructed neotongue with the palate to facilitate swallowing. In such cases,
hemiglossectomy defects with innervated radial forearm free flaps a thicker flap such as the anterolateral thigh flap may be advanta-
and the nonoperated side revealed that the tongue tip, dorsum, geous over the radial forearm flap.
ventral surface, and floor of mouth had comparable two-point Since its introduction 4 decades ago, the radial forearm free
discrimination at 18 months after surgery. Also, light touch sensa- flap has become a staple of head and neck reconstruction. Varia-
tion was similar at the tip and dorsum of the tongue; however, tions on the original procedure have allowed it to become a versa-
pain and light touch along the floor of the mouth were signifi- tile solution for many reconstructive scenarios. Although donor
cantly decreased. Despite the sensation that is gained from rein- site complications persist, it is difficult to discount the technique’s
nervation, these flaps do not offer a major functional advantage proven success through its reliability and favorable characteristics,
over noninnervated flaps. and it will undoubtedly continue as a workhorse of soft tissue
In terms of function, when a glossectomy leaves more than reconstruction in head and neck surgery.
33% to 50% of the original musculature, the emphasis for recon-
struction is on the maintenance of mobility. A thin, pliable soft ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
tissue flap, the radial forearm free flap is an ideal choice because it complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 403.e1

Bibliography Netscher D, Armenta AH, Meade RA, et al: Sensory recovery of inner-
vated and non-innervated radial forearm free flaps: functional impli-
cations, J Reconstr Microsurg 16:179-185, 2000.
Asif M, Sarkar PK: Three-digit Allen’s test, Ann Thorac Surg 84:686-687, Richardson D, Fisher SE, Vaughan ED, et al: Radial forearm flap donor-
2007. site complications and morbidity: a prospective study, Plast Reconstr
Avery C: Prospective study of the septocutaneous radial free flap and Surg 99:109-115, 1997.
suprafascial donor site, Br J Oral Maxillofac Surg 45:611-616, 2007. Ross GL, Ang ES, Golger A, et al: Which venous system to choose for
Avery CM, Pereira J, Brown AE: Suprafascial dissection of the radial anastomosis in head and neck reconstructions? Ann Plast Surg 61:
forearm flap and donor site morbidity, Int J Oral Maxillofac Surg 30: 396-398, 2008.
37-41, 2001. Ross GL, Ang ES, Lannon D, et al: Ten-year experience of free flaps in
Bardsley AF, Soutar DS, Elliot D, et al: Reducing morbidity in the radial head and neck surgery: how necessary is a second venous anastomo-
forearm flap donor site, Plast Reconstr Surg 86:287-292, 1990. sis? Head Neck 30:1086-1089, 2008.
Chen CM, Lin GT, Fu YC, et al: Complications of free radial forearm Santamaria E, Wei FC, Chen IH, et al: Sensation recovery on innervated
flap transfers for head and neck reconstruction, Oral Surg Oral Med radial forearm flap for hemiglossectomy reconstruction by using dif-
Oral Pathol Oral Radiol Endod 99:671-676, 2005. ferent recipient nerves, Plast Reconstr Surg 103:450-457, 1999.
Engel H, Huang JJ, Lin CY, et al: A strategic approach for tongue recon- Scheunemann H: Pull-through surgery in mouth floor: tongue neo-
struction to achieve predictable and improved functional and aes- plasms, Acta Stomatol Belg 72:229-230, 1975.
thetic outcomes, Plast Reconstr Surg 126:1967-1977, 2010. Shnayder Y, Tsue TT, Toby EB, et al: Safe osteocutaneous radial forearm
Fleisher LA, Fleischmann KE, Auerbach AD, et al: 2014 ACC/AHA flap harvest with prophylactic internal fixation, Craniomaxillofac
guideline on perioperative cardiovascular evaluation and management Trauma Reconstr 4:129-136, 2011.
of patients undergoing noncardiac surgery: a report of the American Soutar DS, Scheker LR, Tanner NS, et al: The radial forearm flap: a
College of Cardiology/American Heart Association Task Force on versatile method for intra-oral reconstruction, Br J Plast Surg 36:1-8,
practice guidelines, J Am Coll Cardiol 64(22):e77-e137, 2014. 1983.
Janis JE, Kwon RK, Attinger CE: The new reconstructive ladder: modi- Su WF, Hsia YJ, Chang YC, et al: Functional comparison after recon-
fications to the traditional model, Plast Reconstr Surg 127:205S-212S, struction with a radial forearm free flap or a pectoralis major flap for
2011. cancer of the tongue, Otolaryngol Head Neck Surg 128:412-418,
Liu Y, Jiang X, Huang J, et al: Reliability of the superficial venous drain- 2003.
age of the radial forearm free flaps in oral and maxillofacial recon- Sumi M, Kimura Y, Sumi T, et al: Diagnostic performance of MRI rela-
struction, Microsurgery 28:243-247, 2008. tive to CT for metastatic nodes of head and neck squamous cell car-
Lutz BS, Wei FC, Chang SC, et al: Donor site morbidity after suprafas- cinomas, J Magn Reson Imaging 26:1626-1633, 2007.
cial elevation of the radial forearm flap: a prospective study in 95 Timmons MJ: Landmarks in the anatomical study of the blood supply of
consecutive cases, Plast Reconstr Surg 103:132-137, 1999. the skin, Br J Plast Surg 38:197-207, 1985.
McConnel FM, Pauloski BR, Logemann JA, et al: Functional results of Timmons MJ: The vascular basis of the radial forearm flap, Plast Reconstr
primary closure vs flaps in oropharyngeal reconstruction: a prospec- Surg 77:80-92, 1986.
tive study of speech and swallowing, Arch Otolaryngol Head Neck Surg To EW, Wang JC: Radial forearm free flap: hybrid version, Plast Reconstr
124:625-630, 1998. Surg 104:1066-1069, 1999.
McFalls EO, Ward HB, Moritz TE, et al: Coronary-artery revasculariza- Villaret DB, Futran NA: The indications and outcomes in the use of
tion before elective major vascular surgery, N Engl J Med 351(27): osteocutaneous radial forearm free flap, Head Neck 25:475-481,
2795-2804, 2004. 2003.
McGregor IA, MacDonald DG: Mandibular osteotomy in the surgical Yang G: Forearm free skin flap transplantation; report of 56 cases, Natl
approach to the oral cavity, Head Neck Surg 5:457-462, 1983. Med J China Med J China 61:139, 1981.
Merritt RM, Williams MF, James TH, et al: Detection of cervical metas- Zhang T, Lubek J, Salama A, et al: Venous anastomoses using microvas-
tasis: a meta-analysis comparing computed tomography with physical cular coupler in free flap head and neck reconstruction, J Oral Maxil-
examination, Arch Otolaryngol Head Neck Surg 123:149-152, 1997. lofac Surg 70:992-996, 2012.

t.me/Dr_Mouayyad_AlbtousH
78
Free Fibula Flap for Mandibular
Reconstruction
J AM E S R. DA NIE L L a n d F E L I X SI M

CC the #32 and #31 teeth without improvement 3 months ago and has
now been referred to you for definitive management (Fig. 78.1).
A 56-year-old White male is referred to your office with “worsen-
ing pain in the right side of my jaw, difficulty opening my mouth, PMHX/PDHX/Medications/Allergies/SH/FH
and numbness of my lower lip and chin.”
The patient is otherwise well with no medical comorbidities. He
HPI does have an allergy to penicillin.

The patient was diagnosed with a human papillomavirus p16– Examination

positive squamous cell carcinoma of the base of tongue 6 years
prior. This was pathologically staged T3N3M0 (American Joint General. The patient is a well-nourished male in no acute distress.
Committee on Cancer 8th edition), for which he underwent (Morbid obesity and severe peripheral vascular disease would be
chemoradiotherapy treatment with curative intent. This consisted contraindications to microvascular surgery.)
of 70 Gy to the base of tongue and bilateral neck in 35 fractions Vital signs. Vital signs are stable and within normal limits.
with concurrent cisplatin chemotherapy. The patient is afebrile.
The patient then underwent extraction of his #17 and #18 Maxillofacial. There is no change in the skin overlying the
teeth 2 years ago because of chronic pericoronitis arising from the maxillofacial skeleton, but the patient does have tenderness on
distal aspect of tooth #17. His recovery from these extractions was palpation along the right lower border of the mandible. There is
prolonged, and 6 months afterward, he developed progressive altered sensation of bilateral third divisions (V3) of the trigeminal
paraesthesia in the third division of his left trigeminal nerve as nerve at the mental nerve distribution. There is no palpable cervi-
well as ongoing pain and trismus. An orthopantomogram (OPG) cal lymphadenopathy.
at that time demonstrated an osteolytic process in the left man- Intraoral. There is exposed bone along the crest of the man-
dible with a subsequent computed tomography (CT) scan dem- dible at the #32 and #31 teeth sites. The remaining teeth do not
onstrating a nondisplaced pathological fracture of the left angle of have any apparent caries and are nonmobile.
the mandible. A diagnosis of stage III osteoradionecrosis (ORN) Extremity. The patient has 21 peripheral pulses without clau-
(Notani classification) of the mandible was made. dication or evidence of peripheral vascular insufficiency.
A discussion was held with the patient at this time regarding surgi- The lower extremities should be examined to evaluate for ab-
cal resection and reconstruction. It was the patient’s preference, in sent or diminished pulses in the anterior or posterior tibial arteries
discussion with the treating team, to pursue a trial of conservative because this may suggest atherosclerosis or vascular insufficiency.
therapy with tocopherol and pentoxifylline with soft diet. His symp- Absent or diminished anterior or posterior tibial pulses mandate
toms at this time were well managed with preserved ability to chew, a preoperative angiogram or magnetic resonance angiogram to
mild mouth opening restriction, and no overlying skin changes or define the vascular anatomy.
orocutaneous fistula formation. A follow-up OPG showed bony
healing of the nondisplaced fracture of the left angle of the mandible. Imaging
In the following year, the patient developed ORN of his right
mandible, with radiographic changes extending from the right The panoramic radiograph and CT scan can be used to help de-
body to the ipsilateral condyle; his left-sided disease demonstrated termine the extent of the mandibular resection to aid in predict-
marked improvement. Oral antibiotics were commenced in addi- ing the size of the postresection mandibular defect and for use in
tion to the tocopherol and pentoxifylline. However, throughout the virtual surgical planning (VSP). A CT slice thickness of 1 mm or
review period of a further 12 months, there has been significant less is required for VSP.
progression of the trismus (12 mm interincisally) as well as pain and In the current patient, the OPG showed an extensive lytic le-
paraesthesia in his right third division of the trigeminal nerve. He sion of the right mandible involving the body and ramus and
underwent a debridement of his right mandible with extraction of approaching the condyle (see Fig. 78.1).

404
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 78 Free Fibula Flap for Mandibular Reconstruction 405

• Dental rehabilitation
• Restoration of adequate function (speech, mastication, oral
continence) and cosmesis, enabling the patient to enjoy a rea-
sonable quality of life
Several treatment options are available, each associated with
specific complications and limitations that reflect the difficulty of
managing total mandibular reconstruction. These treatment op-
tions include:
• A vascularized soft tissue flap with or without mandibular re-
construction plate
• Fig. 78.1 A preoperative panoramic radiograph depicting the extensive • A nonvascularized bone graft (e.g., iliac crest, rib)
osteolysis of the right side of the mandible. • A vascularized bone flap (e.g., fibula, ilium, radial forearm,
scapula)
The use of a vascularized soft tissue flap to reconstruct a seg-
Preoperative imaging for the fibula should include CT angi- mental mandibular defect is typically reserved for patients who
ography (CTA) or magnetic resonance angiography (MRA) of are not suitable for bony reconstruction because of reduced life
the lower extremities to evaluate the vascular anatomy for the expectancy or comorbidities. This is because of the inability of a
possible absence or diminished size of the anterior and posterior soft tissue only flap to sufficiently address the goals of mandibular
tibial arteries and for narrowing or occlusion of the vessels sec- reconstruction stated above. Patients who undergo vascularized
ondary to atherosclerosis. In about 10% to 20% of cases, the soft tissue flap reconstruction with a mandibular reconstruction
anterotibial or posterotibial artery may become attenuated; this plate are at significant risk of complications, including plate expo-
is known as peronea magna. In these cases, a communicating sure in up to 46% of patients, loss of fixation, plate fracture, and
branch from the peroneal artery supplies the attenuated vessel’s orocutaneous fistula formation.
territory; therefore, sacrifice of the peroneal artery could result in Nonvascularized bone grafts of up to 6 cm can be used in man-
ischemia of the foot. dibular reconstruction; however, they require well-vascularized,
Preoperative CTA or MRA to evaluate lower extremity vascu- intact mucosa and nonirradiated wound beds, making them an
lature has become routine with their increased availability, the unsuitable choice. Free vascularized bony grafts provide the opti-
increase in use of VSP, and the decrease in cost and radiation. The mal treatment option for segmental mandibular reconstruction
authors perform a clinical vascular examination, supplemented and in particular the fibula free flap. This is because of several fac-
with a lower extremity CTA, for patients who are to have a fibula tors, including the length of bone available, the thickness of the
free flap for vessel assessment and VSP. Conventional angiography bone, the length of the pedicle, vessel caliber, and the possibility of
is reserved for patients with severe vascular disease or if the prior a reliable skin paddle.
studies were inadequate. The patient was treated with VSP segmental mandibulectomy,
right neck dissection for vascular access, tracheostomy, and im-
Labs mediate reconstruction with an osseous fibula free flap with three
osseointegrated implants and immediate fixed dental prosthesis.
Routine laboratory tests, such as a complete blood count and
electrolytes, coagulation studies, and liver function tests are per-
formed to establish a baseline preoperatively.
Virtual Surgical Planning
A VSP session was undertaken before the surgery to plan the ex-
Assessment tent of the mandibular resection. The reconstruction and position
of the fibular was planned by carrying out a digital wax-up of the
Stage III ORN of the mandible. patient’s missing dentition (teeth #28, #29, #30, and #31). The
ideal position of the implants was determined, and the fibula seg-
Treatment ments were placed to ensure the implants are well within the bone
(Fig. 78.2A and B). This usually results in the fibula’s being placed
The current patient presents a complex case with a previously ir- slightly more superior from the lower border (Fig. 78.2C and D).
radiated oral cavity and necrosis of the bone. The core principle A minimum of 6 cm of distal fibula is maintained to maintain
of ORN treatment is to remove nonviable or necrotic bone to ankle stability (Fig. 78.2E).
allow bony healing (see Chapter 7). Patient-specific three-dimensional printed anatomic models
The current patient has now failed medical and conservative (biomodels) were created of the pre- and postoperative mandible
surgical therapy with progression of his disease both symptomati- and fibula. Furthermore, cutting guides for the mandible and
cally and radiographically. In discussion with the patient, it was fibula as well as a patient specific reconstruction plate were cre-
decided that resection and reconstruction of the mandible was ated. The dental prosthesis was printed with a toothborne guide
now indicated. to aid in setting the occlusal height (Fig. 78.3).
The goals of mandibular reconstruction include the following:
• Reestablishment of mandibular continuity and arch form and
maintenance of the existing occlusion, with care taken to
Surgical Technique
maintain the restored mandible’s proper relationship to the The patient underwent a general anaesthetic and tracheostomy to
maxilla to allow dental rehabilitation secure his airway. A right submandibular incision was made deep
• Provision of soft tissue closure and replacement of resected oral to the platysma, and a subplatysmal flap was raised. Next, the
cavity soft tissue marginal mandibular branch of the facial nerve was preserved by

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406 S E C TI O N Reconstructive Oral and Maxillofacial Surgery

45 46 47
47

46

45

13.84 mm 13.40 mm 12.65 mm

A B

C D
Lateral Malleolus

78 mm
Pedicle 96 mm

E Perforator 160 mm
• Fig. 78.2 Screenshots from the virtual surgical planning session. A and B, Positioning the osseointe-
grated implants in the neomandible. C and D, The orientation of the fibula segments in relation to the
native mandible. E, The planned osteotomy sites on the fibula.

mucoperiosteal flap was raised intraorally from the right posterior

mandibular alveolus to the position of the left mandibular canine.
In accordance with the VSP, the cutting guide was then fitted to
the mandible and secured. The mandibular osteotomy was then
performed with a reciprocating saw through the right mandibular
first premolar tooth socket, and the right hemimandible was de-
livered (Fig. 78.4A), with ligation of the right inferior alveolar
neurovascular bundle and preservation of the right temporoman-
A B dibular disc.
Concurrently, the left fibula was selected for harvest, the ana-
• Fig. 78.3 The dental prosthesis with a toothborne guide is trialed on the tomic landmarks were marked, and an elliptical skin paddle of
biomodel. Seen from a birdseye view (A) and lateral view (B). 9 cm 3 5 cm was designed over two skin perforators (Fig. 78.4B).
An incision was made through fascia along the anterior skin inci-
elevating the deep cervical fascia, exposing the submandibular sion to access the lateral compartment of the left lower leg. The
gland. The submandibular gland was removed to allow dissection peroneus muscles, extensor digitorum longus, and extensor hallu-
of the facial artery and facial vein as recipient vessels for the cis longus were reflected off the fibula before incising the interos-
microvascular anastomosis. The external jugular vein was also seous membrane. Next, the posterior skin incision was made. The
identified and isolated as the second recipient vein. Dissection soleus was separated from the flexor hallucis longus (FHL) and the
was continued to the lower border of the mandible before a fibula segment lateralized by careful division of the posterior tibial

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 CHAPTER 78 Free Fibula Flap for Mandibular Reconstruction 407

and FHL muscle, ensuring that the peroneal artery pedicle was not onto the neomandible construct and the occlusion checked again.
damaged. Dissection of the peroneal pedicle was then completed Intermaxillary fixation screws were placed to guide the occlusion
to the point of bifurcation, the distal pedicle was ligated, and the postoperatively (Fig. 78.4L). Microvascular anastomosis was com-
FHL muscle belly was included in the flap. At this point, the VSP pleted with the peroneal artery anastomosed to the facial artery by
cutting guide was fixated to the fibula, and three osseointegrated 9/0 nylon sutures, and vascular couplers were used for the venae
dental implants were placed with the vascular pedicle still intact. comitantes anastomoses to the facial vein and external jugular
The planned osteotomies were then completed, and the neoman- vein. A 15-Fr Blakes drain was placed in the neck incision. The
dible was assembled with the custom mandibular reconstruction left leg donor site wound was closed with a split-thickness skin
plate (Fig. 78.4C and D). Multi-unit abutments (MUAs) were graft harvested from the left thigh.
placed on the dental implants and torqued to 35 Ncm-1, and tem- The patient had an uneventful recovery from surgery and was
porary copings were screwed onto the MUAs. The dental prosthe- discharged 2 weeks after surgery. Upon discharge, he remained in
sis was fitted on the temporary copings, and with the aid of a a left controlled ankle motion boot for 6 weeks in total and was
biomodel, the occlusion was checked against the opposing arch. to continue a puree diet until his review 1 week after discharge.
The prosthesis was picked up and luted on the copings with com- The postoperative OPG showed good apposition of bone seg-
posite resin (Fig. 78.4H–J). After the prosthesis was secured on the ments between fibula and native mandible with parallel place-
temporary copings, the prosthesis was removed and polished. ment of dental implants (Fig. 78.5).
The flap pedicle was then divided and inset intraorally with
sutures securing the temporomandibular disc and lateral ptery- Complications
goid to the neomandible. The occlusion was checked and the
neomandible secured to the native mandible with bicortical The complications related to the use of fibular free flaps for recon-
screws through the custom mandibular reconstruction plate. Be- struction of the mandible can be divided into donor and recipient
cause of radiation-induced fibrosis of the external skin, it is the site complications.
authors’ common practice to place the skin paddle extraorally to
allow tension-free closure of the skin at the submandibular inci- Donor Site
sion site (Fig. 78.4K). The FHL muscle was placed on the lingual
aspect of the neomandible before the mucosa was closed directly Early complications of the donor site include weakness of flexion
over the flap and abutments. The prosthesis was then secured back in the big toe, which occurs in almost all patients because of either

A B C

D E F
• Fig. 78.4 A, The resected right hemimandible demonstrating osteoradionecrosis. B, The intraoperative
fibula free flap design markings; the fibula is marked with the approximate location of the osteotomies as
well as the proposed skin paddle design over the skin perforator. C, After the osteotomies of the fibula have
been performed and the neomandible is assembled with the reconstruction plate. D, The assembled neo-
mandible after the insertion of three osseointegrated implants. E, The dental prosthesis after insertion of
the multiunit abutments to the implants and placement of temporary copings. F, Checking the occlusion
after fixing the neomandible to a biomodel of the native mandible (lateral view) with the dental prosthesis.

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408 S E C TI O N Reconstructive Oral and Maxillofacial Surgery

G H I

J K L
• Fig. 78.4, con’d G, Anterior view. H, Placement of a rubber dam before luting the dental prosthesis to
the temporary copings (superior view). I, Lateral view. J, Placing the composite resin with an orange filter.
K, The fibula skin paddle is positioned extraorally. L, The postoperative occlusion with intermaxillary fixation
screws in situ.

occurs because of disruption of the neurovascular supply to the

muscle intraoperatively.

Recipient Site
Close surveillance of the flap is required postoperatively to moni-
tor for microvascular complications. The bone is more tolerant of
venous thrombosis than an associated skin paddle because of the
skin’s reliance on few small perforator vessels. Any suspected ve-
nous or arterial thrombosis requires a return to the operating
room for reexploration. Total or partial skin flap loss is possible
and less commonly fibula bone flap loss.
• Fig. 78.5 The postoperative panoramic radiograph depicting the recon-
structed mandible.
Other recipient site complications include wound dehiscence,
infection, and salivary leaks in the immediate postoperative
period. Later complications may include nonunion of the neo-
mandible segments to one another and to the native mandible,
FHL inclusion within the flap design, or if not harvested, then reconstruction plate exposure, and malocclusion.
loss of its muscle origin, innervation, or vascular supply. Sensory
changes in the dorsum of the foot are common. Weakness of an- Survival Rates
kle dorsiflexion is less common, but it may result from damage to
the superficial peroneal nerve during flap harvest; it is usually The fibula free flap has excellent survival rates even in the setting
temporary and secondary to retraction intraoperatively. The risk of previously irradiated tissue, with survival rates above 95% in
of foot ischemia was discussed earlier and should be avoided by most case series.
thorough preoperative clinical and radiographic assessment of the
lower limb to ensure there is no dominant peroneal artery or sig-
nificant peripheral vascular disease. Discussion
Subacute or late complications include wound breakdown History
because of failed split-thickness grafting or too much tension in
primary closure. Stiffness or pain of the ankle may occur and less The application of the fibula free flap was first described by Taylor
commonly joint instability. A significant long-term complication and colleagues in 1975. Hidalgo first reported its use in mandibu-
is clawing of the big toe because of contraction of the FHL, which lar reconstruction in 1989. Since then, it has become the method

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 CHAPTER 78 Free Fibula Flap for Mandibular Reconstruction 409

of choice for mandibular reconstruction after trauma and tumor and is suitable for dental implantation. The subscapular vascular
ablation surgeries. system is usually spared from atherosclerosis and is therefore a
useful alternative donor site if the fibula is unsuitable because of
Anatomy significant atherosclerosis. The main disadvantage of a scapula
flap is the inability to have a two-team surgical approach because
The fibula free flap relies on the peroneal artery, which provides a the patient must be positioned laterally or semilaterally during
major nutrient vessel to the fibula and to minor vessels to the harvesting.
periosteum, septum, and surrounding muscle. The nutrient vessel The radius with radial artery forearm flap provides a reliable,
enters the fibula in the middle third of the fibula on its postero- thin, and pliable skin flap and is excellent for reconstructing
medial aspect before dividing into ascending and descending moderate to large intraoral defects. However, the radius bone
branches. The septocutaneous perforators to the lateral lower leg provides only a short segment of unicortical bone (8–10 cm), is
skin arise from the peroneal artery and pass through the posterior of inferior quality for the reception of dental implants, and is
crural septum to reach the skin. They are typically between four easily devascularized with multiple osteotomies. There is also a
and eight in number and variable in position; commonly, they significant risk of radius fracture. For these reasons, it is now
can be located at the junction of the middle and lower thirds of rarely used.
the fibula. The venous drainage of the flap is the venae comitantes As discussed previously, the fibula is the preferred bony free
of the peroneal artery; there are usually two. flap for mandibular reconstruction. It is a versatile flap with
The fibula is a long, straight bone with a dense triangular cortex sturdy cortical bone that allows for variation in osteotomy design
that is relatively even in thickness. It allows for up to 25 cm of and dental implant rehabilitation, with a reliable skin paddle or
bone to be harvested with preservation of 6 cm proximally and paddles of substantial size on a long vascular pedicle of good cali-
distally to support the functional stability of the ankle and knee ber. Criticism of the use of the fibula free flap in mandibular re-
joints. In designing the fibula free flap, the pedicle length is depen- construction has focused on the height discrepancy between the
dent on the osteotomy sites; more distal osteotomies allow for a fibula bone and the native mandible. To decrease the height dis-
longer pedicle with lengths up to 12 to 15 cm being possible. With crepancy between the fibula bone and the native mandible, a
each added osteotomy comes an increased risk of impaired vascular “double-barrel” technique in which the fibula is folded on itself
supply because the distal fibula bone derives its blood supply solely lengthwise has been described. Another method is to position the
from the periosteum, whereas the more proximal bone also re- fibula slightly more superior to the lower border of the mandible
ceives nutrient arterial supply. Therefore, the minimum suggested maintaining a minimum of 15 mm of restorative space between
segment length of bone is between 2.0 and 2.5 cm. the top of the fibula to the occlusal plane.
The fibula free flap can be harvested as a bone flap with or
without the addition of muscle (soleus or FHL) and skin. Large Particulars of Surgical Technique
skin paddles may be raised, with lengths up to 30 cm and widths
up to 14 cm reported, though skin paddles with a width greater The choice of the ipsilateral or contralateral fibula for reconstruc-
than 4 to 6 cm require split-thickness skin grafting because pri- tion depends on the desired orientation of the vascular pedicle for
mary closure is not possible. anastomosis and the location of the skin paddle. In cross section,
the fibula’s lateral surface is suitable for plating, the posterior sur-
Consideration of Flap Selection face has the skin perforators crossing it, and the medial surface has
the vascular pedicle on it. The vascular pedicle is orientated on the
In selecting a bony vascularized free flap for reconstruction of the medial surface of the neomandible, and the vascular pedicle may
mandible, in addition to the fibula, the distal circumflex iliac ar- exit anteriorly or posteriorly depending on the recipient vessels
tery (DCIA) flap, scapular flap, and radius with radial artery and the desired location of the skin paddle (intra- or extraorally).
forearm flap can also be used. In the discussed case, the contralateral fibula was harvested with
The DCIA bone flap uses the iliac bone in its design and has the vascular pedicle exiting anteriorly and the skin paddle posi-
high survival rates. It can supply up to 16 cm of bone with inter- tioned extraorally.
nal oblique muscle and a groin skin paddle. The contour of the The use of nonrigid fixation with mini plates has been sug-
iliac crest can recreate the natural contour of the mandible border gested to be associated with higher rates of plate-related complica-
and offer good bony height to allow for dental implant rehabilita- tions compared with rigid fixation with reconstruction plates.
tion. The disadvantages of the DCIA flap include donor site Reconstruction plates allow for greater accuracy in positioning of
morbidity such as hernia formation, risk of peritoneal perforation the fibula segments, especially in the setting of VSP.
with visceral injury, pain, and fracture. At the recipient site, the
limitations of a DCIA are that the skin paddle is often bulky and Advancements in Dental Rehabilitation
prone to vascular compromise, the internal oblique muscle has
limited bulk, and the pedicle length is shorter than in the fibula A key goal of mandibular reconstruction and rehabilitation after
free flap. segmental resection is restoration of the occlusion. The fibula
The scapular flap includes bone from the lateral border of the provides suitable cortical bone thickness and bone height for the
scapula and derives its arterial supply from the subscapular ar- placement of dental implants. Historically, dental rehabilitation
tery. It is a highly versatile flap with multiple components. It can with implants in patients who have undergone fibula mandible
be harvested as a chimeric flap, which may include bone from reconstruction has been performed as a delayed two-stage proce-
the lateral border of scapula and scapula tip, skin from the dure after healing. Rohner et al. described a two-stage technique
scapular and parascapular region, and muscle from the latissi- in which implants were placed in the fibula approximately
mus dorsi. The scapula flap may provide up to 14 cm of bone 6 weeks before raising the flap with a prosthesis placed at the time

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410 S E C TI O N Reconstructive Oral and Maxillofacial Surgery

of reconstruction. This advancement significantly reduced the Acknowledgment

treatment time. More recently, the Jaw In A Day (JIAD) tech-
nique has been developed, as used in the case discussed, in which The authors and publisher wish to acknowledge Drs. Brian M. Woo,
primary implant placement and immediate loading of the im- Etern S. Park, Tuan G. Bui, and R. Bryan Bell for their contribu-
plants with a fixed provisional prosthesis is performed in the same tions on this topic in previous editions.
surgery as the resection and reconstruction. These techniques are
at this stage only suitable for benign disease such as osteomyelitis, ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
osteonecrosis, and benign tumors of the jaw. complete set of bibliography.

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 410.e1

Bibliography Levine JP, Bae JS, Soares M, et al: Jaw in a Day: total maxillofacial recon-
struction using digital technology, Plast Reconstr Surg 131:1386,
2013.
Anthony J, Rawnsley J, Benhaim P, et al: Donor leg morbidity and func- Markiewicz MR, Bell RB, Bui TG, et al: Survival of microvascular free
tion after fibula free flap mandible reconstruction, Plast Reconstr Surg flaps in mandibular reconstruction: a systematic review and meta-
96:146, 1995. analysis, Microsurgery 35:576, 2015.
Bahr W: Blood supply of small fibula segments: an experimental study on Myung-Rai K, Donoff RB: Critical analysis of mandibular reconstruc-
human cadavers, J Craniomaxillofac Surg 26:148, 1998. tion using AO reconstruction plates, J Oral Maxillofac Surg 50:1152,
Blackwell K, Buchbinder D, Urken M: Lateral mandibular reconstruc- 1990.
tion using soft-tissue free flaps and plates, Arch Otolaryngol Head Neck Notani KI, Yamazaki Y, Kitada H, et al: Management of mandibular
Surg 122:672, 1996. osteoradionecrosis corresponding to the severity of osteoradionecrosis
Blackwell K: Unsurpassed reliability of free flaps for head and neck recon- and the method of radiotherapy, Head Neck 25:181, 2003.
struction, Arch Otolaryngol Head Neck Surg 125:295, 1999. Patel A, Harrison P, Cheng A, et al: Fibular reconstruction of the maxilla
Blanchaert R, Harris C: Microvascular free bone flaps, Atlas Oral Maxil- and mandible with immediate implant-supported prosthetic reha-
lofac Surg Clin North Am 13:151, 2005. bilitation: Jaw in a Day, Oral Maxillofac Surg Clin North Am 31:369,
Boyd J, Mulholland RS, Davidson J, et al: The free flap and plate in 2019.
oromandibular reconstruction: long-term review and indications, Patel A, Levine JP, Brecht L, et al: Digital technologies in mandibular
Plast Reconstr Surg 95:1018, 1995. pathology and reconstruction, Atlas Oral Maxillofac Surg Clin North
Buchbinder D: Discussion of analysis of reconstruction of mandibular Am 20:95-106, 2012.
defects using single stainless steel A-O reconstruction plates, J Oral Pogrel MA, Podlesh S, Anthony J, et al: A comparison of vascularized and
Maxillofac Surg 54:862, 1996. nonvascularized bone grafts for reconstruction of mandibular conti-
Choi S, Schwartz DL, Farwell DG, et al: Radiation therapy does not nuity defects, J Oral Maxillofac Surg 55:1200, 1997.
impact local complication rates after free flap reconstruction for head Qaisi M, Kolodney H, Swedenburg G, et al: Fibula Jaw in a Day: state
and neck cancer, Arch Otolaryngol Head Neck Surg 130:1308, 2004. of the art in maxillofacial reconstruction, J Oral Maxillofac Surg
Cordeiro P, Disa J, Hidalgo D, et al: Reconstruction of the mandible 74:1284.e1, 2016.
with osseous free flaps: a 10 year experience with 150 consecutive Rohner D, Bucher P, Hammer B: Prefabricated fibular flaps for reconstruc-
patients, Plast Reconstr Surg 104:1314, 1999. tion of defects of the maxillofacial skeleton: planning, technique, and
Cordeiro P, Hidalgo D: Soft tissue coverage of mandibular reconstruction long-term experience, Int J Oral Maxillofac Implants 28:e221, 2013.
plates, Head Neck 16:112, 1994. Sadove R, Powell L: Simultaneous maxillary and mandibular reconstruc-
Fong B, Funk G: Osseous free tissue transfer in head and neck recon- tion with one free osteocutaneous flap, Plast Reconstr Surg 92:141,
struction, Facial Plast Surg 15:45, 1999. 1993.
Foster R, Anthony J, Sharma A, et al: Vascularized bone flaps versus Serletti J, Higgins JP, Moran S, et al: Factors affecting outcome in free-
nonvascularized bone grafts for mandibular reconstruction: an out- tissue transfer in the elderly, Plast Reconstr Surg 106:66, 2000.
come analysis of primary bony union and endosseous implant suc- Serlitti J, Coniglio J, Tavin E, et al: Simultaneous transfer of free fibula
cess, Head Neck 21:66, 1999. and radial forearm flaps for complex oromandibular reconstruction,
Gilbert R, Dovion D: Near total mandibular reconstruction: the free J Reconstr Microsurg 14:297, 1998.
vascularized fibular transfer, Oper Tech Otolaryngol Head Neck Surg Shaari CM, Buchbinder D, Costantine PD, et al: Complications of mi-
4:145, 1993. crovascular head and neck surgery in the elderly, Arch Otolaryngol
Goodacre T, Walker C, Jawad A, et al: Donor site morbidity following Head Neck Surg 124:407, 1998.
osteocutaneous free fibula transfer, Br J Plast Surg 43:410, 1990. Singh B, Cordeiro PG, Santamaria E, et al: Factors associated with com-
He Y, Zhang ZY, Zhu HG, et al: Double-barrel fibula vascularized free plications in microvascular reconstruction of head and neck defects,
flap with dental rehabilitation for mandibular reconstruction, J Oral Plast Reconstr Surg 103:403, 1999.
Maxillofac Surg 69:2663-2669, 2011. Sphitzer T, Gullane PJ, Neligan PC, et al: The free vascularized flap and
Hidalgo D, Pusic A: Free-flap mandibular reconstruction: a 10 year fol- the flap plate options: comparative results of reconstruction of lateral
low-up study, Plast Reconstr Surg 110:438, 2002. mandibular defects, Laryngoscope 110:2056, 2000.
Hidalgo D, Rekow A: A review of 60 consecutive fibula free flap man- Sphitzer T, Neligan PC, Gullane PJ, et al: Oromandibular reconstruction
dible reconstructions, Plast Reconstr Surg 96:585, 1995. with the fibular free flap: analysis of 50 consecutive flaps, Arch Oto-
Hidalgo D: Discussion of Fibula osteoseptocutaneous flap for reconstruc- laryngol Head Neck Surg 123:939, 1997.
tion of composite mandibular defects, Plast Reconstr Surg 93:305, 1994. Suh JD, Sercarz JA, Abemayor E, et al: Analysis of outcome and compli-
Hidalgo D: Fibula free flap: a new method of mandible reconstruction, cations in 400 cases of microvascular head and neck reconstruction,
Plast Reconstr Surg 84:71, 1989. Arch Otolaryngol Head Neck Surg 130:962, 2004.
Horiuchi K, Hattori A, Inada I, et al: Mandibular reconstruction using Taylor GI, Miller GD, Ham FJ: The free vascularized bone graft: a clini-
the double barrel fibular graft, Microsurgery 16:450, 1995. cal extension of microvascular techniques, Plast Reconstr Surg 55(5):
Jones N, Swartz W, Mears D, et al: The “double barrel” free vascularized 533-544, 1975.
fibular bone graft, Plast Reconstr Surg 81:378, 1998. Ueyama Y, Naitoh R, Yamagata A, et al: Analysis of reconstruction of
Khatib B, Cheng A, Sim F, et al: Challenges with the Jaw in a Day tech- mandibular defects using single stainless steel A-O reconstruction
nique, J Oral Maxillofac Surg 78:1869.e1, 2020. plates, J Oral Maxillofac Surg 54:858, 1996.
Khouri RK, Cooley BC, Kunselman AR, et al: A prospective study of Urken ML, Weinberg H, Buchbinl D, et al: Microvascular free flaps in
microvascular free-flap surgery and outcome, Plast Reconstr Surg and head and neck reconstruction. Report of 200 cases and review of
102(3):711-721, 1998. complications, Arch Otolaryngol Head Neck Surg 120:633, 1994.
Kim D, Orron DE, Skillman JJ: Surgical significance of popliteal artery Wei FC, Seah CS, Tsai YC: Fibula osteoseptocutaneous flap for recon-
variants: a unified angiographic classification, Ann Surg 210:776, 1989. struction of composite mandibular defects, Plast Reconstr Surg 93:294,
Kroll SS, Schusterman MA, Reece GP, et al: Choice of flap and incidence 1994.
of free flap success, Plast Reconstr Surg 98:459, 1996. Young DM, Trabulsy PP, Anthony JP: The need for preoperative leg an-
Lee E, Goh J, Helm R, et al: Donor site morbidity following resection of giography in fibula free flap, J Reconstr Microsurg 10:283, 1994.
the fibula, J Bone Joint Surg 72:129, 1990.

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79
Iliac Crest Bone Graft: Mandibular
Reconstruction
M A R I A H A R O N , R. B R YA N B EL L , a n d A S H I S H PAT E L

CC Imaging
A 51-year-old male presents with concern that he has facial pres- Preoperative reconstructed panoramic radiograph from a cone-
sure and a growth on his face that is getting larger. beam computed tomography (CBCT) scan as shown in Fig. 79.2
demonstrates a mixed radiolucent and radiopaque osseous lesion
HPI extending from the inferior border of anterior mandible to the
alveolar ridge and from the mandibular first molar to the contra-
The patient has a history of an ossifying fibroma of his anterior lateral first molar. No pathologic fractures are present.
mandible that was excised 18 years prior. He now presents with a
new onset of firm swelling of the anterior mandible with increas- Labs
ing pressure sensation. He denies malocclusion, paresthesia, fe-
vers, weight loss, and constitutional symptoms. Baseline hemoglobin and hematocrit are obtained and found to
This is a benign but locally aggressive tumor, so segmental be within normal limits. Unpredictable blood loss is possible, so
mandibulectomy with fibular free flap reconstruction and imme- it is prudent to obtain preoperative complete blood count. Fur-
diate implant placement with prosthetic rehabilitation was rec- ther laboratory testing is dictated by the medical history.
ommended. However, the patient was opposed to this approach.
He did accept the alternative approach of a transoral excision with Assessment
extraction of mandibular incisors and peripheral ostectomy, ap-
plication of custom reconstruction plate with titanium mesh, and Incisional biopsy demonstrated an ossifying fibroma. This is a benign,
anterior iliac crest bone graft. After healing and graft consolida- recurrent tumor. Extirpation does not require a wide bony margin,
tion, secondary implant placement and prosthetic rehabilitation but this lesion occupies the full thickness of the mandible from the
were planned. alveolus to the inferior border. Tumor extirpation would result in a
near-continuity defect with substantial structural mandibular loss.
PMHX/PDHX/Medications/Allergies/SH/FH Segmental resection with an immediate fibula flap, dental implant,
and hybrid load prosthesis versus transoral marginal resection and
The patient has well-controlled hypertension. reconstruction with an iliac crest bone graft were offered.
The patient accepted the alternative approach of a transoral exci-
Examination sion with extraction of mandibular incisors and peripheral ostec-
tomy, application of custom reconstruction plate with titanium
General. The patient is a well-developed and well-nourished male mesh as shown in eFig. 79.3, and an anterior iliac crest bone graft
in no acute distress. to immediately restore the defect. After graft consolidation, second-
Maxillofacial. Gross deformation of anterior mandible ary implant placement and prosthetic rehabilitation were planned.
and chin with three-dimensional tumor expansion from the Radiographically, the tumor extended from teeth #20 to #30.
posterior mandible bilaterally as shown in eFig. 79.1. Cranial After excision of the tumor intraoperatively, the defect included
nerves II to XII are intact without paresthesias or dysesthesias of the buccal cortex from canine to canine and the marrow space
bilateral V3. from first molar to first molar. Small perforations were present
Intraoral. Submucosal tumor with deformation and buccolin- along the lingual cortex, but it was largely intact.
gual expansion of the anterior mandible and vestibule that ex-
tends from the mandibular first molar to the contralateral first Treatment
molar as shown in eFig. 79.1. Dentition is intact with a full
complement of teeth. Class 2 to 3 mobility of the anterior man- There are many approaches to reconstructing a mandibular defect.
dibular incisors. The approach is contingent on the size of the defect, available

411
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 411.e1

A B C
• eFig. 79.1 Preoperative photography taken in the operating suite demonstrating bony expansion of the
anterior mandible. A, Frontal view. B, Lateral view. C, Intraoral view.

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412 S E C TI O N Reconstructive Oral and Maxillofacial Surgery

A B
• Fig. 79.2 A, Reconstructed panoramic image from cone-beam computed tomography demonstrating
mixed radiolucency in the anterior mandible extending from the mandibular first molar to the contralateral
first molar. B, Axial computed tomography slice demonstrating intraosseous lesion with a mostly intact
lingual cortex.

resources, and patient preferences. In this case, iliac crest bone

graft was used to reconstruct the defect via an intraoral approach
with a free bone graft. The keys to success for this approach are
exposure; sterile technique; and tension free, watertight, multi-
layer closure.
Autologous bone grafts are osteogenic, osteoconductive, and
osteoinductive in nature. There are osteoinductive properties with
intrinsic bone morphogenic protein and other growth factors,
there is the presence of osteoprogenitor cells allowing for osteo-
genesis, and there are osteoconductive properties of osseous hy-
droxyapatite that provide the appropriate scaffolding. In addition,
when a graft is autologous, then it is perhaps less immunologic
without risk of foreign body reaction.
Ileum is advantageous because it can provide corticocancellous
bone as well as cancellous marrow. As a rule of thumb, each 1 cm
of linear bone defect requires 10 mL of harvested uncompressed
bone. Whereas a single anterior ilium may provide an average of
26 mL of uncompressed corticocancellous bone, a posterior ap-
proach to ilium harvest may provide 34 mL of corticocancellous • Fig. 79.4 Complete exposure after subperiosteal dissection of the tumor
bone. However, the posterior approach does require repositioning before excision. The mental nerves are preserved bilaterally.
the patient after prone posterior bone harvest, which is considered
by some to be a major disadvantage. Advantages to the posterior
approach include less postoperative pain and gait disturbances. recombinant human bone morphogenetic protein 2 (Infuse,
Contraindications to ilium harvest include active infection or Medtronic) was used to immediately reconstruct the defect.
history of trauma to the surgical site. Relative contraindications
include irradiation to the skin, chemotherapy, bisphosphonate Anterior Iliac Crest Bone Graft Harvesting
use, and long-term steroid use.
In this case, an intraoral approach with complete exposure Technique
and preparation of the recipient bed was used as shown in This approach is amenable to a two-team strategy, thereby reduc-
Fig. 79.4. During exposure, the clinician must have closure in ing the total surgical time and anesthesia time. The patient is
mind. To achieve sufficient closure, bilateral vertical releasing in- positioned supine with a soft roll bump under the gluteus maxi-
cisions are required. The flap is undermined, and the periosteum mus ipsilateral to the harvest site. In a two-team approach, both
is scored heavily to allow for advancement. A major advantage to surgical sites should be draped separately before the first incision.
this approach is the avoidance of external cutaneous scars on the The anterior superior iliac spine (ASIS) is marked out. A curvilin-
neck and face. However, there are risks with an intraoral ap- ear incision is made 2 cm lateral to the iliac crest as shown in
proach, including the possibility of abolishing the vestibular space Fig. 79.7. This distance reduces the incidence of cutaneous sen-
and graft infection or failure. Excellent exposure of the entire area sory nerve injury, reduces injury from a low waistband or belt,
to be restored is critical. In this case, to excise the tumor com- and creates a more esthetic result. The length of the curvilinear
pletely, the apices of teeth #22, #27, and #31 were shaved as incision is dependent on the needs for adequate exposure but may
shown in eFig. 79.5. The teeth left in place were periodontally be up to 3 cm in length following the natural skin lines.
sound. As shown in Fig. 79.3 and eFig. 79.6, a prebent Stryker To reduce morbidity, it is important to respect fascial planes
2.3-mm locking reconstruction plate with titanium mesh and an and minimize muscle dissection. The incision is made to superfi-
autogenous cancellous iliac crest bone graft with the addition of cial abdominal Camper’s fascia and deep to that, Scarpa’s fascia,

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 412.e1

• eFig. 79.5 Teeth and tumor fragments after complete tumor excision.
• eFig. 79.3 Prebent Stryker 2.3-mm locking reconstruction plate on a
three-dimensional printed model.

• eFig. 79.6 After excision of tumor, photograph demonstrates adaptation

of prebent Stryker plate and titanium mesh while preserving bilateral men-
tal nerves.

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 CHAPTER 79 Iliac Crest Bone Graft: Mandibular Reconstruction 413

Anterior tubercle of the ilium and a self-retaining retractor is applied. At this point, the fascia
Anterior superior iliac spine overlying the iliac crest is sharply incised, and blunt dissection is
carried over the crest to identify the external oblique muscle over
the crest and the tensor fascia lata muscle laterally. On the crest of
the ridge, the fascia and periosteum are sharply incised to expose
the iliac crest without violating the muscle on either side.
The surgeon should remain 2 to 3 cm posterior to the anterior
iliac spine to avoid fracture. The cortical window size depends on
the amount of cancellous bone needed. The osteotome can be
A used to elevate the medial aspect of the cap; it should be directed
laterally to avoid peritoneal penetration. The inferior extent
should not extend more than 3 to 5 cm; otherwise there is risk of
Subcostal n. injury to the lateral femoral cutaneous nerve. The cap is reflected
Posterior iliac crest to expose the cancellous bone with the muscle and periosteum left
Iliohypogastric n. intact laterally. After the marrow space is accessed, bone is har-
Anterior iliac spine Psoas m. vested with curettes and bone rongeurs. Care should be taken not
Tensor fascia lata
Gluteus medius m.
to breach the medial or lateral wall of the iliac crest.
Iliacus m. There are several possible harvesting methods. One approach is
Inguinal ligament
Lateral femoral the outer table approach, which retrieves bone from the outer
cutaneous n. cortex. The intracortical method harvests cancellous bone from
Gluteus
maximus m. between the cortices via a small window in the iliac crest cortex or
Sartorius m. trap door. Alternatively, the modified technique harvests bone
medially from ASIS. The minimally invasive technique uses a
trephine or cylinder osteotome to minimally dissect. Studies show
there is no statistically significant difference in morbidity between
the open and minimally invasive techniques.
B
After harvest, the donor site is thoroughly irrigated, and me-
ticulous hemostasis is achieved. A possible adjunct is an absorbable
sponge such as Gelfoam soaked in bupivacaine to further achieve
hemostasis and to reduce postoperative pain. The periosteum and
fascia are closed with 2-0 absorbable suture. Subcutaneous layers
are closed in a two-layer fashion to minimize dead space. The skin
may be closed with a continuous running suture, and then skin
tape may be applied with an overlying pressure dressing.
The harvested bone is milled and compressed into syringes as
shown in eFig. 79.8. This increases the density of endosteal osteo-
blastic cells. As shown in eFig. 79.9, the graft may be stabilized
Iliacus m. with a crib technique. Cribs may be created with resorbable or
Tensor fascia lata m. titanium mesh, titanium reconstruction plate, cadaveric cribs, or
autogenous ribs. The crib can be secured via suture to the deep
tissues or via screws, as done in this case, to help prevent migra-
tion of the bone graft. The grafted bone is then packed into the
Gluteus medius m.
crib-supported defect from above as demonstrated in eFigs. 79.8
and 79.9. The wound is closed in layers to further stabilize the
graft as shown in eFig. 79.10. The flap is undermined, and the
periosteum is scored heavily to allow for advancement. The flap
should close over the graft without any tension. Mattress sutures
are used to relieve tension from wound edges and achieve water-
C tight closure.
• Fig. 79.7 A, Use of a soft roll under the ipsilateral graft site to elevate and
better expose the anterior iliac crest. The dashed line marks the incision, Posterior Iliac Crest Bone Graft Harvesting
which should remain 2 cm lateral to the crest and posterior to the iliac Technique
spine. B, Anatomic view showing the relationship of muscular and neuro-
vascular structures. C, Lateral view of the anterior iliac crest in relationship If a larger volume of cancellous bone is required, then the opera-
to the surrounding muscles. m, Muscle; n, nerve. (From Atlas of Oral and tor could consider using the posterior approach. This technique
Maxillofacial Surgery. Chapter 121 Anterior Iliac Crest Bone Grafting can provide 34 mL of uncompressed bone, and some studies show
(AICBG). 2016.) up to three times more cancellous bone can be obtained in the
posterior approach than the anterior approach to the iliac crest.
Overall, there is lower morbidity than with the anterior approach.
However, it does require prone positioning, necessitating that the
patient be flipped midway through the general anesthetic, and
only one team can be used.

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 413.e1

• eFig. 79.8 Milled bone harvested from the anterior iliac crest being deposited via a syringe into the re-
cipient bed.

A B
• eFig. 79.9 A, Milled bone harvested from the anterior iliac crest being packed into the recipient bed with
mesh crib to assist in containment of the grafted material. B, View of the grafted material packed in place
with a titanium plate and mesh containment.

• eFig. 79.10 View of the watertight closure.

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 414 S E C TI O N Reconstructive Oral and Maxillofacial Surgery

Complications
When choosing a particular harvesting technique and the overall
surgical approach, the greater the graft volume required, the
greater the donor site complications.

Superior cluneal nn.

Sensory Nerve Injury, Pain, and Gait Disturbance
Pain and sensory disturbances are the most common complaint
Thoracolumbar fascia after iliac crest bone graft, including hyperesthesia, hypoesthesia,
Gluteus maximus m. and dysesthesia. Persistent pain may occur in as many as one-third
of patients. The incidence of chronic pain more than 6 months
Medial cluneal nn.
and sensory disturbances were 7.75% and 4.8%, respectively. The
most common injury is of the lateral femoral cutaneous nerve
(LFCN) or cutaneous branches of the subcostal nerve. It is recom-
mended to terminate the incision 1.5 to 2.0 cm posterior to the
ASIS to reduce LFCN injury. There is a higher chance of LFCN
damage when the graft is larger because there is a larger incision
and the iliacus muscle is widely retracted. When the graft is
smaller than 3 cm in length, there is an 8% chance of LFCN dam-
age. When the graft is 4.5 cm or larger, LFCN damage was 20%.
A A modified technique with a medial approach decreases gait dis-
turbances. Posteriorly, one should be cognizant of the iliohypo-
gastric nerve that travels near the iliac tubercle. In the posterior
technique, violation of the sacroiliac joint is a source of chronic
pain. Excess retraction during the operation increases the inci-
dence of postoperative pain. The iliac crest contour should be
Posterior iliac crest
preserved to reduce the incidence of gait disturbance. Closure of
Gluteus
maximus m. the soft tissue musculature and fascia in a tension-free manner
minimizes gait disturbance and pain. The surgeon may provide
Thoracolumbar fascia local infiltration at the end of the procedure to reduce pain in the
acute period. Studies show a significantly reduced pain score, a
faster time to ambulation, and shorter hospital stays if the surgeon
uses an absorbable sponge, such as Gelfoam, soaked in bupiva-
caine, in the surgical site before closure. After surgery, a patient
B should avoid full-leg weight bearing for at least 1 week on the side
of graft harvest. Patients should be instructed to avoid exercise
• Fig. 79.11 A, Anatomic view illustrating the relationships of the muscular and heavy lifting for at least 6 weeks. Gait disturbance is common
and neuromuscular structures. The dashed line marks the incision, which
in the immediate postoperative period and is usually self-limiting,
should remain 1 cm from the posterior iliac spine. B, Dissection showing
the relationships of important structures. m, Muscle; nn, nerves (From
lasting less than 2 weeks. Gait disturbance can be caused by strip-
Atlas of Oral and Maxillofacial Surgery. Chapter 122 Posterior Iliac Crest ping lateral iliac crest periosteum, which weakens the attachments
Bone Grafting. 2016.) of the gluteal musculature. Gait disturbance may also occur be-
cause of cutting through gluteal muscle in the posterior tech-
nique; if this occurs, then physical therapy can usually reestablish
normal function.
To start, the patient is placed in the prone jackknife position
with the table flexed at 210 degrees. The posterior ilium is identi-
Fracture
fied, and a curvilinear incision is made 1 cm from the posterior
iliac spine extending 5 to 6 cm along the crest superolaterally as Anterior and posterior iliac spine fractures are rare but are slightly
shown in Fig. 79.11. Note the sciatic notch and do not dissect more common with the anterior technique. It may be more likely
too close to avoid the superior gluteal artery and nerve. To reduce if a large cortical graft is retrieved. In the anterior technique, re-
morbidity and pain, remain 3 cm from midline to avoid superior maining 3 cm posterior to the ASIS helps to prevent pathologic
cluneal nerves and to avoid violation of the sacroiliac joint. Blunt avulsion fracture. In the posterior technique, harvest should be
dissection to the periosteum is performed while remaining along inferior to the crest of the posterior iliac ridge to avoid fracture.
the crest to not cut through gluteal muscle. The inferior extent is Overall, the risk of fracture can be reduced with proper osteotomy
5 cm from the crest. The cortical block is removed to harvest design.
cancellous bone with curettes and osteotomes. Any sharp, bony
edges are rounded with a rasp. The operator may decide whether Infection and Delayed Wound Healing
a drain is necessary pending hemostatic control during the op-
eration. Layered closure is achieved, and a pressure dressing is This risk can be minimized with sterile technique and preopera-
applied. tive prophylactic antibiotics.

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 CHAPTER 79 Iliac Crest Bone Graft: Mandibular Reconstruction 415

Hematoma and Seroma Formation an impact on the cosmetic outcome. If the superior cortex
is not replaced, then it leads to skin depressions at the site of
Hematoma formation is more common with the anterior technique. graft removal. One may use hemostatic agents and bone graft
The operator minimizes the risk of hematoma development by care- substitutes such as resorbable mesh and allograft materials
ful surgical technique, minimizing unnecessary dissection and en- or even allogeneic rib to reform the appropriate anatomic
suring hemostasis before wound closure. If an expanding hematoma bony contours. For large defects, corticocancellous allograft
does develop, then drainage and control of the hemorrhage with a chips provide a simple and predictable solution for donor site
return trip to the operating room may be required. Bleeding may be reconstruction.
managed with gelatin sponges, microfibrillar collagen, or electrocau-
tery or ligation for brisk bleeding. In the posterior technique, if the
hematoma is not expansile, then a pressure dressing may be applied Discussion
followed by close observation. Seroma formation is most common When performing an anterior iliac crest bone graft, it is impor-
in the posterior technique, especially when drains are not used or if tant to keep anatomy in mind, especially the lateral femoral
they are removed too early or if exercise is resumed too quickly. cutaneous nerve and iliohypogastric nerve, to avoid long-term
sensory nerve injury. Remaining 2 cm lateral to the anterior iliac
Hernia crest has been shown to be a safe distance to avoid nerve injury.
Excessive traction and dissection of the inner table musculature With a posterior approach, one should remain 3 cm from mid-
and abdominal wall increases the risk of hernia formation. In ad- line to avoid the cluneal nerves. When using an intraoral ap-
dition, the risk of hernia is reduced by maintaining the contour of proach for the recipient bed, it is important to obtain adequate
the iliac crest. The clinician may reconstruct large-volume donor exposure; ensure sterile technique; and provide a tension-free,
sites with bovine block bone substitution to reduce the likelihood watertight, multilayered closure. The iliac crest is an excellent
of hernia formation. source of autogenous bone and can be harvested quickly and
safely if the associated anatomy is respected. Autogenous iliac
Cosmetic Defect crest graft provides predictable outcomes for a variety of oral
and maxillofacial osseous defects.
Contour irregularities can be avoided by harvesting cortical
bone medially when performing an anterior approach to iliac ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
crest bone graft. Treatment of the cortices after harvest has complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 415.e1

Bibliography Ebraheim NA, Yang H, Lu J, et al: Anterior iliac crest bone graft. Ana-
tomic considerations, Spine (Phila Pa 1976) 22(8):847-849, 1997.
Goulet J, Senunas LE, DeSilva GL, et al: Autogenous iliac crest bone
Bauer TW, Muschler GF: Bone graft materials. An overview of the basic graft complications and functional assessment, Clin Orthop Relat Res
science, Clin Orthop Relat Res (371):10-27, 2000. (339):76-81, 1997.
Burk T, Del Valle J, Finn RA, et al: Maximum quantity of bone available Hu R, Hearn T, Yang J: Bone graft harvest site as a determinant of iliac
for harvest from the anterior iliac crest, posterior iliac crest, and crest strength, Clin Orthop Relat Res 310:252-256, 1995.
proximal tibia using a standardized surgical approach: a cadaveric Kilinc A, Korkmaz IH, Kaymaz I, et al: Comprehensive analysis of the
study, J Oral Maxillofac Surg 74(12), 2532-2548, 2016. volume of bone for grafting that can be harvested from iliac crest
Dashow J, Lewis CW, Hopper RA, et al: Bupivacaine administration and donor sites, Br J Oral Maxillofac Surg 55(8):803-808, 2017.
postoperative pain following anterior iliac crest bone graft for alveolar Mirovsky Y, Neuwirth M: Comparison between the outer table and in-
cleft repair, Cleft Palate Craniofac J 46(2):173-178, 2009. tracortical methods of obtaining autogenous bone graft from the iliac
Defino H, Rodriguez-Fuentes AS: Reconstruction of anterior iliac crest crest, Spine 25(13):1722-1725, 2000.
bone graft donor sites: presentation of a surgical technique, Eur Spine Murata Y, Takahashi K, Yamagata M, et al: Injury to the lateral femoral
J 8:491-494, 1999. cutaneous nerve during harvest of iliac bone graft, with reference to
Dimitriou R, Mataliotakis GI, Angoules AG, et al: Complications fol- the size of the graft, J Bone Joint Surg Br 84:798-801, 2002.
lowing autologous bone graft harvesting from the iliac crest and using Shepard GH, Dierberg WJ: Use of cylinder osteotome for cancellous
the RIA: a systematic review, Injury 42:S3-S15, 2011. bone grafting, Plastic Reconstr Surg 80(1):129-132, 1987.
Dusseldorp J, Mobbs R: Iliac crest reconstruction to reduce donor-site Torre J, Tenenhaus M, Gallagher PM, et al: Harvesting iliac bone graft:
morbidity: technical note, Eur Spine J 18:1386-1390, 2009. decreasing the morbidity, Cleft Palate Craniofac J 36(5):388-390, 1999.

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80
Anterolateral Free Flap
CHI T. VI E T, KO LI N A M A H - G I N N , C AIT LY N M c G U E, and AN A S TA SI YA Q U IM B Y

CC involves the mandibular gingiva from premolar to premolar

region. No gross mobility of mandibular teeth. Labial gingival
The patient states, “My surgeon sent me here to discuss recon- recession of adjacent mandibular incisors. No other oral or oro-
struction for cancer surgery.” pharyngeal lesions.
Nasal fiberoptic endoscopy. No nasal, posterior oropharyn-
HPI geal, or laryngeal lesions. Epiglottis, arytenoids, and aryepiglottic
folds with no masses, lesions, or ulcerations. Vocal cords are sym-
A 54-year-old male is referred from otolaryngology for evaluation metric with no masses, lesions, or ulcerations.
of reconstructive needs in anticipation of resection of cT4aN3bM0 Neck. Bilateral submandibular mass, 15 cm in greatest diam-
squamous cell carcinoma (SCC) involving the floor of the mouth, eter with indurated and fixed overlying skin. Mild skin erythema,
anterior mandible, and ventral tongue. The patient reports that he no ulceration. Palpable, indurated level Ib and IIa lymph nodes
has developed a large neck mass over the course of the past several on the right.
months, but because of difficulties obtaining insurance, he was Pulmonary. No wheezes or rhonchi. Respirations even and
unable to see a physician until recently. He reports that he has lost unlabored on room air.
more than 25 lb in the past 6 months, has severe pain in his Cardiac. Regular rate and rhythm.
mouth that makes it very difficult for him to eat, and overall feels Gastrointestinal. Abdomen soft, not tender to palpation, no
more fatigued. Since developing the mouth sore that has progres- distension.
sively increased in size, he switched his diet to a soft diet and then Extremities. Bilateral lower extremities with no edema, no
to a full liquid diet and has been drinking protein shakes to sup- varicosities, no ulceration, and no deformities. Dorsalis pedi and
plement his nutrition. posterior tibial pulses 21.

PMHX/PDHX/Medications/Allergies/SH/FH Preoperative Assessment

The patient has hypertension, hyperlipidemia, chronic obstructive Handheld Doppler ultrasound is used to identify perforators.
pulmonary disease, and benign prostatic hyperplasia. His medica-
tions include lisinopril, atorvastatin, a fluticasone–salmeterol inhaler, Imaging
and tamsulosin. He has no known allergies and no surgical history.
The patient is a current daily cigarette smoker (50-pack-year If the patient has a palpable popliteal pulse, no further preopera-
history). He recently started smoking marijuana to help with tive imaging is warranted before anterolateral thigh free flap har-
pain. He drinks alcohol socially and denies illicit drug use. vesting. However, popliteal pulses can be challenging to palpate
His mother died at 82 years of age because of a heart attack, clinically, especially in patients with higher BMIs. If popliteal
and his father died at age 78 years because of colon cancer. pulses cannot be palpated, the authors recommend handheld
Doppler ultrasound assessment. If the Doppler signal cannot be
Examination identified, preoperative computed tomography (CT) angiography
of the lower extremities could be considered.
General. Thin, tall, in no acute distress but appears uncomfortable.
Vital signs. Blood pressure is 134/86 mm Hg; heart rate is Labs
88 bpm; oxygen saturation is 99% on room air; weight is 145 lb
(65.7 kg); height is 6 ft, 2 in (187 cm); and body mass index There are no specific laboratory tests required before anterolateral
(BMI) is 18.6. thigh free flap harvest; however, standard laboratory tests should
Head. Normocephalic, atraumatic, no gross facial asymmetry. always be obtained before major surgery and typically include a
Intraoral. Maximal incisal opening is 45 mm. Partially eden- complete blood count, basic metabolic profile, prothrombin
tulous maxilla and mandible. Anterior floor of the mouth time, partial thromboplastin time, international normalized ra-
and ventral tongue with 6-cm ulcerative, erosive mass. Decreased tio, type and screen, and a pregnancy test in females of childbear-
tongue mobility, exquisitely tender to palpation. The mass ing age.

416
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 CHAPTER 80 Anterolateral Free Flap 417

Assessment
cT4aN3bM0 (greatest clinical tumor dimension is .4 cm with
depth of invasion .10 mm or tumor invades adjacent structures
only; metastasis in a lymph node .6 cm in greatest dimension or the
presence of clinically evident extranodal extension) SCC of the floor of
the mouth with no mandibular marrow involvement on CT of the
neck (Fig. 80.1).

Treatment
Because the anticipated defect consisted of an intra- and extraoral
soft tissue defect with mandibular continuity maintenance, sev-
eral reconstructive options were discussed with the patient, in-
cluding anterolateral thigh flap (ALT), thoracodorsal artery perfo-
rator flap (TDAP), and a combination of pectoralis major and
supraclavicular flaps, as well as local tissue advancement flaps to
facilitate closure of the extraoral cervical defect. The patient opted
to proceed with an ALT because it appeared to have the least
morbidity to him.
The ablative portion of the procedure was completed and in- • Fig. 80.2 Outline of the planned tumor resection.
cluded a tracheostomy, tumor resection, and bilateral modified
radical neck dissection. The anterolateral thigh free flap was har-
vested simultaneously.
The patient was placed under general anesthesia and under-
went a tracheostomy to secure his airway. The planned resection
was outlined using a marking pen with a 1.5-cm circumferential
margin intraorally and a 1-cm margin around the area of cutane-
ous involvement in the left neck (Fig. 80.2). Modified radical
neck dissections were completed bilaterally to facilitate access to
the primary tumor. The composite resection included the ventral
tongue, floor of the mouth, and marginal mandibulectomy,
which was left in continuity with the lymph node dissection
specimen to allow for appropriate margin assessment (Fig. 80.3).
Resection margins were confirmed to be free of residual tumor
with frozen sections.

• Fig. 80.3 Composite resection including the ventral tongue, floor of the
mouth, and marginal mandibulectomy, maintained in continuity with the
lymph node dissection specimen.

The anterolateral thigh free flap was harvested simultaneously.

The ALT is based on cutaneous perforators from the lateral cir-
cumflex femoral artery (LCFA) and lateral circumflex femoral
vena comitantes. Sensory reinnervation can be achieved using the
lateral femoral cutaneous nerve. A large amount of skin and a
variable amount of subcutaneous tissue are available for transfer,
frequently obtaining primary closure with minimal donor site
morbidity. This makes the ALT a good reconstructive option for
a variety of soft tissue defects in the head and neck.
An elliptical skin paddle should be designed with a width per-
mitting primary closure of the donor site. However, if wider skin
paddles are required, a split-thickness skin graft can be used to
repair the donor site defect. The anterolateral thigh free flap is
centered around a long axis parallel to and a few centimeters lateral
to a line drawn from the anterior superior iliac spine (ASIS) to the
• Fig. 80.1 Patient with cT4aN3bM0 squamous cell carcinoma involving lateral border of the patella, which typically indicates the position
the floor of the mouth, anterior mandible, and ventral tongue. of the intermuscular septum. LCFA cutaneous perforators are

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418 S E C TI O N XI I Reconstructive Oral and Maxillofacial Surgery

• Fig. 80.4 A line is marked from the anterior superior iliac spine to the
• Fig. 80.5 The rectus femoris muscle is retracted medially while the vas-
lateral patella. At the midpoint, a circle with a 3-cm radius denotes the area
tus lateralis muscle is retracted laterally. The descending and oblique
most likely to contain cutaneous perforators. The four Doppler-identified
branches of the lateral circumflex femoral artery can be identified.
perforators are marked with large dots.

typically located within a 3- to 5-cm radius from the midpoint of

this axis (Fig. 80.4).
In the current patient, four cutaneous perforators were identi-
fied with the aid of a handheld Doppler probe. Yu et al. developed
the “ABC” system to localize cutaneous perforators without the
need for preoperative Doppler studies. In their dissection of 72
ALTs, they identified one to three cutaneous perforators in 71 of
the flaps. The most consistently present perforator was located
around the midpoint between the ASIS and the superolateral
patella. A more proximal or more distal perforator may also be
found, with each perforator being approximately 5 cm apart from
each other. These were labeled as perforator A (proximal), perfora-
tor B (middle), and perforator C (distal) to help simplify discus-
sions regarding the anatomic locations of these perforators. Studies
by Yu and Adel showed that Doppler evaluation is highly sensitive • Fig. 80.6 Myofasciocutaneous anterolateral thigh flap pedicle.
(91%–100%) but not specific (0%–55%) in identifying perfora-
tor location intraoperatively. This was particularly true in patients
with higher BMIs. They demonstrated the efficacy of using the divided. After the muscle was freed, the pedicle was mobilized;
previously mentioned landmarks without the need for preopera- wrapped in a moist, warm sponge; and set aside (Fig. 80.6).
tive Doppler evaluation when designing the ALT. The vena comitantes and the descending branch of the LCFA
After the perforators were identified, the medial incision line were individually dissected to allow for division and anastomosis.
of the skin paddle was marked out. Monopolar electrocautery was When the head and neck team were ready, the flap pedicle was
then used to make a skin incision through the subcutaneous plane ligated and brought up to the head and inset was started with 3-0
and rectus femoris muscle fascia. The rectus femoris muscle was Vicryl sutures.
then retracted medially while the rectus femoris muscular fascia Primary flap thinning is a method of thinning the subcutaneous
and fascia lata were retracted laterally (Fig. 80.5). Subfascial dis- fat to a 3- to 4-mm layer at the time of flap harvest when less bulk
section was carried out medially to identify the muscular septum. is preferred. This was not performed in the current patient because
The LCFA was identified and noted to course on the undersurface an increased flap thickness was desired to reduce the risk of an
of the vastus lateralis muscle. Cutaneous perforators were identi- orocutaneous fistula through the floor of the mouth. It should be
fied and the proximal pedicle was dissected out. noted that flap thinning can disrupt the vascular supply at the level
After the ablative team completed the resection, the final de- of the deep fascia, posing a risk for skin necrosis.
fect size was measured to be 11 cm 3 17 cm, including intra- and The facial artery was anastomosed to the recipient artery in an
extraoral components. The extraoral defect measured 7 cm in di- end-to-end fashion using 9-0 nylon sutures. The internal jugular
ameter. The defect was then traced and transferred to the thigh. vein was further dissected, and a branch vein was identified and
The lateral extent of the flap was marked, and monopolar electro- confirmed to be a good match for the recipient vein. Venous
cautery was used to incise through skin, subcutaneous tissues, and anastomosis was then completed with a size 2.0 vein coupler.
fascia. Subfascial dissection was again carefully carried out medi- Clinical assessment of flap color and texture, capillary refill, and
ally. Because of a floor-of-mouth and submental defect, a portion Doppler signals were used to ensure adequate perfusion.
of the vastus lateralis was included for transfer with the flap. Intraoral inset was then performed with 3-0 Vicryl sutures
The muscle was further dissected out with care taken to protect in a watertight fashion (Fig. 80.7). The distal extent of the skin
the pedicle and the identified musculocutaneous perforator. The paddle was transferred to the left neck. The portion of the
motor branch nerve entering the vastus lateralis was clipped and flap traversing medial to the mandible was de-epithelialized. The

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 CHAPTER 80 Anterolateral Free Flap 419

• Fig.80.7 Postoperative photograph demonstrating intraoral inset.

• Fig.80.8 Postoperative photograph of anterolateral thigh flap recon-
struction with a Jackson-Pratt drain in place. Note the skin paddle at the
left neck in addition to the intraoral extent of the flap.
remaining skin paddle was then brought into the cutaneous neck
defect. To reduce the defect size, an additional cervicofacial flap
was designed with the incision placed along the melolabial fold. proximal branches. Only the most proximal branch must be preserved
Subcutaneous dissection was carried out until adequate inferior if multiple rectus femoris branches are present.
and medial rotation was achieved. A combination of cervicofacial Other complications of anterolateral thigh free flap are attrib-
advancement flap and ALT skin paddle allowed for reconstruction utable to anatomic considerations and variations. Many studies
of the extraoral defect with minimal tension and distortion of have demonstrated most cutaneous perforators from the LCFA
facial anatomic subunits. The remaining skin paddle in the neck take a musculocutaneous course through the vastus lateralis
was then inset with 3-0 Vicryl sutures. The cervical incisions were muscle. Although type I musculocutaneous perforators arise from
closed over quarter-inch Penrose drains bilaterally in the typical the descending branch of the LCFA and have a relatively short
fashion using 3-0 Vicryl deep suture and 4-0 running nylon su- course through the vastus lateralis muscle, type II musculocutane-
tures for skin closure (Fig. 80.8). ous perforators that arise from the transverse branch of the LCFA
A 15-Fr Jackson-Pratt drain was placed, and closure of the have a relatively long (#10 cm) intramuscular course before
donor site was completed using 3-0 Vicryl deep sutures and 4-0 reaching the thigh skin. Because this intramuscular course can be
Monocryl running subcuticular suture for the skin. Alternatively, difficult to determine, it is recommended to unroof the muscle
the skin could also be closed with staples. fibers over the perforators to establish the perforator supplying the
skin paddle while avoiding unintentional injury to the perforator
Complications during incision of the muscle. Additional studies have shown evi-
dence of a more proximal “bail-out” perforator in most cases that
Long-term complications of anterolateral thigh free flaps are rare, can be used as an alternative if the initial identified perforator has
and complications that have been reported rarely result in long- a long intramuscular course that would require tedious and time-
term problems affecting daily activities. Although studies have consuming dissection. However, the use of these “bail-out” perfo-
demonstrated minimal donor site morbidity, with sensory loss of rators is limited by shorter pedicle lengths, smaller caliber, and
the upper leg being most frequently reported, there have been thicker subcutaneous tissue in the proximal thigh.
reports that show extensive elevation and harvest of the leg fascia Furthermore, in approximately 5% of cases, on exploration,
with the ALT flap are significantly associated with persistent leg only type III perforators can be identified. Type III perforators are
weakness. Excess bulk of the flap and poor skin match between less than 1 mm in diameter and are not suitable for microvascular
donor thigh skin and recipient facial skin have also been noted. anastomosis. For this reason, it may be prudent to prepare for
Additionally, wide flaps requiring skin grafting of the donor site bilateral thigh exploration in every patient. Alternatively, the ini-
defect or where there was damage to the vastus lateralis muscle tial skin incision could be used to convert the flap harvest to an
have also been associated with increased donor site morbidity. anteromedial thigh or tensor fascia lata flap.
Because the rectus femoris muscle receives its blood supply from
the LCFA, it is at risk of ischemic necrosis when the artery is elimi- Discussion
nated. Therefore, if the LCFA vascular pedicle distal to the rectus
femoris branches has sufficient caliber and length for microvascular Almost 40 years ago, Song et al. first described the anterolateral
anastomosis, it is imperative to preserve these when dissecting the thigh free flap as a soft tissue flap perfused by septocutaneous

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420 S E C TI O N XI I Reconstructive Oral and Maxillofacial Surgery

branches of the LCFA. However, further studies have demonstrated adjusted based on the technique used to harvest the flap. A supra-
most anterolateral thigh free flaps are supplied by musculocutaneous fascial flap dissection produces a thinner cutaneous flap, and a
perforators of the LCFA that penetrate the medial edge of the vastus subfascial dissection produces a thicker fasciocutaneous flap. As
lateralis muscle. Since that time, ALTs have become popular options demonstrated in this case presentation, variable amount of vastus
for reconstruction of head and neck defects. lateralis muscle can also be taken to further increase flap bulk.
Because of their versatility, ALT flaps can be used to recon- Thin ALT flaps can be used for tongue reconstruction after
struct a variety of soft tissue defects in the head and neck hemiglossectomy. Farace et al. demonstrated that speech and
(Fig. 80.9), especially defects of the oral cavity such as those in- swallowing outcomes using an ALT flap compared with a radial
volving the tongue, buccal mucosa, palate, and lips. Additionally, forearm flap for hemiglossectomy were not significantly differ-
they can be used for reconstruction of the pharyngoesophageal ent. When a defect leaves less than 33% of the original tongue,
segment, skull base, face, and scalp. They offer the advantage of reconstruction shifts to the restoration of bulk, favoring a thick
allowing for transfer of a large skin paddle, harvesting flaps up to ALT flap that can be harvested for total or near-total glossecto-
30 cm in length and 20 cm in width. Additionally, they can be mies. ALTs containing vascularized fascia lata can be used for
harvested as a chimeric flap, and with variable amounts of subcu- reconstruction of extensive lip defects, providing static suspen-
taneous tissue. Chimeric ALT flaps can be designed to have inde- sion of lip position. Fascia lata can also be harvested to repair
pendent skin paddles and muscle and can include tensor fascia resected dura.
lata. Chimeric ALT flaps are especially useful in total glossectomy Anterolateral thigh flaps provide a sufficient source of skin that
defects in which the skin paddle can be thinned out and folded might be needed for pharyngoesophageal reconstruction. Multi-
into a complex three-dimensional structure resembling a tongue, ple studies have demonstrated the efficacy of ALTs in restoration
and the muscle component is used to provide bulk in the floor of of tracheoesophageal speech and the ability to tolerate a regular
the mouth to support it (Fig. 80.10). ALT flaps provide an inter- oral diet in patients who have undergone laryngopharyngectomy.
mediate thickness of subcutaneous fat, with studies demonstrat- Furthermore, Agostini and Agostini discuss an adipofascial flap
ing a range from 7 to 15 mm. This varies based on gender and that can be harvested by excising the skin and superficial subcuta-
BMI. The volume of subcutaneous tissue to be transferred can be neous tissues to yield a flap composed of vascularized fascia lata

A B

C D
• Fig. 80.9 A, Squamous cell carcinoma recurrence in the submental region. B, Resected specimen. C,
Bilateral neck dissections with soft tissue defect of the submental region. D, Final inset of ALT flap, with
prolene suture marking the perforator signal. The ALT flap was chosen for its bulk and availability of a large
skin paddle.

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 CHAPTER 80 Anterolateral Free Flap 421

A B

C D
• Fig. 80.10 Example of a chimeric anterolateral thigh flap used to reconstruct a glossectomy defect. A,
Chimeric ALT flap with harvest of septocutaneous and myocutaneous components connected to perfora-
tor vessels. B, Harvested chimeric flap. C, The septocutaneous portion of the flap has been folded into a
3D configuration resembling a tongue. D, Final inset of the chimeric flap with the septocutaneous portion
reconstructingt the tongue and the myocutaneous portion providing bulk in the floor of the mouth.

with variable subcutaneous fat. Adipofascial flaps can more pre- settings. These flaps offer many advantages for head and neck re-
cisely match the volume of the defect and have improved scar construction, including long and consistent vascular pedicles; the
contracture. This allows them to better simulate the appearance ability to be harvested with a two-team approach; a large cutane-
and function of the oral mucosa. ous area for transfer; the possibility for reinnervation; and the
Sensory reinnervation of ALTs using the lateral femoral cuta- ability to be raised as septocutaneous, fasciocutaneous, or myocu-
neous nerve has also been achieved. Studies have shown improved taneous flaps (Alkureishi, Shaw-Dunn, & Ross, 2003; Blackwell,
two-point discrimination, monofilament threshold testing, pain 2012; Chana & Wei, 2004; Chen, Chen, & Lai, 2005; Lipa,
sensation, and temperature sensation compared with nonsensate Novak, & Binhammer, 2005; Mureau, Posch, & Meeuwis, 2005;
flaps. Yu demonstrated similar sensory ranges for two-point dis- Nakayama, Hyodo, & Hasegawa, 2002; Ross, Dunn, & Kirkpat-
crimination and threshold testing to those for native tongue and rick, 2003; Yu, 2004a, 2004b). Furthermore, there are minimal
reinnervated radial forearm free flaps. This greatly improved pa- donor site complications, and the donor site can often be closed
tient satisfaction and may be related to significant improvements primarily. These advantages and the proven success of the ALT
in swallowing function in the same study. flap will continue to make it one of the preferred reconstructive
In summary, the anterolateral thigh free flap is a versatile and options in head and neck surgery.
reliable option for reconstruction of numerous head and neck
defects. Variations on flap harvest technique have allowed its use ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
to be broadened to restore form and function in a wide variety of complete set of bibliography.

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 421.e1

Bibliography Mureau MA, Posch NA, Meeuwis CA, et al: Anterolateral thigh flap re-
construction of large external facial skin defects: a follow-up study on
functional and aesthetic recipient- and donor-site outcome, Plast Re-
Agostini T, Agostini V: Further experience with adipofascial ALT flap constr Surg 115(4):1077-1086, 2005.
for oral cavity reconstruction, J Plast Reconstr Aesthet Surg 61(10): Nakayama B, Hyodo I, Hasegawa Y, et al: Role of the anterolateral thigh
1164-1169, 2008. flap in head and neck reconstruction: advantages of moderate skin
Alkureishi LW, Shaw-Dunn J, Ross GL: Effects of thinning the anterolat- and subcutaneous thickness, J Reconstr Microsurg 18(3):141-146,
eral thigh flap on the blood supply to the skin, Br J Plast Surg 2002.
56(4):401-408, 2003. Rosenthal EL, King T, McGrew BM, et al: Evolution of a paradigm for
Amin A, Rifaat M, Civantos F, et al: Free anterolateral thigh flap for re- free tissue transfer reconstruction of lateral temporal bone defects,
construction of major craniofacial defects, J Reconstr Microsurg 22(2): Head Neck 30(5):589-594, 2008.
97-104, 2006. Ross GL, Dunn R, Kirkpatrick J, et al: To thin or not to thin: the use of
Blackwell KE: Anterolateral thigh free flap. In: Urken ML, Cheney ML, the anterolateral thigh flap in the reconstruction of intraoral defects,
Blackwell KE, et al., (eds): Atlas of Regional and Free Flaps for Head Br J Plast Surg 56(4):409-413, 2003.
and Neck Reconstruction, ed 2, Lippincott Williams & Wilkins, Saint-Cyr M, Schaverien M, Wong C, et al: The extended anterolateral
Philadelphia, 2012, pp 234-256. thigh flap: anatomical basis and clinical experience, Plast Reconstr Surg
Chana JS, Wei FC: A review of the advantages of the anterolateral thigh 123(4):1245-1255, 2009.
flap in head and neck reconstruction, Br J Plast Surg 57(7):603-609, Shieh SJ, Chiu HY, Yu JC, et al: Free anterolateral thigh flap for recon-
2004. struction of head and neck defects following cancer ablation, Plast
Chen CM, Chen CH, Lai CS, et al: Anterolateral thigh flaps for recon- Reconstr Surg 105(7):2349-2360, 2000.
struction of head and neck defects, J Oral Maxillofac Surg 63(7): Shimizu T, Fisher DR, Carmichael SW, et al: An anatomic comparison
948-952, 2005. of septocutaneous free flaps from the thigh region, Ann Plast Surg
Choi SW, Park JY, Hur MS, et al: An anatomic assessment on perforators 38(6):604-610, 1997.
of the lateral circumflex femoral artery for anterolateral thigh flap, Song YG, Chen GZ, Song YL: The free thigh flap: a new free flap concept
J Craniofac Surg 18(4):866-871, 2007. based on the septocutaneous artery, Br J Plast Surg 37(2):149-159,
Farace F, Fois VE, Manconi A, et al: Free anterolateral thigh flap versus 1984.
free forearm flap: functional results in oral reconstruction, J Plast Steve AK, White CP, Alkhawaji A, et al: Computed tomographic angiog-
Reconstr Aesthet Surg 60(6):583-587, 2007. raphy used for localization of the cutaneous perforators and selection
Genden EM, Jacobson AS: The role of the anterolateral thigh flap for of anterolateral thigh flap “bail-out” branches, Ann Plast Surg 81(1):
pharyngoesophageal reconstruction, Arch Otolaryngol Head Neck Surg 87-95, 2018.
131(9):796-799, 2005. Wei FC, Jain V, Celik N, et al: Have we found an ideal soft-tissue flap?
Kimata Y, Uchiyama K, Ebihara S, et al: Anterolateral thigh flap donor- An experience with 672 anterolateral thigh flaps, Plast Reconstr Surg
site complications and morbidity, Plast Reconstr Surg 106(3):584-589, 109(7):2219-2230, 2002.
2000. Wolff KD, Grundmann A: The free vastus lateralis flap: an anatomic
Kimata Y, Uchiyama K, Ebihara S, et al: Anatomic variations and techni- study with case reports, Plast Reconstr Surg 89(3):469-477, 1992.
cal problems of the anterolateral thigh flap: a report of 74 cases, Plast Xu DC, Zhong SZ, Kong JM, et al: Applied anatomy of the anterolateral
Reconstr Surg 102(5):1517-1523, 1998. femoral flap, Plast Reconstr Surg 82(2):305–310, 1988.
Koshima I, Kawada S, Etoh H, et al: Flow-through anterior thigh flaps Yildirim S, Avci G, Akoz T: Soft-tissue reconstruction using a free antero-
for one-stage reconstruction of soft-tissue defects and revasculariza- lateral thigh flap: experience with 28 patients, Ann Plast Surg 51(1):
tion of ischemic extremities, Plast Reconstr Surg 95(2):252-260, 1995. 37-44, 2003.
Kuo YR, Jeng SF, Wei FC, et al: Functional reconstruction of complex lip Yildirim S, Gideroglu K, Aydogdu E, et al: Composite anterolateral
and cheek defect with free composite anterolateral thigh flap and thigh-fascia lata flap: a good alternative to radial forearm-palmaris
vascularized fascia, Head Neck 30(8):1001-1006, 2008. longus flap for total lower lip reconstruction, Plast Reconstr Surg
Lin SJ, Rabie A, Yu P: Designing the anterolateral thigh flap without pre- 117(6):2033-2041, 2006.
operative Doppler or imaging, J Reconstr Microsurg 26(1):67-72, 2010. Yu P: Characteristics of the anterolateral thigh flap in a Western popula-
Lipa JE, Novak CB, Binhammer PA: Patient-reported donor-site mor- tion and its application in head and neck reconstruction, Head Neck
bidity following anterolateral thigh free flaps, J Reconstr Microsurg 26(9):759-769, 2004.
21(6):365-370, 2005. Yu P: Reinnervated anterolateral thigh flap for tongue reconstruction,
Lueg EA: The anterolateral thigh flap: radial forearm’s “big brother” for Head Neck 26(12):1038-1044, 2004.
extensive soft tissue head and neck defects, Arch Otolaryngol Head Yu P, Robb GL: Pharyngoesophageal reconstruction with the anterolat-
Neck Surg 130(7):813-818, 2004. eral thigh flap: a clinical and functional outcomes study, Plast Reconstr
Makitie AA, Beasley NJ, Neligan PC, et al: Head and neck reconstruc- Surg 116(7):1845-1855, 2005.
tion with anterolateral thigh flap, Otolaryngol Head Neck Surg Yu P, Youssef A: Efficacy of the handheld Doppler in preoperative iden-
129(5):547-555, 2003. tification of the cutaneous perforators in the anterolateral thigh flap,
Malhotra K, Lian TS, Chakradeo V: Vascular anatomy of anterolateral Plast Reconstr Surg 118(4):928-933, 2006.
thigh flap, Laryngoscope 118(4):589-592, 2008.

t.me/Dr_Mouayyad_AlbtousH
81
Pectoralis Major Myocutaneous Flap
A L L E N C H EN G

CC tender to palpation. The patient has lip incompetence and sialor-

65 year old woman with history of oral squamous cell carcinoma rhea (Figs. 81.2 and 81.3).
with chief complaint of new painful ulcer. Chest. The patient’s lungs are clear to auscultation. Her pecto-
ralis major muscles are symmetric and of normal morphology and
HPI size. If a pectoralis flap is being considered as a reconstructive
option, the chest should be examined to ensure that the muscle is
A 65-year-old female presents with a recurrent oral squamous cell adequately developed. Very rarely, the pectoralis major muscle can
carcinoma (SCC). She was initially diagnosed with a cT1N0M0 be completely absent in patients with Poland’s syndrome.
SCC of the right oral tongue. This was treated with a right partial
glossectomy and selective neck dissection 10 years prior. She did Imaging
not have any high-risk features on pathology and was placed on a
surveillance schedule. Unfortunately, she was diagnosed with a A positron emission tomography/computed tomography (PET/CT)
second primary SCC involving the right buccal mucosa 9 years af- examination demonstrated a fluorodeoxyglucose (FDG)-avid focus
ter her initial diagnosis. She was then treated with a composite re- corresponding to the right facial mass. No FDG avidity or lymph-
section of the right buccal mucosa and marginal mandibulectomy. adenopathy was identified in the neck or other parts of the body.
She was found to have perineural invasion but negative margins Many imaging modalities are available for evaluating patients
and no bone invasion. At that time, she was reconstructed with an with head and neck SCC. PET/CT has the advantage of combin-
anterolateral thigh flap and cervicofacial advancement flap. The ing the ability to identify areas of high metabolic activity by PET
surgery was followed by adjuvant radiation therapy. Unfortunately, with the anatomic detail of CT. This is often useful in patients
within 1 year of completion of her adjuvant radiation therapy, she with metastatic disease from an unknown primary, indeterminate
developed a rapidly growing recurrence in the right buccal mucosa findings on CT or magnetic resonance imaging, high risk for or
invading through her skin and lip (eFig. 81.1 and Fig. 81.2). suspected distant metastases, or surveillance of patients after treat-
ment. Patients, particularly smokers, should have their chests
PMHX/PDHX/Medications/Allergies/SH/FH imaged by a plain chest film, chest CT, or PET/CT to screen for
distant metastases and second primary tumors.
The patient has hypertension, depression, and anxiety. She had
prior head and neck surgery. She is allergic to latex. She is taking Labs
aspirin and Lexapro.
She has a 30-pack-year smoking history, which she continued Laboratory testing is dictated as much by the patient’s past medical
after first cancer diagnosis but quit after her second primary can- history and co-morbidities as the cancer itself. At a minimum, this
cer diagnosis. includes a complete blood count, metabolic panel, and a coagula-
She has no notable family history. tion panel. Many oncologic surgeons include liver function testing
as a screen for distant metastases to the liver.
Examination
Assessment
General. Thin, anxious female. She is visibly distressed because of
pain. The patient was diagnosed with a very advanced local recurrence.
Neck. No lymphadenopathy is appreciated. The right neck Although she was initially diagnosed and treated for an early-stage
shows prior surgery and radiation effects. oral SCC with recurrence-free survival period of 10 years, she devel-
Oral. There is a massive indurated and ulcerated mass arising oped a second primary that very quickly recurred after standard-of-
from the right oral commissure and buccal mucosa, extending care treatment. This phenomenon of the development of a second,
into the mandibular gingiva, retromolar trigone, and maxillary more aggressive oral cavity primary years later has been described in
gingiva. It invades through the skin and is visible externally. On the literature and justifies the role of ongoing cancer surveillance of
the right facial skin, there is a 5-cm 3 5-cm ulcer. It is extremely patients beyond 5 years.

422
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422.e1

• eFig. 81.1 Recurrent squamous cell carcinoma of the right buccal mucosa. In this image, you can see
the tumor involving the right oral commissure but also extending through to the skin. The indurated mass
is also visible posterior to this.

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 CHAPTER 81 Pectoralis Major Myocutaneous Flap 423

microvascular free tissue transfer or regional flaps. Free tissue

transfer is an essential component of the head and neck recon-
structive surgeons’ armamentarium that is versatile and capable of
filling large composite defects. These are discussed elsewhere.
Because of the size of the soft tissue defect involving both the
oral mucosa and external skin, her mandibular defect, and her
prior use of a cervicofacial advancement flap, she would either
need a chimeric flap with multiple skin paddles or two separate
flaps. We decided to use two flaps: an osteocutaneous fibula free
flap to reconstruct the mandible and oral mucosa and a pectoralis
major myocutaneous flap to reconstruct the facial skin.
Several regional flaps can be used for reconstruction of head
and neck defects. These include the deltopectoral fascial flap,
pectoralis major flap, and the latissimus dorsi flap. Bakamjian
initially described the deltopectoral fascial flap for head and neck
construction, but it has several shortcomings, including a lack of
tissue bulk, unreliable distal perfusion when reconstruction is
performed primarily, and the need for skin grafting at the donor
site. As such, when Ariyan first described the use of the pectoralis
major myocutaneous flap for head and neck reconstruction, it
very quickly supplanted the deltopectoral fascial flap as the re-
gional flap of choice.

Anatomy
• Fig. 81.2 With retraction, the tumor is visible involving the entire buccal
mucosa and extending onto the mandible, maxilla, and retromolar trigone. The pectoralis major is a broad, fan-shaped muscle that originates
from the medial clavicle, sternum, costal cartilages of the first
through six ribs, and external oblique muscular aponeurosis. It
inserts into the crest of the greater tubercle of the humerus. The
pectoralis major muscle serves as an adductor, medial rotator, and
extender of the arm.
The muscle is invested in the pectoralis fascia, which is distinct
from the clavipectoral fascia that lies deep to it. The clavipectoral
fascia is composed of the pectoralis minor fascia, subclavius fascia,
costocoracoid ligament, costocoracoid membrane, and suspensory
ligament of the axilla. This is important because the reconstructive
Parasternal surgeon uses the avascular plane between the clavipectoral fascia
and pectoralis major fascia to raise the pectoralis major flap. The
inferior free border of the pectoralis major forms the anterior axil-
lary fold as it narrows to its insertion into the humerus. The supe-
Inframammary rior and lateral boundary is with the deltoid muscle. The plane
between to the deltoid and pectoralis major forms the deltopec-
toral groove and is marked by the cephalic vein, which runs
within it (eFig. 81.4).
The vascular supply to the pectoralis major is based off
branches of the axillary artery. The thoracoacromial artery is a
• Fig. 81.3 A variety of skin paddle designs can be used with a pectoralis branch off of the middle portion of the axillary artery, deep to the
major myocutaneous flap. These skin paddles receive their vascular sup- pectoralis minor. This artery has four main branches: the pectoral,
ply from myocutaneous perforators. Here a parasternal skin paddle and clavicular, acromial, and deltoid. The pectoral branch runs along
an inframammary skin paddle are outlined. A larger skin paddle combining
and around the medial aspect of the pectoralis minor, pierces the
these two can also be used.
clavipectoral fascia along with the medial and lateral pectoral
nerves, and runs inferiorly and obliquely along the deep aspect of
Treatment the pectoralis major. It is the dominant pedicle of the pectoralis
major muscle. However, the clavicular head has contributions
Treatment with curative intent would involve a large resection of from the deltoid branch; the medial portion of the pectoralis
her facial skin, oral commissure, lips, buccal mucosa, retromolar major is supplied by the internal mammary artery perforators,
trigone, segmental mandibulectomy, and partial maxillectomy. which are branches from the superior thoracic artery; and there
Reconstruction would require replacement of the right body can be important contributions by the lateral thoracic artery. The
of the mandible, soft tissue to replace the oral mucosa, obturation superior thoracic artery branches from the first portion of the
of the posterior maxilla, and replacement of the facial skin. This axillary artery over the first intercostal space. The lateral thoracic
type of ablative surgery would leave a sizeable composite bone and artery branches from the middle portion of the axillary artery at
soft tissue defect. Options to reconstruct soft tissue include the lateral edge of the pectoralis minor muscle (Fig. 81.5).

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 423.e1

Clavicular
origin

Pectoralis
minor

Humeral
Sternal origin insertion

External oblique
aponeurosis origin

• eFig. 81.4 The pectoralis major muscle originates from the clavicle, sternum, costal cartilage of the first
six ribs, and aponeurosis of the external oblique muscle. It inserts into the greater tubercule of the hu-
merus, which is the lateral lip of the bicipital groove.

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424 S E C TI O N Reconstructive Oral and Maxillofacial Surgery

Subclavian artery

Pectoral branch of
Internal mammary thoracoacromial
artery artery

Lateral thoracic
artery

• Fig. 81.5 The pectoralis major myocutaneous flap is primarily based off of the pectoral branch of the
thoracoacromial artery. It receives minor contributions from the lateral thoracic artery. The muscle also
receives segmental contributions from branches off of the internal mammary artery, although these are
often divided during the flap harvest.

The skin overlying the pectoralis major receives its blood sup- should use caution in patients with significant restrictive lung
ply from fasciocutaneous perforators and myocutaneous perfora- disease, peripheral vascular disease affecting the thoracoacromial
tors. The fasciocutaneous perforators run along the lateral and axis, or coverage of mandibular segmental defects without the
inferior borders of the pectoralis major. ability to perform a bony reconstruction. For the latter, although
Venous drainage is by the vena comitantes of the supplying adequate soft tissue coverage of mandibular hardware can be
arteries. Innervation is by the lateral and medial pectoral nerves achieved, without a bony reconstruction, the pectoralis major flap
off of the brachial plexus. has a high rate of wound dehiscence, which leads to plate expo-
The lateral pectoral nerve innervates the clavicular head, and sure, fracture, and infection. This is particularly true in previously
the medial pectoral nerve innervates the sternocostal heads. The radiated patients. Therefore, in this clinical scenario, the pectoralis
use of innervated pectoralis major flaps to improve swallowing in major flap should be reserved for patients with poor prognoses
pharyngeal or esophageal reconstruction has not been shown to who cannot tolerate bony reconstruction. In addition, although
provide a measurable functional benefit. it is useful for esophageal, pharyngeal, floor-of-mouth, and
even tongue reconstructions, when stretched to close maxillary or
Indications palatal defects, the skin paddle is prone to dehiscence from the
pull of gravity.
• Soft tissue defects of the oral cavity, oropharynx, hypopharynx,
and skin of the head and neck Flap Design
• Hypopharyngeal or pharyngoesophageal reconstruction
• Coverage of the carotid artery, especially after radical neck dis- The pectoralis major myocutaneous flap is a Mathes and Nahai
section with prior or anticipated radiotherapy type V muscle flap with one dominant pedicle (pectoral branch of
• Skull base coverage the thoracoacromial) and secondary segmental pedicles (internal
• Alternative to free flaps in the instances of free flap failure, lack mammary perforators). It is an axial pattern flap based off and
of availability of free flap reconstruction, or patient unable to following a named vessel. Several designs also incorporate random
tolerate microvascular surgery patterned extensions of the flap, based off Taylor’s angiosome
Although there are not any specific contraindications outside concept, which theorizes the perfusion of adjacent angiosomes via
of absence of the pectoralis major muscle, reconstructive surgeons choke vessels. Choke vessels are smaller communicating unnamed

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 CHAPTER 81 Pectoralis Major Myocutaneous Flap 425

arteries connecting the vasculature of adjacent angiosomes, which

are based on named arteries. In the case of the pectoralis major
myocutaneous flap, the internal mammary and superior epigastric
angiosomes are supplied by choke vessels communicating with
the pectoral branch of the thoracoacromial artery.
The original flap design was a longitudinal skin paddle run-
ning along the axis of the pedicle (using a line drawn from the tip
of the shoulder to the xiphoid) from the clavicle inferiorly and
medially. The flap design included the skin, subcutaneous tissue,
and pectoralis major muscle, elevated in a plane above the clavi-
pectoral fascia with direct visualization and protection of the
pedicle on the underside of the muscle. The intervening skin was
tubed as part of a staged reconstruction. Ariyan later modified this
to an island skin paddle over a muscle flap that is elevated and
then tunneled under the skin. In this way, it could be used as a
single-stage reconstruction. Several other variations have been
described to optimize the flap for different reconstructive pur-
poses (see Fig. 81.3):
• Inframammary skin paddle, which lengthens the arc of rota-
tion, decreases cosmetic deformity of the donor site, and pre-
serves the blood supply to the deltopectoral fascial flap for
concurrent or later use
• Fasciocutaneous random pattern extension of flap inferior • Fig. 81.6 The patient has now had the tumor resected, leaving a com-
to the pectoralis major by including the rectus abdominis posite defect of the right body of the mandible, right posterior maxilla, right
sheath buccal mucosa, and lower lip and commissure, as well as a large skin
• Parasternal skin paddle, which reduces morbidity, provides a defect.
thinner skin paddle, and extends the arc of rotation
• Muscle flap only with skin graft (either two stage or single
stage), which reduces the bulk of the flap
• Variety of tunneling techniques, including subcutaneous,
underneath the clavicle, and removal of a segment of clavicle
• Bilobed “Gemini” skin paddle for reconstruction of two epi-
thelial surfaces (intraluminal and cutaneous defects)
• Two separate flaps based off the thoracoacromial and lateral
thoracic arteries
• Janus flap using an imbedded skin graft in a two-stage fashion
to create a flap with two epithelial surfaces
• Inclusion of the fifth rib for an osteomusculocutaneous flap
for reconstruction of bony defects

Surgical Technique
In this clinical case, we used a parasternal skin paddle (Fig. 81.6,
eFig. 81.7, Figs. 81.8 to 81.9, eFig. 81.10, Figs. 81.11 to 81.12).
A curvilinear incision was marked out from the clavicle, curving
inferiorly into a parasternal limb, and then posteriorly into a
horizontal inframammary limb. The planned skin paddle
was drawn out (see Fig. 81.8). A #10 blade was used to make the
incision down to the pectoralis fascia, starting from the lateral
edge of the skin paddle. A skin flap was developed laterally in this
suprafascial plane, exposing the entire pectoralis major muscle.
The circumferential incision was completed around the skin
paddle. The skin paddle was sutured down to the underlying
muscle to prevent shearing between the skin and muscle and dam-
age to the skin perforators (see Fig. 81.9). These sutures were
removed before inset. Blunt and sharp dissection was used to
• Fig. 81.8 Right pectoralis major myocutaneous flap crescent incision
separate the sternocostal attachments. The internal mammary ar-
marked out for a parasternal skin paddle (different patient from the clinical
tery perforators were carefully ligated or cauterized during flap case). If a deltopectoral fascial flap is also to be used, the skin paddle is
elevation. Failure to do so may result in retraction of the severed placed farther inferiorly, and the superior horizontal limb is placed inferiorly
vessel into the chest wall, making hemostasis difficult to achieve. to avoid perforators arising from the internal mammary artery. This supe-
After the chest wall attachments were divided, the dissection rior incision would correspond with the inferior border of the deltopectoral
above the pectoralis minor was done bluntly. As the flap is fascial flap.

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 425.e1

A B C
• eFig. 81.7 A, The specimen viewed from the facial side. The tumor is seen invading through the skin.
B, The specimen viewed from the oral side. The tumor is seen to extend along the buccal mucosa onto
the mandible, retromolar trigone, and posterior maxilla. C, The specimen viewed from the anterior. The
tumor is seen centered on the right oral commissure.

• eFig. 81.10 Before inset of the pectoralis major flap, the fibula flap is inset using patient-specific hard-
ware and microvascular anastomosis performed. The fibula skin paddle is used to reconstruct the oral
mucosal defect.

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426 S E C TI O N Reconstructive Oral and Maxillofacial Surgery

• Fig. 81.9 Skin flap developed laterally in a plane superficial to the pec- • Fig. 81.11 The flap is elevated off the chest wall and underlying pecto-
toralis fascia (different patient from the clinical case). The lateral extent of ralis minor in a plane superficial to the clavicopectoralis fascia. The lateral
this dissection is taken to where the pectoralis major muscle narrows to aspect of this is done bluntly with finger dissection. Electrocautery is used
its humeral attachment. The attachment is divided lateral to the pedicle, to divide the sternal attachments of the pectoralis major muscle. The in-
which is visualized on the underside of the flap. A gastrointestinal anasto- ternal mammary artery perforators are identified and ligated to avoid ves-
mosis stapler can be used to divide the muscle. This provides good he- sel retraction and annoying bleeding. A subcutaneous tunnel is developed
mostasis and leaves a staple line that can be used for tacking sutures. The under the bridge of skin with blunt or sharp dissection. Enough room
skin paddle is tacked down to the muscle before elevation of the flap to needs to be created to allow for four fingers to pass easily to avoid com-
avoid shear injury to skin perforators (optional). pression of the pedicle as it passes over the clavicle.

elevated, the pectoral branch of the thoracoacromial artery was her neck movements restricted. Excessive flexion and rotation of
identified entering the deep aspect of the muscle. The attachment the neck should be avoided. Aspirin is started immediately
to the humerus were identified and divided. The clavicular head and prescribed daily per rectum if the patient cannot swallow and
may also be divided if necessary to decrease bulkiness in the cla- does not have a feeding tube. Vasopressors should be avoided if
vicular region. Similarly, the medial and lateral pectoral nerves possible. Hypothermia should be avoided because it may lead to
can be divided to increase reach. A tunnel was created from the vasoconstriction. Later in the postoperative period, surgical site
chest wall dissection into the neck dissection. This was done in a infections should be treated aggressively because infections around
subplatysmal plane. The tunnel should be large enough to accom- the pedicle can lead to arterial thrombosis and flap failure. Physi-
modate four fingers passing through comfortably. This is critical cal therapy and occupational therapy are started as early as post-
to avoid compression of the flap pedicle. The flap was then passed operative day 2.
through into the neck for inset (see Fig. 81.11). Closed-suction
drains were placed under the skin flaps of the chest wall, and Complications
primary closure was performed (see Fig. 81.12).
Complications may include:
Postoperative Care • Total flap necrosis (1%–7%)
• Partial flap necrosis (4%–14%)
The postoperative care of a patient with a flap is geared toward • Donor site hematomas or seromas
preventing factors that will lead to vascular thrombosis and then • Donor site wound dehiscence or skin necrosis
flap failure. It is critical to avoid compression of the pedicle un- • Pulmonary complications
derlying the neck skin flaps. It is helpful to mark the location of • Surgical site infection
the pedicle so that nursing staff will know to avoid pressure in • Osteochondronecrosis of the ribs
these areas from dressings or tape. This includes tracheostomy ties • Wound dehiscence and plate exposure
if the patient has a surgical airway. The patient should have his or • Masking of recurrent malignancy

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 CHAPTER 81 Pectoralis Major Myocutaneous Flap 427

• Distortion of breast tissue

• Orocutaneous fistulas
• Hair growth
• Muscle atrophy
Total or partial flap necrosis occurs a minority of the time.
Higher rates in initial reports have been attributed to not includ-
ing fasciocutaneous perforators, not including the rectus sheath
when extending the flap caudally, and compression by the clavi-
cle. Hematomas and seromas are rare. Donor site wound dehis-
cence can occur with closure of wound under tension when larger
skin paddles are used. Hair growth is an anticipated consequence
of this flap in males; it is somewhat mitigated with radiation. The
skin paddle can also be treated with electrolysis if the hair is an-
noying to the patient. Similar to all muscle flaps that have been
denervated, the pectoralis major atrophies with time. This can be
either problematic or beneficial depending on the application but
should be expected. This atrophy is partially mitigated if the pec-
toral nerves are not divided.

,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for

complete set of bibliography.

• Fig. 81.12 The pectoralis major flap is then inset. The flap is passed over
the clavicle underneath a subplatysmal tunnel. The pectoralis skin paddle
is used to replace the cutaneous defect. The incisions are closed primarily.

t.me/Dr_Mouayyad_AlbtousH
 427.e1

Bibliography Ossoff RH, Wurster CF, Berktold RE, et al: Complications after pectora-
lis major myocutaneous flap reconstruction of head and neck defects,
Arch Otolaryngol 109:812-814, 1983.
Ariyan S: The pectoralis major myocutaneous flap. A versatile flap for recon- Reid CD, Taylor GI: The vascular territory of the acromiothoracic axis,
struction in the head and neck, Plast Reconstr Surg 63(1):73-81, 1979. Br J Plast Surg 37:194-212, 1984.
Bakamjian VY: A two-stage method for pharyngeoesophageal reconstruction Rikimaru H, Kiyokawa K, Inoue Y, et al: Three-dimensional anatomical
with a primary pectoral skin flap, Plast Reconstr Surg 36:173-84, 1965. vascular distribution in the pectoralis major myocutaneous flap, Plast
Dennis D, Kashima H: Introduction of the Janus flap. A modified pec- Reconstr Surg 115:1342-1352, 2005.
toralis major myocutaneous flap for cervical esophageal and pharyn- Shah GV, Wesolowski JR, Ansari SA, et al: New directions in head and
geal reconstruction, Arch Otolaryngol 107:431-435, 1981. neck imaging, J Surg Oncol 97:644-648, 2008.
Donegan JO, Gluckman JL: An unusual complication of the pectoralis Shah JP, Haribhakti V, Loree TR, et al: Complications of the pectoralis
major myocutaneous flap, Head Neck Surg 6:982-983, 1984. major myocutaneous flap in head and neck reconstruction, Am J Surg
Ferraro GA, Perrotta A, Rossano F, et al: Poland syndrome: description 160:352-355, 1990.
of an atypical variant, Aesth Plast Surg 29:32-33, 2005. Sharzer LA, Kalisman M, Silver CE, et al: The parasternal paddle: a
Freeman JL, Walker EP, Wilson JS, et al: The vascular anatomy of the modification of the pectoralis major myocutaneous flap, Plast Reconstr
pectoralis major myocutaneous flap, Br J Plast Surg 34:3-10, 1981. Surg 67:753-762, 1981.
Hodgkinson DJ: The pectoralis major myocutaneous flap for intraoral Ueda M, Torii S, Nagayama M, et al: The pectoralis major myocutaneous
reconstruction: a word of warning, Br J Plast Surg 35:80-81, 1982. flap for intraoral reconstruction: surgical complications and their
Moloy PJ, Gonzales FE: Vascular anatomy of the pectoralis major myo- treatment, J Maxillofac Surg 13:9-13, 1985.
cutaneous flap, Arch Otolaryngol Head Neck Surg 112:66-69, 1986. Weaver AW, Vandenberg HJ, Atkinson DP, et al: Modified bilobular
Ord RA, Isaiah A, Dyalram D, et al: Is long-term follow-up mandatory (“gemini”) pectoralis major myocutaneous flap, Am J Surg 144:
for stage I oral tongue cancer?, J Oral Maxillofac Surg 76(12): 482-488, 1982.
2676-2683, 2018.

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82
Botulinum Toxin
B E H N A M B O H LULI

CC visibility of the forehead lines. (Subtle observations about appear-

ance may be the key to successful patient rapport.)
A 44-year-old female presents to your office for consultation regard- Maxillofacial. There are no pustules or signs of active derma-
ing the wrinkles and overexpression on her forehead. Patients with tologic infections or pathology in the facial region. (Injections are
dynamic wrinkles, which are formed during facial expressions, have contraindicated if an active infection exists at the injection site.)
the best indication for botulinum toxin (BoTN) injections. Static There is no marked facial asymmetry or hypertrophic scarring.
wrinkles can also be treated by BoTN. However, the results are less (Thick skin or a susceptibility to hypertrophic scars may be a rela-
dramatic, and adjunctive treatments such as fillers may be needed. tive contraindication to injections.) No significant eyebrow ptosis
is noted. (This is important for injections around the eyes or
PMHX/PDHX/Medications/Allergies/SH/FH on the forehead. Impairing the functioning of the frontalis
can also lower the eyebrow position from unopposed muscle ac-
The patient does not have any known medical conditions. Spe- tion, resulting in an unappealing outcome. Similarly, large
cifically, she has no known history of neuromuscular disorders, amounts of BoTN injected around the eye can diffuse toward the
including myasthenia gravis or Lambert–Eaton syndrome or levator palpebrae muscle, causing impaired eyelid closure. The
neurodegenerative diseases such as amyotrophic lateral sclerosis. degree of preoperative ptosis can be documented for postoperative
(Despite the absence of specific studies, BoTN should be used comparison.)
cautiously in individuals with neuromuscular disorders because of Several prominent horizontal forehead wrinkles (caused by
the potential exacerbation of any preexisting conditions.) There is frontalis muscle action) are present at rest (Fig. 82.1A) and are
no significant family history of neuromuscular disorders. accentuated with animation (Fig. 82.1B). Multiple hyperdynamic
The patient is not currently taking any aminoglycoside antibi- rhytids (lines on the face) are seen lateral to the eye and are most
otics or other medications that could interfere with neuromuscu- pronounced on animation (orbicularis oculi region, also known as
lar transmission. (It is recommended that BoTN injections be “crow’s feet”; Fig. 82.2). At rest, fine vertical glabellar furrows are
delayed or avoided in patients taking aminoglycosides.) She is not present, and upon animation and frowning, the glabella muscle
taking aspirin, a nonsteroidal antiinflammatory drug, or other bulge becomes significantly more prominent (Fig. 82.3). (The
medication that can interfere with coagulation or platelet func- corrugator muscle is responsible for the vertical glabellar furrows,
tion (such drugs increase the risk of hematoma formation and and the procerus muscle is responsible for the horizontal glabellar
bruising). She smokes a half pack of cigarettes per day. (Smoking furrows.) A glabellar spread test reveals that the glabellar lines are
is not a contraindication to BoTN injection.) substantially reduced when physically manipulated or spread
There is no history of allergies to human albumin or of any apart. (This is a good indication that the muscle and its overlying
previous adverse reactions to BoTN. (Human albumin [HSA] is soft tissue are the etiology of the lines. During the physical ex-
added to most commercially available BoTNs. It is thought that amination, it is important to distinguish between dynamic and
HSA stabilizes and protects BoTN from unspecific binding to static wrinkles.)
glass and plastic surfaces.) No significant horizontal lines are present at the nasal root
The patient is not pregnant or lactating at this time. (BoTN is (“bunny lines”), and no prominent perioral vertical (“lipstick”)
contraindicated during nursing or pregnancy; it is classified by the rhytides are visible.
US Food and Drug Administration [FDA] as Pregnancy Category C,
meaning that its safety profile during pregnancy has not been studied. Imaging
It is unknown whether the toxin can cross the placenta or is excreted
during lactation. However, the localized application of the drug Standard facial photographic documentation of the areas to be
would suggest the safety of application during pregnancy or nursing). treated is recommended for BoTN injection. Comparisons of
preinjection and postinjection photograms may be important for
Examination future dosing and for surgeon education toward optimal results.

General. The patient is a thin, well-dressed female. She wears an Labs

extensive amount of makeup, which masks some of her age-
related facial features. She wears her hair in a style that reduces the No routine laboratory tests are indicated in healthy patients.

430
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 82 Botulinum Toxin 431

A B
• Fig. 82.1 Multiple horizontal wrinkles (A) that are exaggerated in function (B).

A B
• Fig. 82.2 A and B, Crow’s feet wrinkles.

(Although there may be many findings amenable to cosmetic surgery,

the assessment and treatment are dictated by the patient’s desires.)

Treatment
After a complete discussion of the procedure, risks, and alterna-
tives, the patient signed the informed consent (which addressed
all the complications listed later). Botox was chosen for the treat-
ment of this patient. (There are five BoTN products that have
FDA approval for cosmetic use: Dysport, Botox, Xeomin,
and Daxi.). A vial of 100 units of BoTN A was reconstituted with
• Fig. 82.3 Globular vertical wrinkles in function.
3.3 mL of nonpreservative normal saline. (Many practitioners use
preservative saline because they believe it causes less pain during
Assessment injections; see Discussion.) Botox is available in a sealed vacuum
container that allows for easy reconstitution with saline. The re-
Multiple areas of hyperfunctioning facial muscles and signs of aging sulting solution provides 3 units per 0.1 mL or 15 units per
are present involving the periorbital, glabellar, and horizontal fore- 0.5 mL. Botox should be reconstituted by gentle side-to-side
head regions. The patient desires injection of BoTN for effacement of movements or rolling the vial. (Shaking and trauma to the toxin
the wrinkles associated with the periorbital and forehead regions. can diminish its potency.)

t.me/Dr_Mouayyad_AlbtousH
432 S E C TI O N XI I I Facial Cosmetic Surgery

A B
• Fig. 82.4 Injection sites on the frontal (A) and periorbital (B) regions.

The patient was seated upright, close to a 60-degree position. Complications

After the injection sites had been prepared with alcohol, the pa-
tient was asked to frown (or lower the eyebrows) to highlight the Many patients have been safely treated with BoTN since its intro-
regions of maximum muscular contraction. Twelve injection sites duction. The complications of treatment with BoTN include:
were identified to inject the frontalis muscle (Fig. 82.4). To mini- • Injection site reactions: Transient headaches, pain, edema,
mize the chance for blepharoptosis, the injections were performed and erythema at the injection site are common but transient
at least 1 cm above both the central eyebrow and the supraorbital complications of BoTN injection. Proper needle depth may
ridge. It is important to avoid injections on the forehead lateral to considerably reduce the incidence of these adverse effects. Sub-
the lateral canthus to prevent inhibition of temporalis function. periosteal injection may result in pain, while superficial injec-
The goal of forehead injections is not to completely eliminate the tions in larger volumes will end up in bumps and swelling.
frontalis muscle action because this can cause undesirable eyebrow • Eyebrow shape deformities, lifted eyebrow tails, and asym-
ptosis. Ice packs were applied immediately before the injection to metry: Brow shape may be disturbed after BoTN injections.
blunt the pain response from the needle. The needle was inserted A common scenario is to inject and disable the central parts
into the belly of the muscle, aspiration was performed, and Botox of the frontal muscles while the lateral portions are left
was then slowly injected. After the injections, no manipulation was intact or injected inadequately; this causes compensatory
performed, and an ice pack was allowed to rest on the area. overfunction of the remaining frontal muscles and raising
(Manipulation can enhance diffusion into other muscles, affecting of the eyebrows. This condition is commonly known as
the levator palpebrae superioris and causing blepharoptosis, espe- Mephisto or Spock eyebrows. This may happen bilaterally or
cially with injections near the eyelid.) Attention was then turned unliterally. Management would be a small touch-up to dis-
to the orbicularis oculi region. After the area had been prepared with activate lateral parts of the frontal muscle on the involved
alcohol, 9 units total were injected into three sites on each side just side(s).
below the skin (to minimize diffusion in this area). A total of 36 • Eyebrow ptosis and blepharoptosis: Ptosis of the eyebrow or
units were used for the forehead and crow’s feet regions (18 units in upper eyelid may occur in 1% to 5% of periorbital injections.
the forehead and 18 units total for both eyes) (see Fig. 82.4). Eyelid ptosis results from the spread of toxin through the or-
Ice was allowed to rest on the injection sites for as long as the bital septum and involves the levator palpebral superioris
patient tolerated. The patient was instructed to remain upright for muscle of the eye. Eyebrow ptosis shows that the lower fibers
at least 4 hours and was allowed to apply makeup 4 hours after of the frontal muscles are disabled. Practical advice to avoid
injection (to minimize manipulation and thus diffusion of the this adverse effect is to remain 2 to 3 cm from the supraorbital
toxin). She was allowed to resume exercise the next day. She was rim or 1.5 to 2.0 cm above the eyebrows. When this complica-
instructed to expect a noticeable effect in 3 to 4 days, with maxi- tion happens, the patient should be reassured about transient
mum benefit in 30 days (see Fig. 82.3). Follow-up was scheduled condition. Apraclonidine 0.5% eye drops or phenylephrine
in 1 week. The areas can be reinjected after a minimum of may be used. These medications work on muscle, which is a
3 months has elapsed. (Earlier injections can increase the chance simple mimetic muscle of the upper eyelid, and can help raise
of antibodies developing.) the upper eyelid for 1 to 2 mm.

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 82 Botulinum Toxin 433

Discussion by the FDA. Most of these indications are very technique sensitive
and require a solid base in anatomy. Table 82.1 shows some of the
Botulinum toxin is one of the most potent and poisonous toxins common off-label indications.
and has caused many outbreaks of food poisoning over the centu-
ries. BoTN is produced by Clostridium botulinum, a gram-positive
anaerobic bacterium. Up until now, seven serotypes of this toxin
Preparation and Storage of Botulinum Toxin
have been detected, which are named from A to G. Botulinum toxins need to be reconstituted to prepare a clear solu-
Clostridium botulinum types A and B are widely investigated tion for injection. Manufacturers’ leaflets recommend the use of
and used in medicine. The first therapeutic use of this toxin was nonpreservative normal saline to prepare the solution (the way
in the 1970s, when BoTN was used for selective paralysis of ex- they received FDA approval). Meanwhile, several studies show
traocular muscles to treat patients with strabismus. In fact, the considerably less pain when the toxin solution is prepared with
first cosmetic use of BoTN was an incidental finding when an preservative normal saline.
ophthalmologist discovered that some of her patients with strabis- The reconstituted solution, if refrigerated (2–8°C), can be
mus got better in their glabellar frowns after receiving botulinum effective for 8 weeks. Most practitioners suggest storing it for a
injections. Thereafter, there was a burst in the cosmetic use of this maximum of 2 weeks.
drug, and very soon after, myriad indications started to develop. It is noteworthy that manufacturers’ instructions recommend
not to keep reconstituted solution more than 24 hours (the way
Indications they received FDA approval).

The FDA has approved three indications in facial cosmetic medicine:

• Temporary improvement in the appearance of moderate to
Albumin in BoTN Products
severe glabellar lines related to corrugator and/or procerus All four commercially available cosmetic BoTNs (Dysport, Botox,
muscle activity (FDA 2002) Xeomin, and Jeuveau) have different concentrations of human
• Temporary improvement in the appearance of moderate to albumin. Albumin is generally added to stabilize the BoTN con-
severe lateral canthal lines related to orbicularis oculi activity tent and to avoid aggregation and destruction of toxin in contact
(FDA 2013) with vial containers. Although the albumin content is strictly
• Temporary improvement in the appearance of moderate to screened, tested, and pasteurized, there is an extremely rare pos-
severe forehead lines related to frontalis muscle activity (FDA sibility that prions causing disease such as Creutzfeldt-Jakob can
2017) be transmitted from the donor human to the recipient human. In
addition, some people are reluctant to receive human blood com-
Off-Label Use ponent and decline the treatment if properly informed. Daxi
BoTN is a new formulation that does not contain albumin.
There are many established and emerging indications, some of A short duration of action and resistance to BoTN are
which are supported by literature but have not yet been approved commonly attributed to formation of neutralizing antibodies.

TABLE
82.1 Off-Label Cosmetic Indications of Botulinum Toxin

Problem Advocated Treatment

Eyebrow lift Depressor muscles of the eyebrows (orbicularis oculi, procerus, Three injection sites on the lateral aspect of the orbicularis
and corrugator supercilii) oculi
Bunny lines Contraction of the transverse nasalis muscle and lower medial or- Injection on the nasal dorsum
bicularis muscles
Nasal tip ptosis Contraction of the depressor septi nasal muscle Injection below the nose tip in the columella
Gummy smile Eversion of the upper lip by the levator labii superioris alaeque nasi Injection on the levator labii superioris alaeque nasi bilat-
muscles; at the same time, the depressor septi nasi muscle erally and depressor septi nasi muscles centrally
draws the nasal tip downward and lifts the medial tubercle
Vertical perioral rhytids Reputed functioned of orbicularis oris Small amount of injection on very superficial layers of
muscle
Drooping oral commissures Overfunction of the depressor anguli oris One injection on each side to let contractions of the
muscles lift the commissures
Platysma band Lipodystrophy and skin laxity in conjunction with overactive Three to four injection sites spaced 1–2 cm apart
platysma
Dimpled chin Overactivation of the mentalist muscles and local loss of collagen Two-site injections on the mentalist muscles
and fat
Masseter hypertrophy Benign hypertrophy of the masseter muscle Three points per side

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434 S E C TI O N XI I I Facial Cosmetic Surgery

Although the issue is still controversial and a great deal of research keloid formation are a few of these evolving indications. New
is ongoing, it is suggested to: formulations of BoTN may improve the current limitations of
• Use the minimum doses needed. (Most reported resistant cases available BoTNs. Daxxify or Daxi (daxibotulinumtoxinA) is a
had more than 100 units per treatment.) novel formulation of a neurotoxin that is approved by the FDA to
• Avoid too many touch-ups and short intervals. It is recom- treat glabellar lines. The mechanism of action and active contents
mended to have 3-month intervals. (Most reported cases had are similar to previous products. Its unique formulation causes
less than a 1-month interval.) longer results, potentially two to three times longer than Botox
for the same patient. In addition, Daxi does not contain albumin
Future or other animal byproducts, which may eliminate many potential
complications of BoTN injections.
It is no surprise that many new indications are emerging that
some are going to be game changers. Male pattern baldness, man- ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
agement of depression, wound healing, and management of complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 434.e1

Bibliography Malhotra R, Huilgol SC, Selva D: Botulinum toxin and human serum
albumin, Arch Ophthalmol 121(11):1661-1162, 2003. doi:10.1001/
archopht.121.11.1661-a.
Dressler D: Botulinum toxin drugs: brief history and outlook, J Neural Phan K, Younessi S, Dubin D, et al: Emerging off-label esthetic uses of
Transm (Vienna) 123(3):277-279, 2016. doi:10.1007/s00702-015- botulinum toxin in dermatology, Dermatol Ther 35(1):e15205, 2022.
1478-1. doi:10.1111/dth.15205.
Hong SO: Cosmetic treatment using botulinum toxin in the oral and Solish N, Carruthers J, Kaufman J, et al: Overview of Daxibotulinum-
maxillofacial area: a narrative review of esthetic techniques, Toxins toxinA for injection: a novel formulation of botulinum toxin type A,
(Basel) 15(2):82, 2023. doi:10.3390/toxins15020082. Drugs 81(18):2091-2101, 2021. doi:10.1007/s40265-021-01631-w.
Hunt SV, Malhotra R: Bacteriostatic preserved saline for pain-free Zargaran D, Zoller F, Zargaran A, et al: Complications of cosmetic botu-
periocular injections: review, Eye (Lond) 36(8):1546-1552, 2022. linum toxin A injections to the upper face: a systematic review and
doi:10.1038/s41433-021-01925-z. meta-analysis, Aesthet Surg J 42(5):NP327-NP336, 2022. doi:10.1093/
Kroumpouzos G, Kassir M, Gupta M, et al: Complications of botulinum asj/sjac036.
toxin A: an update review, J Cosmet Dermatol 20(6):1585-1590,
2021. doi:10.1111/jocd.14160.

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83
Facial Resurfacing
LANDON McLAIN

CC Imaging. Standardized preoperative and serial postoperative

photography is mandatory for cosmetic procedures. Frontal
A 41-year-old female presents to you complaining of generalized animated and repose as well as oblique and profile images are
sun damage from years of “tanning.” recommended.
Labs. Routine preoperative laboratory testing is not required
HPI for resurfacing procedures unless dictated by the patient’s medical
history.
She would like to have her skin “lasered” to erase the years of ex-
cessive sun exposure. She states that despite her blue eyes, she Assessment
could tan with sun exposure in her youth. She grew up in Califor-
nia and used to “live at the beach.” She thinks she will eventually Middle-aged female with Fitzpatrick skin type II and signs of photo-
need a facelift but wants to avoid it for now. aging. As a general rule, lighter skin types are more favorable to resur-
facing, particularly laser resurfacing. Given her slightly tanned skin,
PMHX/PDHX/Medications/Allergies/SH/FH she is at risk for hyperpigmentation postoperatively.

Noncontributory. She takes lisinopril for mild hypertension and

quit smoking 25 years ago. She denies any recent use of Accutane Treatment
but does use some Retin A when she “remembers to.” She denies
any history of abnormal scarring and herpetic outbreaks. She had
Skin Preparation
an upper eyelid blepharoplasty 10 years ago. It is recommended that patients undergoing resurfacing proce-
There are contraindications to CO2 laser resurfacing: dures prepare the skin with hydroquinone and topical tretinoin 4
• Fitzpatrick skin types IV to VI (there is an increased risk of to 6 weeks earlier to minimize risk of postoperative complications
dyspigmentation in patients with darker skin; Fig. 83.1) and speed healing after resurfacing. Use of hydroquinone preop-
• History of keloids eratively is strongly recommended for this patient.
• Recent oral isotretinoin therapy (a 12-month waiting before
resurfacing is traditionally recommended) Anesthesia
• Morphea
• Scleroderma If the patient is not under general anesthesia, thoughtful anes-
• Prior radiation therapy (which limits the skin’s ability to heal thetic technique is a must. A combination of intravenous (IV)
in a timely fashion) sedation with complete blockade of facial sensory as described by
• Cutaneous disorders (vitiligo, lichen planus, and psoriasis are Zide and Swift will allow the patient to tolerate laser application.
relative contraindications) Topical anesthetic alone is unlikely to provide sufficient comfort
• Active herpes outbreaks or other ongoing infections in the to tolerate ablative resurfacing.
targeted area (laser treatment should be postponed until the
condition has resolved)
• Ongoing ultraviolet exposure
Resurfacing
• Recent medium or deep chemical In general, two forms of fractional CO2 resurfacing are used,
Examination. The patient appears older than her stated age high fluence with low density versus low fluence and higher den-
but is in good spirits and interactive. She has several scattered sity. The higher fluence treatments are more uncomfortable and
brown dyschromias throughout her face with fine static and dy- require more postoperative healing but tend to result in more
namic rhytids under her eyes and around her mouth particularly. improvements versus the lower energy treatments. Treatment of
She has some age-related atrophic changes to the midface and the neck and chest have higher risk of scarring given the signifi-
temporal regions as well as platysmal banding, laxity to the ante- cant reduction on pilosebaceous unit density (30–403 less) in
rior neck, and early jowling. Her skin is otherwise clear without these areas, thereby reducing the healing capacity of the epider-
scarring or active comedones. She has Fitzpatrick skin type II (see mis. Before resurfacing, the face is cleaned and prepped with an
Fig. 83.1). alcohol swab and allowed to fully dry before laser application.

435
t.me/Dr_Mouayyad_AlbtousH
436 S E C TI O N XI I I Facial Cosmetic Surgery

Type Features of unexposed skin Tanning and burning

Very pale white skin, often with green or blue

1 Burns without tanning
eyes and fair or red hair

2 White skin, often with blue eyes Burns and does not tan easily

3 Fair skin with brown eyes and brown hair Burns first then tans

4 Light brown skin, dark eyes, and dark hair Burns a little and tans easily

Easily tans to a darker color

5 Brown skin, dark eyes, and dark hair
and rarely burns
Dark brown or black skin, dark eyes, and
6 Never burns but tans darker
dark hair

• Fig. 83.1 Fitzpatrick skin types I to VI.

Lower eyelids often require treatment, and care must be taken to rule out contact dermatitis or infectious causes. Fortunately, al-
protect the cornea with either corneal shields or obstructing care- though common, persistent erythema is rarely permanent.
fully with a tongue depressor when treating near the eye itself.
Avoid the vermillion border because it is possible to efface this
Acne
well-defined anatomic margin with resurfacing. One pass of
higher energy treatment is generally sufficient, but deeper or It is important that acne be under good control before resurfac-
denser rhytids may require a second pass, particularly around the ing, given that severe acne can lead to atrophic scarring, which
lower eyelids and cheeks and periorally. Caution: More aggressive may the reason some patients seek resurfacing. Minor flares in
treatment requires a more ideal patient and skin type and signifi- acne may occur during the posttreatment phase because of use of
cantly more experience. Debridement between passes is not re- heavy emollients in the first days and weeks. These flares should
quired, and when the treatment is completed, a generous coat of resolve when these emollients are discontinued. If persistent,
petroleum jelly or Aquaphor is applied. topical or oral antibiotics may be required. After skin sensitivity
has diminished, other topical agents such as glycolic acids and
Postresurfacing Care tretinoin may be used.

Although more cumbersome dressing are available, they do not

Infection
seem to provide a significant improvement versus more simpli-
fied techniques in the author’s opinion. Cold compresses may The primary role of the skin is to prevent infection; however, dur-
benefit in postoperative discomfort but come with an increased ing the postlaser period, this function is temporarily compro-
risk of scratching, irritating, or even frostbiting the lasered skin. mised. Perioperative use of oral antibiotics and antivirals is the
In general, postlaser discomfort is brief and mild. Starting on standard of care for most CO2 laser treatments. Oral antiviral
postoperative day 1, the patient should gently wash the lasered prophylaxis should start 24 to 48 hours before resurfacing and be
areas with a mild hypoallergenic soap, pat dry, and reapply Aqua- continued through the first 5 to 7 days postoperatively. Standard
phor three to five times daily. On postoperative day 3 or 4, vin- prophylactic doses of famciclovir or valacyclovir are usually suffi-
egar soaks may be added to the regimen three times daily. Note cient, but if a breakthrough infection occurs, the dose should be
that some patients may develop a contact allergy and irritation to increased or a second agent considered. Rarely, IV antivirals may
vinegar with frequent use. After the treated areas have fully be required in nonresponsive cases.
reepithelialized around day 6 to 9, Aquaphor may be switched to
a gentle topical moisturizer, and makeup may be applied if de-
Scarring
sired. Postlaser resurfacing care is perhaps the most tedious of any
of the facial cosmetic surgery procedures and mirrors burn care The most effective ways to prevent scarring are to use proper in-
in many ways. A fastidious patient and an observant provider are traoperative technique, meticulous postoperative care, and infec-
a must. tion prevention. For instance, overlapping or stacking of laser
scans may lead to scarring. More worrisome, scarring in the lower
eyelid or cheek region has the potential to disrupt the lower eyelid
Complications adaptation to the globe of the eye and result in ectropion. Fortu-
Erythema nately, scarring is fairly rare when the aforementioned guidance is
adhered to, but some patient factors may also contribute to cica-
Some degree of erythema after treatment is expected, but if tricial formation, including prior resurfacing, recent use of isotret-
the erythema persists, it may become problematic. More aggres- inoin, history of keloids or hypertrophic scarring, and poor
sive treatments in lighter skinned individuals usually result in compliance with care. If scars occur, initial therapy should include
prolonged redness but can also occur in patients with a history topical or intralesional corticosteroids, silicone sheeting, or
of facial flushing, eczema, and rosacea. Short courses of topical pulsed-dye laser therapy. Multimodal and multiple treatments
steroids may be effective, but if not quickly responsive, be sure to may be required in the most difficult cases.

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 CHAPTER 83 Facial Resurfacing 437

Pigment Disorder
It is common for post-laser patients to experience postinflamma-
tory hyperpigmentation after resurfacing. Although pretreatment
of the skin with topical tretinoin and hydroquinone may reduce
the risk, it still occurs, particularly in those with darker skin types.
Fortunately, this almost always resolves with time. Good postop-
erative skin care and avoidance of irritation as well as judicious use
of topical steroids creams can reduce the frequency somewhat, but A
the most effective treatment is preparing the patient for transient
hyperpigmentation and close follow-up when it occurs. Hypopig-
mentation, a more uncommon and unfortunate complication, is
the loss of functional melanocytes after deeper resurfacing treat-
ment; it may become permanent. This is more common in deep
phenol peels and aggressive dermabrasion, but it can occur with
laser treatments when the excess energy reaches the melanocytes
or melanosomes. Pseudohypopigmentation can also occur and is
simply the improvement in laser-treated skin versus untreated and
is more likely to occur when the treatment lines in moderately
and severely damaged skin are not carefully blended during the B
procedure.
• Fig. 83.2 A, Frontal pre- and postoperative photographs after CO2 laser
resurfacing. B, Right lateral oblique pre- and postoperative photographs
Discussion after CO2 laser resurfacing.

CO2 laser resurfacing is the gold standard for skin rejuvenation in

patients with photoaging; however, it should not be viewed as a common risks and benefits. Successful postlaser resurfacing man-
panacea for total facial rejuvenation, which involves age-related agement requires the acceptance that some complications (hope-
changes that are unaffected by laser treatment, particularly ptosis fully, minor) will occur rather than hoping they can be entirely
and volume changes. It is best viewed and used as an adjunctive avoided. But when applied in the correct setting and with a well-
or finishing treatment in a cache of other surgical and nonsurgical prepared patient and an even better prepared surgeon, it can yield
rejuvenation procedures. Resurfacing alone can lead to disap- beautiful and predictable results (Fig. 83.2).
pointment in a patient who expects to look 10 or 20 years
younger with one isolated procedure. Thus, preoperative guidance ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
with softened expectations is as vital as counseling the patient for complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 437.e1

Bibliography Lewis AB, Alster TS: Laser resurfacing: Persistent erythema and post in-
flammatory hyperpigmentation, J Geriatr Dermatol 4:75-76, 1996.
Niamtu J: To debride or not to debride? That is the question: rethinking
Alster TS: Side effects and complications of laser surgery. In Alster TS char removal in ablative CO2 laser skin resurfacing, Dermatol Surg
(ed): Manual of Cutaneous Laser Techniques, Philadelphia, 1997, 34(9):1200-1211, 2008.
Lippincott-Raven, pp 142-151. Ruiz-Esparza J, Barba Gomez JM, Gomez de la Torre OL, et al: Ery-
Burhardt BR, Maw R: Are more passes better? Safety versus efficacy with thema after laser skin resurfacing, Dermatol Surg 24(1)31-34, 1998.
the pulsed CO2 laser, Plast Reconstr Surg 100(6):1531-1534, 1997. Zide BM, Swift R: How to block and tackle the face [published correction
Fife DJ, Fitzpatrick RE, Zachary CB: Complications of fractional CO2 appears in Plast Reconstr Surg 1998 Jun;101(7):2018], Plast Reconstr
laser resurfacing: four cases, Lasers Surg Med 41(3):179-184, 2009. Surg 101(3):840-851, 1998. doi:10.1097/00006534-199803000-00041.
Formica KJ, Alster TS: Cutaneous laser resurfacing: A nursing guide,
Dermatol Nurs 9:19-22, 1997.

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84
Fat Grafting and Fillers
B E H N A M B O H LULI

CC Assessment
A 46-year-old female presents for consultation regarding the Comprehensive examination and evaluations of the patient show the
shape of her nose and progressive changes in her face. early signs of aging; hollowing of temporal areas on both sides are
evident. Malar prominences are flattened, and submalar depressions
HPI are apparent. Nasolabial grooves are deepened. The vermilion show is
near zero. Marionette lines are visible. Skin quality is the other com-
The patient has felt the process of aging since a few years ago. She plaint of the patient. Dry and brittle skin has developed in the past
has used several hydrating over-the-counter products and uses a few years.
lot of makeup to conceal skin changes and improve her upper lip
contour. Treatment
PMHX/PDHX/Medications/Allergies/SH/FH Fifty mL of the fat graft was planned and performed. The donor
sites were discussed with the patient, and since because was rela-
The patient is a healthy nonsmoker. (Smoking may negatively af- tively lean, lateral and medial sides of both tight prepared and
fect graft survival.). She has is no history of a bleeding disorder or draped to avoid possible contour changes from single donor sites.
use of blood thinners (Aspirin and other nonsteroidal antiinflam- Then the following steps were performed consecutively:
matory drugs should be withheld 2 weeks before surgery, as • Mapping and marking the face based on the treatment plan.
should smoking. Vitamin E and some herbal products that inter- • Injection of a total of 50 mL of wetting solution (almost equal
fere with bleeding are also discontinued before surgery.) to the volume of fat to be harvested) on four donor sites (250
cc of normal saline, 5 cc of lidocaine, 1 cc of epinephrine
Examination 1/1000) (eFig. 84.4, Fig. 84.5, eFig. 84.6 to Fig. 84.7).
• After 15 minutes, fat was harvested with 10-mL syringes and
The examination starts with a comprehensive interview. It is fea- cannula
sible to discuss the risks and limitations of fat grafting in com- • Centrifuge of retrieved fat for 5 minutes (with 1280 g)
parison with dermal fillers. • Fat transfer: Refined fat was transferred to several 1cc syringes
Donor sites are to be evaluated preoperatively. In extremely and injected into planned areas on the face (see Fig. 84.7).
lean patients as in the present patient, there are no massive fat
sources, and multiple donor sites may be needed. The inner and Complications
outer sides of the thigh provide four possible donor sites without
the need for intraoperative position changes. In addition, using Fat grafting is a relatively safe and predictable procedure even
multiple donor sites may be beneficial to avoid donor site contour though simple mistakes may end up in serious and sometimes
changes. In case of inadequate donor reservoirs, it would be better nonreversible consequences.
to think about alternative treatments such as fillers.
Blindness and Stroke
Imaging
Blindness and stroke mean that fat has been injected through a
A standard series of photography needs to be done before and after blood vessel, and then the injected fat may travel with normal blood
surgery. Photography is the best tool to communicate with the flow to the ophthalmic artery and end up in blindness or move
patient during the preoperative consultation sessions and record through the internal carotid arteries to the cerebral arteries and
the preoperative condition and postoperative changes (Fig. 84.3). cause a stroke. Fortunately, new blunt cannulas and improved sur-
gical techniques have considerably decreased the risk of blood vessel
Labs intrusions. Meanwhile, it is recommended to aspirate the syringe
before injections around high-risk areas, avoid pressure on fat trans-
No routine laboratory testing is indicated for cosmetic rhino- fer, and consider pertinent anatomy in high-risk areas of the face,
plasty unless dictated by the medical history. especially the inner corners of the eyes and dorsum of the nose.

438
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 CHAPTER 84 Fat Grafting and Fillers 439

A feasible way to avoid this complication is to deliver the proper

amount of fat and be ready for small possible touch-ups if resorp-
tion happens.

Contour Irregularities on the Recipient or Donor

Site
Fat graft should be delivered in small aliquots at proper depth.
A B Bigger volumes and improper depth of fat transfer may result in
bumps and irregularities.
• Fig. 84.1 CO2 laser resurfacing. When applied in the correct setting, it
yields beautiful and predictable results. A, Before resurfacing. B, After re-
surfacing. Bruising and Swelling
Patients undergoing cosmetic surgery expect minimal downtime.
Proper use of wetting solution and waiting for 15 minutes mini-
mize donor site morbidity. In recipient sites, meticulous tech-
nique and gentle hand passes of the surgeon and delivering small
aliquots of fat may be the key points to avoid swelling and bruises
on recipient sites.

Discussion
For more than 100 years since the initial advent of fat grafting in
1893 by Adolf Neuber, there have been longstanding debates on
A B all aspects of this procedure, and fat grafting frequently appears
• Fig. 84.2 *** and fades in the literature. Sydney Coleman is commonly credited
as the surgeon who established the basics of structural fat grafting
and showed that proper fat grafting is a quite predictable proce-
Overcorrection dure.
Some practitioners believe that the fat needs to be overfilled to Here our patient desired simultaneous rhinoplasty and fat
compensate for possible resorption even though overcorrection can grafting. Fat grafting may be done as an isolated procedure or as
be a two-edged sword and in case of no resorption or inadequate an adjunct to other surgeries such as facelifting, eyebrow lifting,
resorption overcorrection is accounted as a serious complication. and blepharoplasty.

A B C D E

F G H I J

• Fig. 84.3 A–E, Standard preoperative photos. F–J, The same series repeated 6 months after the
operation.

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 439.e1

• eFig. 84.4 Wetting solution is infiltrated into donor sites. (From Bagheri SC, Bohluli B, Consky EK. Cur-
rent techniques in fat grafting, Atlas Oral Maxillofac Surg Clin North Am. 2018.)

A B C D
• eFig. 84.6 A, Centrifuge of harvested fat. B, In centrifuged tubes, fat stays in middle. C and D, Discard-
ing excess material from top and bottom of centrifuged tubes and using the middle part that is pure fat.
(From Bagheri SC, Bohluli B, Consky EK. Current techniques in fat grafting, Atlas Oral Maxillofac Surg Clin
North Am. 2018.)

t.me/Dr_Mouayyad_AlbtousH
440 S E C TI O N XI I I Facial Cosmetic Surgery

A B
• Fig. 84.5 A and B, Fat harvest by a 10-cc syringe connected to a cannula. (From Bagheri SC, Bohluli
B, Consky EK. Current techniques in fat grafting, Atlas Oral Maxillofac Surg Clin North Am. 2018.)

Fat grafting is commonly divided into the following steps: fat

harvesting, graft processing, and fat transfer.

Fat Harvesting
Fat harvesting is a very technique-sensitive procedure. A wetting
A B solution is usually used to suspend fat cells. The most common
• Fig. 84.7 Fat transfer. Refined fat was transferred to several 1-cc sy- solutions are a combination of a solvent (normal slime or Ringer’s
ringes (A) and injected into planned areas on the face (B). lactate), a local anesthetic (lidocaine), and epinephrine. The
solution is injected and spread on the donor side, and after 10 to
15 minutes, 2- to 3-mm stab incisions are made and fat is har-
Autogenous fat cells can be harvested from any accessible fat vested by creating slight negative pressure on the syringe and
reservoir in the body. Meanwhile, the abdomen, tight, and flanks gentle back-and-forth movements of the hand. Many other suc-
are the most common sites to harvest fat. Some recent studies tion methods and machines are advocated to retrieve fat; the only
show that there is no substantial difference in the quality and common point is to insert minimum tension and pressure on fat
survival rate of fat cells from different donor sites; therefore, the cells in the syringe and cannula techniques. It is recommended to
availability of fatty reservoir, patient compliance, and surgeon’s avoid more than a 2-millimeter negative presser on the plunger of
preference may be the main criteria to choose a donor site, though the syringe.
it is prudent to avoid adhesion zones. Adhesion zones are the areas
where fibrous extensions connect deep fat compartments to the Graft Processing
epidermis. Fat harvesting in these areas can be very traumatic and
may damage donor sites and provide damaged fat cells and less The purpose of processing is to remove any redundant compo-
predictable results (Fig. 84.8). nents from harvested materials and prepare a concentrated viable

1. Lateral gluteal
depression
2. Gluteal crease

3. Distal posterior
thigh
4. Mid medial thigh

• Fig. 84.8 Best practices indicate preoperative marking and avoidance of these areas. (From Rohrich RJ,
Smith PD, Marcantonio DR, et al. The zones of adherence: role in minimizing and preventing contour
deformities in liposuction, Plast Reconstr Surg 2001;107:1564; with permission.)

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 84 Fat Grafting and Fillers 441

source of adipocytes. Many methods are advocated to refine fat. other component that may remain in processed fat and endanger
Centrifuge, washing and filtering, and sedimentation are three the vitality of fat cells by inducing vasoconstriction.
well-supported techniques in the literature for fat processing. Blood in harvested fat shows a technical flaw. Blood may pro-
mote phagocytosis of vital fat cells and affect the late outcome of
Fat Transfer the procedure. As a whole, it is critical to remove all excess mate-
rials from fat grafts and prepare a pure adipocyte component for
Fat injection is usually done by 1-cm syringes that are connected grafting.
to delicate cannulas. Fat cells are delivered in small fat parcels. It
is noteworthy that in the first few days, fat parcels survive by dif- Storing and Freezing the Fat
fusion of nutrients; therefore, it is strictly recommended to place
very small aliquots of graft in each hand movement. It is advised Some studies show that fat cells may survive after freezing and
to transfer 0.1 cc of fat in each hand possession, meaning that a defrosting. However, clinical use of this defrosted fat is not com-
1-cc syringe needs a minimum of 10 hand passes to transfer the monly accepted, and most experts prefer to harvest and use new
content of a 1-cc spring. fat in their touch-ups instead of storing the patient’s fat.
Lidocaine is commonly used in donor and recipient sites.
Some studies show that lidocaine can interfere with glucose me- ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
tabolism and affect the survival of fat cells. Epinephrine is the complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 441.e1

Bibliography Bohluli B, Varedi P, Bayat M, et al: Submental fat transfer: an approach

to enhance soft tissue conditions in patients with submental lipoma-
tosis after orthognathic surgery, J Oral Maxillofac Surg 72(1):164.
Bagheri SC, Bohluli B, Consky EK: Current techniques in fat grafting, Atlas e1-164.e7, 2014. doi:10.1016/j.joms.2013.08.032.
Oral Maxillofac Surg Clin North Am 26(1):7-13, 2018. doi:10.1016/ Coleman SR, Lam S, Cohen SR, et al: Fat grafting: challenges and de-
j.cxom.2017.11.001. bates, Atlas Oral Maxillofac Surg Clin North Am 26(1):81-84, 2018.
Bohluli B, Aghagoli M, Sarkarat F, et al: Facial sculpturing by fat grafting, doi:10.1016/j.cxom.2017.10.006.
2013. Coleman SR: Fat injection: from filling to regeneration, ed 2, United
Bohluli B, Bagheri SC, Consky EK: Fat grafting as an adjunct to facial States, n.d. CRC Press LLC.
rejuvenation procedures, Atlas Oral Maxillofac Surg Clin North Am Coleman SR: Structural fat grafting, United States, 2004, Thieme.
26(1):51-57, 2018. doi:10.1016/j.cxom.2017.10.005.

t.me/Dr_Mouayyad_AlbtousH
85
Rhinoplasty
B E H N A M B O H LULI

CC a forced respiration test. The patient is asked to make deep respi-

ration while the nostrils are monitored (Fig. 85.2).
The patient is a 26-year-old male. His main concern is the shape Internal nasal is evaluated by the Cottle test. This examination
of his nose. He believes it is badly deviated and is a little bit bulky, is a simple test that gives essential information about the compe-
which causes difficulty in breathing and an unpleasant appearance. tency and function of the internal nasal valve (Fig. 85.3).
Finally, the nasal septum is visualized by a speculum and ade-
HPI quate light.

The patient has had a bulky big nose since he remembers. About Imaging
5 years ago, he had an accident with facial trauma that caused a
nasal fracture. His nose was reduced in an outpatient setting. He Preoperative and serial postoperative photoimaging is mandatory
claims that deviation was corrected for some time and relapsed for cosmetic procedures. Standard photography for cosmetic rhi-
gradually. noplasty includes frontal, right and left lateral, right and left
oblique, and basal (“worm’s eye”) views. Photographs should be
PMHX/PDHX/Medications/Allergies/SH/FH standardized to allow optimal preoperative and postoperative
comparisons (Fig. 85.4).
The patient has a previous history of closed reduction of the frac- Computed tomography is not necessary for cosmetic rhino-
tured nose. He has no history of cosmetic rhinoplasty. (Previous plasty, but it can be used in selected cases to delineate the severity
nasal surgery is particularly important because the anatomy may of septal deviation and identify sinus pathology.
be altered. If the septal cartilage has been previously harvested or
adjusted and there is a need for cartilage grafting, ear or rib carti- Labs
lage can be used.) He denies any seasonal or drug allergies. (It is
important to note symptoms of allergic rhinitis or recent upper No routine laboratory testing is indicated for cosmetic rhino-
respiratory tract infections.) There is no history of psychiatric plasty unless dictated by the medical history.
disorders or treatment. (Patients with certain psychiatric disorders
may not be candidates for elective cosmetic procedures.) There is Assessment
no history of smoking or cocaine or other drug use. (Cocaine-
induced vasoconstriction compromises wound healing and in- The patient desires a smaller but normal-looking nose (not operated
creases the risk of septal perforation.) He also has no history of look). The skin is thick, and the tip is bulky. A 2- to 3-mm excessive
granulomatous or autoimmune disorders (e.g., Wegener granulo- hump is seen. The nasal septum is dislocated from the maxillary crest.
matosis, which can affect the nasal mucosa) or of epistaxis. (A The assessment shows that the nasal framework needs to be reinforced,
history of unexplained epistaxis should be investigated for blood and a considerable amount of cartilage graft is needed that may be
dyscrasias, such as von Willebrand disease.) provided from septoplasty.

Examination Treatment
A clinical examination is usually initiated with a comprehensive An open approach septorhinoplasty was planned and performed
interview to find out the expectations of the patient and detect after general anesthesia. A 6-cc amount of local anesthetic (lido-
any unrealistic demands. caine 1 epinephrine 1/200,000) was precisely injected into in-
Physical evaluation should encompass the entire face, but for cision lines, dissection planes, and the septum. After 10 min-
planning the rhinoplasty, the nose can be examined in six utes, a stair-step midcolumella incision was made and connected
regions: the skin, radix, dorsum, tip, nostrils, and alar base to infracartilaginous incisions. Wide subperichondrial and peri-
(Fig. 85.1). osteal dissection was made. After skeletonization, the following
Each region is evaluated in three dimensions. The nose is pal- steps were performed:
pated to assess the thickness of the skin and bony–cartilaginous • 3-mm cephalic trimming of lower lateral cartilage
framework of the nose. Then the external nasal valve is assessed by • Intradomal suture

442
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 85 Rhinoplasty 443

CEPHALIC DORSUM

Frontal bone
Radix

Nasal bone
Rhinion

Upper lateral
cartilage Scroll area A
Supratip

Lower lateral Tip defining

cartilage point

Accessory
cartilage Columella

Ala

CAUDAL
• Fig. 85.1 Anatomy of the nasal structures as seen from profile.

• Interdomal sutures
• Component hum reduction
• Septoplasty and graft harvesting
• Lateral osteotomy
• External taping and internal splinting (Fig. 85.5)

Complications
Rhinoplasty may be accompanied by a wide range of complica-
tions from simple temporary eyelid edema to blindness or brain
B
• Fig. 85.3 A and B, The Cottle test to evaluate the internal nasal valve
either by finger traction or with a cotton swab.

damage. Table 85.1 shows the complications that are listed on the
consent form of the American Society of Plastic Surgeons with
relative possibilities in the second column.

A Hematoma and Bleeding

Like any surgical complications, the best way to deal with bleed-
ing and hematoma is prevention. Hypotensive anesthesia, 5- to
10-degree head elevation, precise infiltration of local anesthetic,
and moving in the proper surgical plane (subperichondrial or
subperiosteal) may guarantee a dry surgical field. Meanwhile, it is
feasible to manage any unexpected bleeding intraoperatively
before proceeding to the next step.

B Bleeding
• Fig. 85.2 A and B, The forced respiration test to evaluate the external Bleeding may also occur postoperatively. In most cases, the source
nasal valve. of postoperative bleedings is incision lines that are easily managed

t.me/Dr_Mouayyad_AlbtousH
444 S E C TI O N XI I I Facial Cosmetic Surgery

A B C D E F G

H I J K L M N
• Fig. 85.4 A–G, Standard preoperative photo imaging. H–N, The same photos repeated postoperatively.

A B C D E
• Fig. 85.5 A, Stair-step incision. B, Subperichondrial dissection. C, Strut placement. D, Cap graft.
E, shield graft.

TABLE Adverse Events Listed in the American Society

85.1 Necrosis
of Plastic Surgeons’ Consent for Rhinoplasty
and the Associated Rate Range Found During Necrosis is a relatively rare but devastating complication in rhino-
This Systematic Review of the Literature plasty. The best practice is to remember risk factors and plan the
surgery based on those risk factors (Table 85.2).
Adverse Event Event Rate (%)
Nasal septal perforation 0–2.6
Infection 0–4 Irregularities
Bleeding 0–23.4 Irregularities are the most common reason for revision rhino-
Nasal airway obstruction 0–23.7 plasty. Sharp edges of grafts are to be feathered or shaved.
Hypertrophic scarring 0.55–9.1
Delayed healing —
Intraoperative irregularities are best corrected by crushed
Dehiscence 5 cartilage grafts.
Skin discoloration 1.7–21.8
Firmness 2–2.5 Cerebrospinal Fluid Leakage
Need for revision surgery 0–10.9
Numbness or paresthesia 4.0–49.1 Cerebrospinal fluid (CSF) leakage is an excessively rare rhino-
Seroma 7.4 plasty complication. Manipulation and damage to the cribriform
Fat necrosis — plate during osteotomies or aggressive manipulation of the bony
septum may lead to CSF leakage.
Clear rhinorrhea and positional headaches need special atten-
by cleaning, gentle pressure, and dressing in a small gauze. Continu- tion diagnosis and management.
ous and serious bleeding is extremely rare, and the author has never To prevent CSF rhinorrhea, it is suggested not to extend oste-
encountered it in more than 5000 rhinoplasty surgeries. However, a otomies beyond the internal canthus and not to manipulate the
rhinoplasty surgeon should be ready for rare possibilities. bony septum aggressively during septoplasties.

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 CHAPTER 85 Rhinoplasty 445

TABLE Risk Factors for Necrosis and Ways to Avoid TABLE Advantages and Limitations of Closed
85.2 Them 85.3 and Open Approach Rhinoplasty

Risk Factor Handling Open Approach Closed Approach

Smoking Avoid smoking for a minimum of 5 days Advantages Easier to learn Less postoperative
before surgery; closed approach in Easier and more precise graft swelling
patients with thin skin and smokers; fiction No visible scar
subperichondrial dissection to create Appropriate for complex cases
a stronger soft tissue flap such as revisions and con-
genital deformities
Revision rhinoplasty Subperichondrial dissection; monitoring
after surgery Limitations Possibility of a visible scar Possible mistakes in
Longer postoperative edema complex cases
Vigorous thinning of skin; Subperichondrial dissection; no or
improper surgical plane minimal defatting
or defatting
Tight taping and splinting Gentle taping; splints molded by gentle
finger pressure both techniques, and be skilled in one that works better in the
surgeon’s hand (Table 85.3). In the current patient, a lot of sutur-
ing and grafting was planned, so an open approach was planned
and performed.
It is very important to perform precise incisions. Any flaws in
Discussion incision lines may damage the cartilage or delicate skin on the
nostrils, which is very difficult or sometimes impossible to man-
Rhinoplasty is an extremely unforgiving procedure. Although a age. Fig. 85.6 shows common incisions in rhinoplasty.
successful operation improves both the function and esthetics of It is prudent to dissect in the subperichondrial and subperios-
the nose, an unacceptable result may end up in very complicated teal plane. The proper surgical plane may help the surgeon to have
revision rhinoplasty. Diagnosis and treatment planning make up a clean and bloodless field intraoperatively; in addition, subtle
the backbone of an optimal procedure. Palpation of the nose irregularities are covered by a thicker soft tissue envelope, and
provides an overview of the bone, cartilage, and covering soft tis- better postoperative results will be expected.
sue of the nose. Thick skin hardly shows details of the framework, The suture tip plasty is a very conservative and predictable ap-
and very thin skin may show small irregularities and even small proach to refining the tip. In this patient, two basic techniques
suture knots. were used. Interdomal sutures were mattress sutured to shape each
Rhinoplasty is generally done either by a closed or open ap- dome, and interdomal sutures adjusted the distance and angle of
proach. There is an everlasting debate to choose one over the other, two domes to each other.
although the current literature shows that both approaches are ef- In almost all nose surgeries, some kind of autogenous cartilage
fective and can end in optimal results. It is advised to be familiar graft is needed. Septal cartilage is usually the first choice, though
with both approaches, know the advantages and limitations of conchal cartilage from the ear and costochondral grafts may be

Nasal bone

Upper lateral cartilages

Limen vestibula incision Septal cartilage
(intercartilaginous)
Lower lateral cartilages
Cartilage splitting incision
(intracartilaginous) Transfixion incision
Marginal incision Transcolumellar incision
(infracartilaginous)

• Fig. 85.6 Common sites of incisions for rhinoplasty.

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446 S E C TI O N XI I I Facial Cosmetic Surgery

considered when the septal graft is not available or is not enough valve would be necessary. Several techniques are advocated for this
in major augmentation cases. The columellar strut is a very com- purpose, though spreader grafts are still the gold standard in the
mon graft used to reinforce nasal tip support and minimally in- reconstruction of internal nasal valves.
crease tip projection. A cap graft and shield graft are two other Osteotomy is an integral part of rhinoplasty. It is done to close
common tip plasty grafts. A cap graft is a small piece of cartilage an open roof deformity, to narrow a wide bony pyramid, or to
that is placed and sutured over the tip. It increases tip definition straighten a deviated bony vault.
and can add 1 to 2 mm to the tip projection. In this patient, the Osteotomy may be done with three different planes: low to
intraoperative evaluation showed that the cap graft is not ade- high, low to low, and double-layer osteotomy. It is noteworthy to
quate, so a shield graft was used. A shield graft is a very strong remain that finger pressure should shape the bony vault after os-
graft that can easily increase tip projection and definition. How- teotomy; if much pressure is needed, it is better to redo the oste-
ever, late complications such as visible shadows of graft distortion otomies or add medial osteotomy to avoid uncontrolled fracture
limit its use to extremes of thick skin and when the other more lines.
conservative approaches do not provide an ideal result.
The internal nasal valve may be incompetent before surgery or ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
damaged during surgery. Then reinforcement of the internal nasal complete set of bibliography.

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 446.e1

Bibliography Bohluli B, Khabir F, Haeri A: Controversies in modern rhinoplasty. In

Integrated procedures in facial cosmetic surgery, 2021, Springer Interna-
tional Publishing, pp 271-281. https://doi.org/10.1007/978-3-030-
Bagheri SC, Khan HA, Bohluli B: Modern rhinoplasty and the manage- 46993-1_21Revision rhinoplasty.
ment of its complications, Oral Maxillofac Surg Clin North Am Bohluli B, Moharamnejad N, Bayat M: Dorsal hump surgery and lateral
33(1):xiii-xiv, 2021. Available at: https://doi.org/10.1016/j.coms. osteotomy, Oral Maxillofac Surg Clin North Am 24(1):75-86, 2012.
2020.09.009. Available at: https://doi.org/10.1016/j.coms.2011.10.005.
Bohluli B, Bagheri SC, Behkish B, et al: Immediate effects of different Bohluli B: Esthetic Rhinoplasty in the multiply operated nose, J Oral
steps of rhinoplasty on nasolabial angle and tip projection, J Craniofac Maxillofac Surg 77(7):1466.e1-1466.e13, 2019. Available at: https://
Surg 25(5):e404-e406, 2014. Available at: https://doi.org/10.1097/ doi.org/10.1016/j.joms.2019.02.042.
SCS.000000000000060. Khan HA, Bohluli B, Eshkevari PS: The initial examination. In Rhino-
Bohluli B, Bagheri SC: Revision rhinoplasty. In Bagheri SC, Bell RB, plasty, 2023, Elsevier Inc, pp 16-19. Available at: https://doi.org/10.
Khan HA (eds): Current Therapy in Oral and Maxillofacial Surgery, 1016/B978-0-323-69775-0.00003-2.
St. Louis, 2012, Saunders, pp 901-910. Moharamnejad N, Bohluli B: Dorsal hump deformity in compromised
Bohluli B, Hadadi S, Khan HA: Internal lateral and medial osteotomy. internal valve. In Rhinoplasty, 2023, Elsevier Inc, pp 112-115. Avail-
In Rhinoplasty, 2023, Elsevier Inc, pp 127-129. Available at: https:// able at: https://doi.org/10.1016/B978-0-323-69775-0.00024-X.
doi.org/10.1016/B978-0-323-69775-0.00028-7.

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86
Nasal Septoplasty
SH AH R O K H C. B AG H ER I a n d E VAN BU SB Y

CC Examination
A 28-year-old male presents for a consultation regarding difficulty The nose is examined in conjunction with the other facial struc-
breathing through the left side of his nose. tures for both its functional and cosmetic aspects. The physical
examination should include inspection and direct visualization of
HPI the septum, turbinates (inferior, middle, superior), nasal mucosa,
nasal passages, nasal valve (internal and external), radix, dorsum,
The patient states he has had difficulty breathing since he was a columella, and anterior nasal spine. (Occasionally, a tumor occurs
child and always remembers his nose being deviated. The patient in the nasal passages, and an area showing changes suspicious for
also reports his nose was forcefully struck in a sporting accident neoplasia should be biopsied.) The examination of the current
4 years ago at age 24 years. (Prior nasal injury is a risk factor for patient proceeded as follows.
deviated septum.) He reports that he underwent a closed reduc-
tion of nasal bone fractures at the time of injury; however, he was External Nasal Examination
still unable to breathe well afterward. No further surgical inter-
vention was provided at that time. Subsequent to that injury, he The nasal bones are stable and symmetric. The tip and columella
has not been able to breathe through his left nostril. (Nasal ob- are deviated to the left. The anterior nasal spine is palpated and
struction caused by septum deviation can occur because of birth appears coincident with the facial midline, but the cartilaginous
trauma or, more likely, secondary to developmental changes or, as caudal septum is deviated to the left. The bony radix and dorsum
in the current patient, facial trauma.) He has tried over-the- are in the midline. The external cartilaginous caudal nasal struc-
counter nasal sprays (Afrin and Flonase), all without relief. He tures (dorsum, tip, columella) show only mild deviation to the
used these as directions stated and not for extended purposes. left. (Significant septal deviation is not always associated with a
cosmetic nasal deformity of the columella, dorsum, or tip.)
PMHX/Medications/Allergies/SH/FH
Rhinoscopy
The patient has no significant medical illness. The patient denies
a history of abuse of cocaine or other nasally inhaled substances, Rhinoscopy is examination of the nose with a speculum. The
such as nose drops or sprays. (Rhinitis medicamentosa can nasal mucosa is nonerythematous with normal moisture and
cause postoperative septal perforation caused by chronic mucosal absence of polypoid tissue. (Erythema, excessive secretions, and
vasoconstriction.) He does not have symptoms of nasal allergy polyps would be indicative of allergic rhinitis.) The quadrangu-
(seasonal, caused by pollens; perennial, caused by inhaled or in- lar cartilage and bony septum are significantly deviated to the
gested irritants; infectious agents; or a combination of these) or left, closing the nasal valve angle with nearly complete blockage
vasomotor rhinitis (nasal congestion, hypersecretion, sneezing of the airway, prominent midseptal bowing, and contact of
caused by parasympathetic system instability). Such conditions the septum with the left inferior turbinate. The septum is also
should be diagnosed and controlled or resolved before nasal septal deviated inferiorly to the left. Bilateral inferior turbinates are
surgery. It is important to discuss with the patient that these may enlarged, with the right larger (compensatory turbinate hyper-
not resolve after a septoplasty. There is no history of Wegener trophy) than the left. The left nasal valve is obstructed by this
granulomatosis (small- and medial-sized vasculitis that can affect deviation.
the nose, causing pain, epistaxis, and nasal deformities caused
by septal perforation). The patient denies tobacco use. (Tobacco Endoscopic Nasal Examination
smoke is irritating to the nasal mucosa, and nicotine causes
generalized vasoconstriction. Smoking after a nasal (or any) After spraying the nose with oxymetazoline (a1 agonist and par-
operation seriously interferes with the healing process and may tial a2 agonist), endoscopic examination confirms the presence of
become a critical factor in wound breakdown or the development right inferior turbinate hypertrophy and leftward deviation of the
of an infection.) septum with no visible mucosal pathology. (Endoscopy is not

447
t.me/Dr_Mouayyad_AlbtousH
448 S E C TI O N XI I I Facial Cosmetic Surgery

necessary to diagnose and treat a deviated septum. However, it Imaging

can be helpful in the evaluation of the posterior nasal structures,
i.e., the superior nasal passages, the paranasal sinus meatuses, and Advanced imaging studies (CT) are not necessary to diagnose a
the posterior nasal choanae, especially in the absence of computed deviated septum. However, CT or in-office cone-beam computed
tomography [CT] examination.) tomography (CBCT) are helpful in the evaluation of the location
and extent of the deviation and in the assessment of the turbi-
nates, paranasal sinuses, and other related structures for addi-
Cottle’s Test tional pathology. Imaging like this also helps visualize the bony
The test result was negative and did not improve airflow in the septum discrepancies. The panoramic radiograph is not used for
current patient. The test is done to evaluate airflow caused by definitive evaluation of the nasal septum. However, this routinely
nasal valve obstruction or compromise. The contralateral nostril is obtained plain film does afford basic two-dimensional anteropos-
gently closed by the examiner, and the ipsilateral cheek is pulled terior visualization of the septal position and can be used as a
laterally to open the nasal valve. If airflow is improved by this screening tool.
maneuver, the internal nasal valve deficiency is potentially con- In the current patient, axial and coronal CBCT imaging
tributing to airflow obstruction. (This is an unreliable test that demonstrated significant leftward deviation of the septum with
produces many false-positive results; that is, lateral retraction of reduced air space and compensatory enlargement of the right in-
the cheek improves the airway in many patients who only have ferior turbinate (Fig. 86.1A and B). The panoramic radiograph
temporary nasal mucosal ingestion, not collapse of the nasal valve. obtained for third molar evaluation in this patient shows impac-
Therefore, the examiner should be wary of the validity of this test tion of the mandibular third molars and demonstrates the devi-
with regard to nasal valve integrity.) ated septum (Fig. 86.1C).

A B

C
• Fig. 86.1 A, Coronal reconstruction computed tomography (CT) scan showing significant midseptal
deviation. B, Axial CT scan of septum showing deviated bony and cartilaginous septum with significant
right inferior turbinate hypertrophy. C, Panoramic radiograph showing deviated septum.

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 CHAPTER 86 Nasal Septoplasty 449

Labs In the current patient, 12 mL of 0.5% bupivacaine (Marcaine)

with 1:100,000 epinephrine was injected into the septum and
No routine laboratory tests are indicated for nasal septoplasty inferior turbinates for vasoconstriction and hydrodissection both
surgery in an otherwise healthy patient. However, patients with a anteriorly and posteriorly. Oxymetazoline (for vasoconstriction)
family history of clotting disorders are screened for possible undi- was applied into both nasal passages using cotton pledgets.
agnosed coagulopathies (e.g., von Willebrand disease, platelet (Inferior turbinate removal is best performed before septoplasty
deficits or dysfunction, liver pathology, and clotting factor defi- surgery to avoid injury to the operated nasal septum during re-
ciencies). Patients taking anticoagulant medications are at risk for traction. The inferior turbinate is removed [Fig. 86.3A] along
hematoma formation and uncontrolled hemorrhage. with any prominent bony segment to increase the airway space. A
submucous resection combined with turbinate outfracture was
Assessment used, with careful attention to hemostasis. The inferior turbinates
are resected using angled scissors, with hemostasis achieved by
A 28-year-old male with severely deviated nasal septum to the left, electrocautery.)
involving the quadrangular cartilage and the bony septum, causing
impaired left nostril airflow and compromised flow in the right be-
cause of compensatory inferior turbinate hypertrophy.

Treatment
In the current patient, general anesthesia was induced, and an oral
endotracheal tube was placed for airway maintenance and admin-
istration of oxygen and anesthetic agents.
Two main incisions are used to approach the septum:
the Killian incision and the hemitransfixion incision (Fig. 86.2).
The Killian incision is the most common and is used to approach
the septum without direct access to the caudal segment. It is the
best incision for preserving tip support. The hemitransfixion inci- A
sion allows exposure of the caudal septum and anterior nasal spine
by placing the incision in the membranous septum just anterior
to the cartilage. Critics of this incision argue that it can weaken
tip support by affecting the foot plates of the lower lateral carti-
lage. The septum can also be approached via the open rhinoplasty
incision (transcolumellar). This is usually done when nasal and
septal surgery for both cosmetic and functional correction are
planned. Access to the septum via the Le Fort I osteotomy is eas-
ily done in combination with orthognathic surgery. Correction of
the deviated septum should be included in the orthognathic surgi-
cal plan. Special consideration is required with maxillary impac-
tion because the vertical height of the septum must be reduced
adequately to allow the planned amount of maxillary superior
intrusion and to avoid compression and postoperative nasal sep-
tum deviation.
B

C
• Fig. 86.2 Sagittal view of septum showing the Killian and hemitransfixion • Fig. 86.3 A, Resection of inferior turbinate. B, Exposure of the deviated
incisions. (From Azizzadeh B, et al: Master techniques in rhinoplasty, septum via a Killian incision. C, Cartilage and bone removed via the Killian
Philadelphia, 2011, Saunders.) incision.

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450 S E C TI O N XI I I Facial Cosmetic Surgery

A Killian incision was made in the right nasal mucosa (after

adequate time for vasoconstriction [i.e., 5–7 minutes]), and a full
mucoperichondrial flap was raised using a Cottle elevator. The
deviated septum was exposed (Fig. 13.3B) and showed significant
leftward deviation of the quadrangular cartilage. The dissection
was carried out inferiorly to the floor of the nose, allowing reflec-
tion of the periosteum off the nasal crest of the maxilla inferiorly
and laterally. (This is the most common location of septal perfora-
tion, especially with prominent bony deviations.)
After full exposure of the bone and cartilaginous septum, a
segment of the cartilage was removed with preservation of ap-
proximately 1 cm at the dorsum and caudal strut (Fig. 13.3C).
(Removal of the bony septum, including the perpendicular plate
of the ethmoid bone, should be done with care using double-ac-
tion or through-cutting rongeur forceps and with minimal lateral
movement to avoid a cribriform plate fracture and possible cere- • Fig. 86.4 Nasal septal hematoma. (From Nease CJ, Deal RC: Septo-
brospinal fluid [CSF] leak.) After irrigation, closure of the inci- plasty in conjunction with cosmetic rhinoplasty, Oral Maxillofac Surg Clin
sion was done with 4-0 chromic gut suture. (A quilting suture is North Am 24[1]:49-58, 2012.)
done with 4-0 chromic and a straight [Keith] needle to approxi-
mate the opposing mucoperichondrium, reduce the potential seen with nasal fractures.) Bleeding occurs between the perichon-
dead space, and prevent septal hematoma formation.) Bilateral drium and underlying or remaining cartilage (Fig. 86.4). Because
internal Silastic nasal splints were inserted to prevent synechia septal cartilage derives its blood supply from the perichondrium,
formation and provide additional protection against septal hema- a hematoma separates the underlying cartilage from its nutrient
toma. The splints were sutured to the caudal septum. (Nasal vessels and causes ischemia or necrosis of both the cartilage and
splints are removed 1–7 days after surgery, depending on the mucosa. The patient may present with pain, nasal deviation, nasal
surgeon’s preference. Recent studies suggest that early removal mass, ecchymosis, and possibly fever. Early recognition and drain-
[within 48 hours] is sufficient for synechia prevention.) age are important. Careful hemostasis, placement of a quilting
suture to closely approximate the opposing perichondrium (using
Complications a straight Keith needle), and nasal packing are surgical steps that
reduce the risk of this complication.
The risks and complications of nasal septoplasty can be divided Because of the extensive blood supply of the nasal septum and
into intraoperative, early, and late types. mucosa, postoperative infections are rare except when an allogenic
or alloplastic material is used for concomitant nasal or septal
Intraoperative reconstruction. In isolated instances of infection, any foreign
material should be removed, adequate drainage created, and
Intraoperative bleeding should be promptly recognized and appropriate antibiotic cover provided. A septal abscess is an emer-
treated. Posteriorly, bleeding from the posterior ethmoidal and gency because, similar to a septal hematoma, it can cause septal
sphenopalatine arteries can be brisk and its source difficult to vi- cartilage or mucosal necrosis. If the infection ascends via the an-
sualize and staunch. Maintenance of a subperichondrial dissection gular veins to communicate with intercranial vessels, it might
can usually prevent injury to these vessels. Bleeding from Kies- progress to cavernous sinus thrombosis. A single dose of preop-
selbach’s plexus (formed by the confluence of the superior labial, erative intravenous antibiotics is thought to reduce the incidence
anterior ethmoidal, and incisive arteries) in the anterior septum is of postoperative nasal infections.
more easily identified and controlled. Intraoperative control of Cerebrospinal fluid leakage is rare. Patients may present with
hemorrhage can usually be achieved with reinjection of vasocon- headache or nasal pain or have no symptoms whatsoever. There
strictor, electrocautery, or applied pressure (anterior or posterior may or may not be visible CSF rhinorrhea. An easy bedside clini-
nasal packing). In rare circumstances, vessel ligation or arterial cal test can be performed to differentiate nasal secretions from
embolization might be required. Septal perforations (either preex- CSF. A handkerchief is placed beneath the nose to collect nasal
isting or those created during the operation) should be repaired at fluid, and this material is allowed to dry. Mucus starches (stiffens)
that time and carefully evaluated postoperatively for maintenance the handkerchief, whereas CSF does not. A double halo test can
of closure. CSF leakage is a rare occurrence and is usually associ- also be used to evaluate nasal secretions if concerned for a CSF
ated with fracture of the cribriform plate during removal of the leak. If the result is positive, a halo will be seen around the secre-
perpendicular (cribriform) plate of the ethmoid bone (PPEB). To tions, blood being in the center, with CSF surrounding it as a
avoid this complication, the PPEB should be removed with a halo. Neurosurgical consultation is indicated. A CSF leak is usu-
crushing instrument (e.g., a side-cutting rongeur). Attempts at ally treated expectantly with antibiotics and bed rest (with the
lateral mobilization (rocking) and outfracture of the PPEB that head elevated). Occasionally, surgical intervention is necessary to
can lead to fracture of the skull base through the cribriform plate obliterate the communication between the intracranium and the
are to be avoided. superior nasal passage.

Early Late
A septal hematoma is a surgical emergency. It is the consequence Complications from nasal septoplasty can arise from days to sev-
of postoperative bleeding after septal manipulation. (It can also be eral months after surgery. Assessment for internal valve collapse is

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 86 Nasal Septoplasty 451

done after several weeks of healing. This can be caused by scarring possibly reducing mouth breathing and reducing or eliminating
at the nasal valve angle because of the proximity of the incision, the symptoms of snoring, and perhaps lessening the severity of
excessive cartilaginous reduction, or the development of adhe- obstructive sleep apnea syndrome.
sions. The selective use of spreader grafts in conjunction with Nasal septoplasty is indicated as an isolated procedure to im-
septoplasty can improve the nasal valve angle. prove the airway or for correction of a noticeable septal deviation.
Failure to improve airway patency and breathing can be re- Frequently, however, it is done in combination with inferior tur-
lated to undercorrection of the deviated septum or inadequate binectomies and cosmetic rhinoplasty. A nasal septal cartilage
reduction of the turbinates. Posterior anatomic abnormalities graft is commonly used for nasal tip reconstruction (tip graft,
that escaped preoperative diagnosis and went uncorrected can struts, spreader grafts, shield grafts), correction of a deviated nose,
also compromise nasal airflow. Soft tissue edema or polyp forma- or improvement of the internal and external nasal valve angles. In
tion from allergic phenomena or vasomotor effects that were not a recent review of 101 rhinoplasties, we found that most patients
recognized and treated preoperatively can cause distressing post- initially requested consultation solely regarding cosmetic nasal
operative nasal airway obstruction despite proper correction of surgery (80%); only 20% desired correction of the nasal airway in
bony and cartilaginous abnormalities in the nasal septum and addition to the appearance of the nose. However, the majority of
turbinates. the patients (63%) were treated with a septorhinoplasty, either for
A saddle nose deformity (collapse of the nasal dorsum) cartilage harvest or correction of septal deviation compromising
can result from excessive removal of cartilage. Maintaining at nasal airway patency.
least 1 cm caudal and dorsal cartilaginous support prevents this Among many who have contributed to advances in nasal septal
complication. surgery, three individuals cannot go without mention. In 1904,
When a nasal septal perforation develops postoperatively, it Killian described the incision that bears his name and the impor-
can be because of mucosal tears (especially when bilateral), septal tance of cartilage preservation for support for the nasal dorsum
hematoma, septal infections, and abuse of recreational vasocon- and tip. He introduced the idea of preserving at least 1 cm of
strictor drugs (e.g., cocaine, nose drops, or sprays). caudal and dorsal cartilaginous support, which to this day remains
The development of nasal adhesions (synechiae) after septo- a fundamental concept of septal surgery. Freer, whose elevator is
plasty or turbinectomy is an undesirable complication that can be still widely used in nasal surgery, developed a similar operation at
avoided. The use of internal nasal splints, although sometimes about the same time as and independently of Killian. Cottle
associated with discomfort, prevents synechiae. A short duration (1898–1981), the designer of an eponymous surgical instrument
of intranasal splinting (5–7 days) is sufficient to preclude this (elevator), advocated the elevation of a mucoperichondrial flap on
complication. only one side of the nasal septum and promoted the hemitransfix-
ion incision and the closed rhinoplasty approach.
Discussion Postoperative management for septoplasty should be focused
on detecting a septal hematoma, infection, or perforation and
A newborn infant usually has a straight nasal septum unless the verifying that the septum is correctly positioned. Nasal splints are
nose is subjected to birth trauma. However, as the child grows and removed 5 to 7 days after surgery. Moderate nasal mucosal edema
develops, the nasal septum commonly becomes curvilinear or is expected and gradually resolves within 2 to 4 weeks. Nasal ir-
otherwise deformed to various degrees, the form and size of the rigations with saline solution are used to prevent excessive dryness
nasal turbinates change in response, and nasal breathing, except in and crusting.
cases of severe developmental or traumatic deformity, commonly The patient who undergoes a successful nasal septoplasty op-
adapts accordingly. Neither the mere presence of a deviated nasal eration experiences improved nasal breathing. Preoperative diag-
septum nor the patient’s complaint of a “stuffy nose” or ob- nosis and treatment of reactive nasal soft tissues (e.g., excessive
structed nasal breathing, in the absence of other findings, indi- secretions, edema or polyp formation because of allergic condi-
cates that the nasal septum is the cause. As discussed previously, a tions, vasomotor rhinitis) improves airway conditions not correct-
thorough preoperative evaluation of the nasal airway includes at- able by surgical intervention. Surgical removal of those hard tissue
tention to both the soft tissue components and the hard tissues (bone, cartilage) components (septum, turbinates) that interfere
elements (bone, cartilage). with nasal airflow should provide the patient with definitive relief
Cosmetic rhinoplasty cannot be done without a full under- of obstructed breathing. As a result of proper management of
standing of nasal septal surgery. There is an intimate relationship nasal soft tissue and hard tissue abnormalities, better spontaneous
between “form and function” in nasal surgery. All surgeons who drainage of the paranasal sinuses is a frequent benefit to the pa-
undertake cosmetic rhinoplasty must master septoplasty not only tient. Retention of an adequate amount of septal cartilage ensures
to harvest cartilage but also to preserve or improve the shape and nasal support so that the external appearance of the nose is not
position of the nasal septum. Septoplasty for treatment of the adversely affected.
deviated septum and nasal obstruction can make a dramatic
change in the patient’s quality of life by facilitating nasal airflow, ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
allowing for better spontaneous drainage of the paranasal sinuses, complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 451.e1

Bibliography Cottle MH: Concepts of nasal physiology as related to corrective nasal

surgery, Arch Otolaryngol 72:11, 1960.
Freer OT: The correction of deflections of the nasal septum with a mini-
Aksoy E, Sering GM, Polat S, et al: Removing intranasal splints after mum of traumatism, JAMA 16:362-375, 1902.
septal surgery, J Craniofac Surg 22(3):1008-1009, 2011. Killian G: Die sumucose Fensterresektion der Nasenscheiwand, Arch
Bagheri SC, Khan HA, Jahangirian A, et al: An analysis of 101 primary Laryngologie Rhinologie 16:362-394, 1904.
cosmetic rhinoplasties, J Oral Maxfac Surg 70(4):902-909, 2012. Nease CJ, Deal RC: Septoplasty in conjunction with cosmetic rhino-
Bagheri SC: Primary cosmetic rhinoplasty. In Bagheri SC, Khan HA, plasty. In Bagheri SC, Khan HA, Cuzalina A (eds): Rhinoplasty: cur-
Cuzalina A (eds): Rhinoplasty: current therapy, Oral Maxillofac Surg rent therapy, Oral Maxillofac Surg Clin North Am 24:49-58, 2012.
Clin North Am 24:49-58, 2012. Newman MH: Surgery of the nasal septum, Clin Plast Surg 23:271,
Bagheri SC: Rhinoplasty: current trends in rhinoplasty. In Bagheri SC, 1996.
Bell RB, Khan HA (eds): Current Therapy in Oral and Maxillofacial Oneal RM, Beil RJ, Schlesinger J: Surgical anatomy of the nose, Clin
Surgery, St. Louis, 2012, Saunders, pp 891-900. Plast Surg 23:195, 1996.
Behbrohm H, Tardy M: Essentials of Septoplasty. New York, 2004, Thieme.

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87
Otoplasty
B E H N A M B O H LULI

CC Assessment
A 27-year-old male presents to your office because of protruding ears. A healthy 27-year-old male requests the correction of protruding ears.
The patient’s desires are realistic, and he wants only a normal-looking
HPI appearance. The clinical examination shows both ears are of normal
size; all anatomic components are existing; and the ear-to-cranium
The patient has had protruding ears since he remembers. His distance is only exaggerated in the helical apex, midpoint, and lobule.
parents used pressure bands and hats when he was a child to cor- The cephaloauricular angle is about 35 degrees. (A normal cephalo-
rect the deformity. It has not helped, and since then he has not auricular angle is 15–20 degrees.). On palpation of the ears, the
done anything else in this regard. conchal cartilages are very stiff and thick (Fig. 87.3).

PMHX/PDHX/Medications/Allergies/SH/FH Treatment
The patient is a healthy nonsmoker. (Smoking may increase the Otoplasty may be done with different levels of anesthesia from
risk of skin necrosis and is to be avoided 1 week before surgery.) local anesthesia to deep sedation and general anesthesia. Here, the
He has no history of keloid or bad scar formation. surgery was combined with rhinoplasty. Therefore, general anes-
A thorough review of past medical history and physical ex- thesia was chosen.
amination was done to detect any syndromic conditions. In many Traditional patients are placed in a supine position. This posi-
craniofacial syndromes, ear deformity may be accompanied by a tion provides appropriate access to both ears by tilting the head
variety of soft and hard tissue anomalies that need a comprehen- and a complete intraoperative judgment by holding the head
sive treatment plan, and otoplasty alone cannot solve the issues. upright. The prone position is also frequently reported in the
On the other hand, many craniofacial syndromes may be associ- literature.
ated with serious systemic (especially cardiac) malformations, In the current case, a strong cartilage framework and severely
which need to be clarified before any cosmetic and reconstructive protruding ears were diagnosed, so the combination of cartilage
surgeries. cutting and suture techniques were planned and performed
as follows:
Examination • General anesthesia
• Prep and drape with special attention to keep away hair from
A thorough analysis and diagnosis of each auricle was performed the surgical field
preoperatively. Anatomic compartments were assessed to identify • 5 mL of local anesthesia (lidocaine 1 1/200,000 epinephrine)
any existing malformations. The cephaloauricular angle and dis- • Skin marking and mapping
tance of ear to head are two common parameters used to assess • Skin resection
protruding ears (Figs. 87.1 and 87.2). • Cartilage resection
• Sutures
Labs • Pressure bandage (Fig. 87.4)

No laboratory tests are indicated for otoplasty unless dictated by

medical history or anesthesia concerns. Complication
Bleeding
Imaging
Bleeding may occur during or after the otoplasty. There is no
A series of standard photographs, including full face, lateral, and secret to intraoperative bleeding during otoplasty, and like all
posterior views, is recommended. These images are used in preop- facial cosmetic surgeries, the best practice is to prevent bleeding
erative planning and consultations and can be repeated with the and keep the surgical field dry and clean. Possible blood dyscrasias
same standards after 6 months to evaluate and record the results are to be detected in preoperative examinations. Local anesthetic
of surgery. with epinephrine is dispersed in the surgical field, and after 10 to

452
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 CHAPTER 87 Otoplasty 453

Antihelical crura

10- to 12-mm helical apex

Antihelical scapha Cymba conchae

Tragus
16- to 18-mm midpoint

Antihelix
Cavum conchae

Helix
antitragus Lobule

• Fig. 87.1 Anatomy of the outer ear. 16- to 18-mm lobule

15 minutes, dissection is performed in the proper plane. Adequate

hemostasis needs to be achieved before closing the wounds, and
then a pressure bandage is applied and continued for 1 week.
Postoperative bleeding is usually managed by changing the pres- • Fig. 87.2 Normal measurements of the ears in relation to the head.
sure bandage. Meanwhile, patients need to be under strict super-
vision to prevent hematoma and other major complications. disproportionate unilateral pain. Drainage may be done by a
needle or by opening a few stitches (Fig. 87.5).
Hematoma
Infection and Chondritis
Hematoma is a major complication that may end up in infection,
necrosis of cartilage and skin, and cauliflower ear. Therefore, it Typical signs and symptoms of infection usually appear 3 to
is prudent to diagnose and treat hematoma in the shortest 5 days after otoplasty. Serious pain that does not resolve by anal-
time possible. An ear hematoma is usually manifested by sudden gesics, erythema, and swelling around the surgical field indicates

A B C D

E F G H
• Fig. 87.3 A–D, Photo series for otoplasty. E–H, Postoperative photographs.

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454 S E C TI O N XI I I Facial Cosmetic Surgery

A B

C D
• Fig. 87.4 A, Skin marking. B, excess skin resection. C, Cartilage resection. D, Suturing.

Overcorrection
Overcorrection of the middle third of the ear results in the “tele-
phone deformity.” Overcorrection of the superior and inferior
parts of the ear may end up in the “reverse telephone” deformity.
Management of overcorrection may be controversial; some sur-
geons prefer to wait for partial possible relapse and spontaneous
corrections, but others prefer early intervention to revise the
deformity (Fig. 87.6).

Discussion
Protruding ear is a relatively common deformity. It is estimated
that 5% of the population has some kind of overprotruded ears.

Timing
A common issue is finding the best timing for this surgery. Stud-
ies show that ears find 85% of their size by the age of 4 years;
therefore, otoplasty can be safely done after age 4 years. Mean-
while, most surgeons prefer to postpone the otoplasty to the age
of 5 or 6 years (before school). They believe that at this age, there
is no risk of ear growth damage, and patients will have the best
compliance with the surgery.

Nonsurgical Otoplasty
• Fig. 87.5 Cauliflower ear caused by untreated hematoma.
In this patient, the parents had a failed attempt to correct pro-
infection or chondritis. Drainage and antibiotic therapy are the truding ears by pressure. Noteworthy, current literature shows
mainstays in the management of infection, and in case of that nonsurgical otoplasty is quite an effective technique, though
chondritis, debridement would be needed. As in all incisions and it needs to be done early after birth. It is believed that maternal
drainage in the body, an antibiogram sensitivity test may be done estrogen affects the ear cartilages and makes them malleable
while an empirical antibiotic is immediately started. during the first days and a maximum of 3 to 6 weeks after birth

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 CHAPTER 87 Otoplasty 455

Telephone Reverse telephone

deformity deformity

A B C
• Fig. 87.6 A, Telephone deformity. B, Reverse telephone deformity. C, Normal ear.

and can be easily molded to correct ear deformities. Custom- Cartilage cutting techniques are mostly indicated in strong,
made splints and simple banding are frequently reported to be thick cartilages that need to weaken the strength and memory of
effective in nonsurgical otoplasty. conchal cartilages. In this approach, one or two or more cuts may
be made; cartilage may be abraded, scored, or morselized; in some
Surgical Technique techniques, a segment of cartilage may be excised.
Compared with suture techniques, it is clear that the memory
Numerous techniques with different success and complication of cartilage is completely disrupted, and the final result would be
rates are advocated. Generally, surgical techniques can be divided more stable, but there is a big risk that irregular strap edges of
into cartilage-cutting approaches and suture techniques (cartilage- cartilage will be apparent any time after surgery.
sparing techniques).
In the suture technique, multiple horizontal mattress sutures Postoperative Care
are used to recreate the antihelical fold (Mustardé 1963). Then a
conchal-mastoid mattress suture (Furnas 1968) may be applied to Otoplasty is generally a predictable and safe procedure. Mean-
decrease the projection of a deep conchal bowl. while, a simple complication may end in devastating conse-
Suture techniques are appropriate in thin cartilages that are quences. Most patients undergoing otoplasty are very young.
easily shaped. These approaches do not create irregular cartilage Trauma to the surgical field, pain, and swelling are common.
edges, which mean there is a lower rate of complications, though
the risk of cartilage memory and relapse would be higher. ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 455.e1

Bibliography Lentz AK, Plikaitis CM, Bauer BS: Understanding the unfavorable result
after otoplasty: an integrated approach to correction, Plast Reconstr
Surg 128(2):536-544, 2011. doi:10.1097/PRS.0b013e31821e7113.
Ali K, Meaike JD, Maricevich RS, et al: The protruding ear: cosmetic and Romo T, Baratelli R, Raunig H: Avoiding complications of microtia and
reconstruction, Semin Plast Surg 31(3):152-160, 2017. doi:10.1055/s- otoplasty, Facial Plast Surg 28(3):333-339, 2012. doi:10.1055/s-
0037-1604241. 0032-1312692.
Assis MS, Miranda LS: Performance-optimized otoplasty, BMC Surg Shiffman MA (ed): Advanced Cosmetic Otoplasty Art, Science, and New
22(1):182, 2022. doi:10.1186/s12893-022-01587-y. Clinical Techniques, ed 1, 2013, Springer Berlin Heidelberg. https://
Berghaus A, Braun T, Hempel JM: Revision otoplasty: how to manage doi.org/10.1007/978-3-642-35431-1.
the disastrous result, Arch Facial Plast Surg 14(3):205-210, 2012.
doi:10.1001/archfacial.2012.61.

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88
Cervicofacial Lifting
T IRBO D FAT TA H I an d E VAN B U SB Y

CC is pleasant and appropriate during her evaluation and assessment.

Her focused physical examination is as follows:
The patient is a 56-year-old White female who presented for facial Forehead and eyebrows. The eyebrows are symmetrical and in
rejuvenation surgery (Fig. 88.1, eFig. 88.2 to Fig. 88.3). Her chief good position compared with the supraorbital rims. She has static
complaints include looking tired around the mid face, loose skin and dynamic transverse and vertical forehead lines.
around the lower face, and loose skin under her chin. Upper and lower eyelids. A slight amount of excess skin
associated with the upper eyelids (dermatochalasia); the
HPI lower eyelids are in good position with normal eyelid distrac-
tion and SNAP tests. Mild amount of excess skin in the lower
The patient has seen another surgeon already and wants a sec- eyelids with fat prolapse across all three fat pads. She has
ond opinion. The original surgeon recommended liposuction of hollowed nasojugal areas, mild to moderate skin laxity, and
submental area and thread lift of the face. Recovery time and crow’s feet.
expenses are not a concern for the patient. The patient points Midface. Mild midfacial ptosis and hollowing of the eyelid-
to the submental areas and jaw line as the areas where she cheek junctions; mild to moderate depth nasolabial folds; laxity of
believes she has loose skin and the perioral region for looking midfacial skin.
tired. Lower face. Laxity of the skin overlying the jaw bone; mild to
The patient has never had any type of facial surgery. She had moderate jowling; jaw line fairly intact with some obliteration
noninvasive procedures, including injectables (dermal fillers caused by the jowling.
around the mouth) approximately 1 year ago and was pleased Neck. Platysmal redundancy in the midline; obtuse cervico-
with the results. She appears to have appropriate surgical expec- mental angle; normal chin projection; small amount of submental
tations and is motivated. She also states that she has lost about lipomatosis.
25 lb over the past few months to reach an ideal weight before Perioral. Mild to moderate depth nasolabial folds; down-
surgery. turned commissures; mild to moderate depth marionette lines.
Skin. Dry skin; thick biotype; areas of melasma and dyspig-
PMHX/PDHX/Medications/Allergies/SH/FH mentation; photoaging.

The patient is a healthy, American Society of Anesthesiology Imaging

(ASA) class I 56-year-old female. She is seen by her primary care
physician annually. She has no active or previous medical history Standard full facial photography for facial cosmetic surgery was
and does not make any prescription medications. She takes daily obtained. This includes a frontal view, three-quarter oblique
multivitamins, does not smoke, and does not have any allergies to views, profile views, and a submental view.
foods or medications. Her only previous surgical procedure in-
cluded removal of her tonsils as a teenager. She denies having any Labs
facial surgical procedures except injection of perioral dermal fillers
about 1 year ago. She does not have any history of perioral herpes Considering that the patient is quite healthy (ASA class I), no fur-
outbreak. ther medical clearance or any laboratory blood work was required.

Examination Assessment
The patient is a Fitzpatrick class II and Glogau 2 during her as- Bilateral lower eyelid dermatochalasia with fat prolapse,
sessment. She is of average height (5 ft, 5 inches) and weight. She bilateral mid and lower face dermatochalasia and laxity, platysmal

456
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 CHAPTER 88 Cervicofacial Lifting 457

deep plane facelift were explained, and the patient opted to

choose the deep plane as her best option.
The surgery is performed under general anesthesia with an
endotracheal tube in place. The sequence of the surgical proce-
dure was as follows:
1. Skin markings
2. Administration of local anesthesia with vasoconstrictor or
tumescent anesthesia
3. Elevation of skin flap in anterior neck
4. Open liposuction of submental fat (supraplatysmal fat)
5. Platysmaplasty
6. Pack the neck and keep it open until closure at end
7. Elevation of skin flap, right face
8. Elevation of superficial musculoaponeurotic system (SMAS)
flap, right face
9. SMAS resection and reposition
10. Fibrin sealant application
11. Skin flap reposition and closure, right face
• Fig. 88.1 Preoperative frontal photograph.
12. Elevation of skin flap, left face
13. Elevation of SMAS flap, left face
14. SMAS resection and reposition
15. Fibrin sealant application
16. Skin flap reposition and closure, left face
17. Closure of submental incision after application of fibrin sealant
18. Bilateral transconjunctival lower eyelid blepharoplasty with
fat repositioning
19. Application of pressure dressing
Skin markings are performed in the preoperative area with the
patient sitting and looking straight ahead (Fig. 88.4, eFigs. 88.5–6
to Fig. 88.7). The inferior border of the mandible is marked, both
edges of the anterior borders of the sternocleidomastoid (SCM)

• Fig. 88.3 Preoperative profile photograph.

redundancy and submental lipomatosis, and intrinsic facial aging

and photoaging.

Treatment
The patient was given several options for addressing her cosmetic
concerns. These included a two-phase approach, including a cer-
vicoplasty, facelift, and lower eyelid blepharoplasty in the first
operation followed by a full-face laser resurfacing about 4 to
6 months after the initial procedure. She was counseled on the • Fig. 88.4 Markings for cervicoplasty. The inferior border of the mandible,
different available facelift techniques, including thread lift, super- the anterior borders of the sternocleidomastoid muscles, and the inferior
ficial facelifting, and deep plane facelifting. Advantages of the extent of the platysmal redundancy are marked.

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• eFig. 88.2 Preoperative three-quarters oblique photograph.

• eFig. 88.5 Side view of cervicoplasty markings. In addition to markings • eFig. 88.6 Preauricular and postauricular markings of the facelift. Note
in Fig. 88.4, the extent of the jowls is also marked.
the outline around the temporal tuft.

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• Fig. 88.7 Outline of the anterior and posterior incisions. • Fig. 88.10 Resected portion of the right and left platysma muscles.

• Fig. 88.12 Pre-tunneling using blunt instrumentation.

• Fig. 88.9 Outline of platysmaplasty after resection of the central aspect
of the muscle.
imbricated similar to the corset platysmaplasty described by Feld-
man. After the cervicoplasty is completed, the neck is packed and
muscles are marked, the extent of jowling is marked, and a 3-cm left open until the end of surgery.
midline incision is marked just posterior to the submental crease. The facelift portion of the surgery is initiated by blunt under-
Facial markings include a preauricular outline connected to a tem- mining and tunneling of the subcutaneous planes, which will
poral incision around the temporal hair tuft. Posteriorly, the out- aid in the elevation of the skin flap (eFig. 88.11 and Fig. 88.12).
line is marked just above the postauricular crease on the ear until It is critical to bevel the facelift incision to preserve as many hair
the widest part of the ear and then gently fades posteriorly into the follicles as possible. Typically, the preauricular portion of the face-
hairline. lift is elevated initially and then connected to the postauricular
After administration of local anesthesia with a vasoconstrictor, aspect. The skin flap of the facelift must be connected to the cer-
surgery begins with cervicoplasty (open liposuction and platysma- vicoplasty skin flap to ensure proper repositioning and redraping
plasty) first. The submental incision is incised, and the submental of the skin at the end of surgery. Skin flap elevation is advanced
crease is completely subcised from underneath to eliminate it. A anteriorly onto the cheek as much as necessary (Fig. 88.13). Care
skin flap with 4 to 5 mm of subdermal fat is then elevated be- is taken to identify and recognize the great auricular nerve run-
tween the two SCM muscles and the inferior border of the man- ning approximately 6.5 cm inferior to the earlobe crossing over
dible, after which an open liposuction of the supraplatysmal fat is the SCM muscle. After an appropriate skin flap has been elevated,
performed until the underlying platysma muscle is well visualized the deep plane portion of the facelift begins. To maximize the
(eFig. 88.8). Next, the redundant portion of the platysma and/or longevity of the facelift and create a natural result, a SMAS flap is
platysmal bands are elevated off the anterior mandible, and a outlined. This flap is marked in a vertical fashion from the zygo-
submuscular dissection is performed in the central compartment matic arch region down the face and past the jaw line into the
of the neck. The central portion of the right and left platysma is neck (Fig. 88.14). More local anesthesia is administered along this
then sharply excised in a diamond-shape pattern, thus creating line to hydrodissect and assist in the elevation of the SMAS
two free edges of muscle (medial edges of right and left platysma) flap. Sharp and then blunt dissection is performed, and the SMAS
(Figs. 88.9 and 88.10). Free edges of the muscles are then flap is elevated off the parotidomasseteric fascia anteriorly and

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• eFig. 88.11 Pretunneling of the facelift before its elevation.

• eFig. 88.8 Appearance of platysma after liposuction.

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 CHAPTER 88 Cervicofacial Lifting 459

• Fig. 88.13 Elevation of a wide skin flap.

• Fig. 88.17 Elevation of the superficial musculoaponeurotic system flap

all the way past the jawline and onto the neck.

• Fig. 88.14 Outline of superficial musculoaponeurotic system flap (dotted

lines represent the zygomatic arch).

inferiorly past the jaw line (eFigs. 88.15–16 to Fig. 88.17). Blunt
dissection on the underside of the SMAS flap greatly aids in its
elevation and mobilization. It also allows release of the osteocuta- • Fig. 88.18 Application of fibrin sealants into the cervicoplasty incision at
neous retaining ligaments of the face. After the SMAS flap is ap- completion of surgery.
propriately elevated, it can be lifted and pulled in a posterior and
superior vector. If there is redundant SMAS, it is sharply excised,
and the SMAS flap is then anchored to fixed points of stability into the neck and after application of pressure, and the wound is
such as the deep temporal fascia. After the insetting of the SMAS closed in a layered fashion (Fig. 88.18).
flap, the skin flap is redraped. Conservative backcuts around the The face and hair are then washed. A pressure dressing is then
earlobe and temporal tufts are performed to allow the skin flap to applied and kept for 24 hours until the next morning when the
lie quite passively. The postauricular flap is elevated posteriorly patient is seen in the office. Surgical drains are not necessary be-
and superiorly as well, and the excess tissue is excised. Before cause fibrin sealants are used routinely during this procedure.
closure of the skin flap, fibrin sealant is sprayed into the wound The next morning, after examining the patient for potential
(between the SMAS and underside of skin flap), and pressure is seroma or hematoma formation, a new pressure dressing is ap-
applied for a few minutes. Then a layered closure of the skin flap plied and kept for the next 2 or 3 days.
is completed.
After the right side of the facelift is completed, attention is Complications
directed to the left side, and the same procedure is done. SMAS
elevation and insetting and skin closure are done completely. Dur- Fortunately, complications of face and neck lifting are infrequent.
ing this entire time, drainage of fluid and blood is occurring into It is important to remind patients about “expected” and “short-
the submental area. This is why the cervicoplasty incision is kept lived” sequelae of surgery. Most patients may experience numb-
open. After the left side of the facelift is completed, attention is ness of the earlobe and around incisions. The earlobe numbness
redirected toward the submental area. Any fluid that has accumu- can be greatly reduced by identifying the great auricular nerve
lated during the procedure is suctioned; fibrin sealant is sprayed during the skin elevation over the posterior neck area. Moderate

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• eFig. 88.15 Elevation of the superficial musculoaponeurotic system flap. • eFig. 88.16 Fibers of masseter muscles seen under the elevated super-
ficial musculoaponeurotic system flap.

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460 S E C TI O N XI I I Facial Cosmetic Surgery

edema and ecchymosis is expected for 7 to 14 days. The authors maintained during this time after which topical creams such as
routinely use Arnica herbal supplement starting 1 week before silicone can be applied for optimum healing.
surgery to reduce bruising. All multivitamins, herbal medications, After the first few weeks, most of the swelling and edema will
and supplements are also stopped at least 2 weeks before surgery. subside, and an appropriate assessment of the final results can be
Equally beneficial are limited intravenous fluids during surgery obtained. Appropriate wound care is maintained and modified as
and maintaining a stable blood pressure during surgery and avoid- necessary (steroid injections, sun protection, and so on).
ing blood pressure spikes, especially upon extubation. Final photos are typically obtained 3 to 4 months after surgery
The patient is always seen within 24 hours after surgery, and (Fig. 88.19).
wounds are checked for viability and to rule out any fluid collec-
tion. All fluid collections must be aspirated or drained to avoid Discussion
flap necrosis and other potential complications. Patients are ex-
amined frequently during the first several weeks after surgery to Facelifting and neck lifting are commonly performed surgical
ensure proper healing of incisions. Appropriate wound care is procedures to combat the signs of intrinsic facial aging. When the

B C
• Fig. 88.19 A–C, Final outcome 6 months after face and neck lift.

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 CHAPTER 88 Cervicofacial Lifting 461

procedures are done appropriately, the results can be quite power- neck lifting will improve deep facial rhytids and folds, it will have
ful and rewarding. An understanding of facial aging is imperative little to no effect on the intrinsic appearance of the facial skin.
to understand the best surgical options to address it. Descent of Photoaging and sun damage of the skin are addressed secondarily
facial musculature and fascia along with the subcutaneous fatty via chemical peeling or full-face laser resurfacing a few months
layer, resorption of the underlying bony structure, laxity of the after a face and neck lift.
overlying skin, genetics, and photoaging play critical roles in creat-
ing the “aged” look that many patients wish to reverse. It is impor- ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
tant to recognize and remind patients that although facelifting and complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 461.e1

Bibliography Hamra ST: Composite rhytidectomy, Plast Reconstr Surg 90(1):1-13,

1992. doi:10.1097/00006534-199207000-00001.
Khan HA, Bagheri S: Management of the superficial musculo-aponeurotic
Chaffoo RA: Complications in facelift surgery: avoidance and manage- system (SMAS), Atlas Oral Maxillofac Surg Clin North Am 22(1):17-23,
ment, Facial Plast Surg Clin North Am 21(4):551-558, 2013. doi:10. 2014. doi:10.1016/j.cxom.2013.11.006.
1016/j.fsc.2013.07.007. Khan HA, Bagheri S: Surgical anatomy of the superficial musculo-
Charafeddine AH, Drake R, McBride J, et al: Facelift: history and anat- aponeurotic system (SMAS), Atlas Oral Maxillofac Surg Clin North
omy, Clin Plast Surg 46(4):505-513, 2019. doi:10.1016/j.cps.2019. Am 22(1):9-15, 2014. doi:10.1016/j.cxom.2013.11.005.
05.001. Luu NN, Friedman O: Facelift surgery: history, anatomy, and recent in-
Fattahi T: Open brow lift surgery for facial rejuvenation, Atlas Oral novations, Facial Plast Surg 37(5):556-563, 2021. doi:10.1055/s-
Maxillofac Surg Clin North Am 24(2):161-164, 2016. doi:10.1016/j. 0040-1715616.
cxom.2016.05.003. Nahai F, Bassiri-Tehrani B, Santosa KB: Hematomas and the facelift
Fattahi TT: Management of isolated neck deformity, Atlas Oral Maxillo- surgeon: it’s time for us to break up for good, Aesthet Surg J 43(10):
fac Surg Clin North Am 12(2):261-270, 2004. doi:10.1016/j.cxom. 1207-1209, 2023.
2004.04.006.

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89
Upper and Lower Blepharoplasty
MAR AWA N EL N A B O U L S Y, FA IS AL A . Q U E R E S H Y, a n d V I C T O R I A A . M A Ñ Ó N

CC The upper eyelid margin is within normal limits (covers

2–3 mm of the superior iris).
A 61-year-old female presents for consultation regarding excess The upper eyelid has two fat pads with the lacrimal gland lo-
skin on her upper and lower eyelids (dermatochalasis). She states cated laterally and the lower eyelid with three fat pads. (Herniated
she would like to look younger. fat pads are usually medial. Gentle pressure on the globe with the
eyes shut exacerbates fat herniation to identify weaknesses in the
HPI septum.)
The eyelid crease is identified 9 mm above the eyelid margin.
The patient identifies regions of excess skin over her upper and The vertical interpalpebral fissure distance measures 10 mm
lower eyelids. She is unhappy with the “bags” under her eyes, (normal, 10–12 mm).
claiming that they age her. She denies any visual disturbances, dry Reduction of vertical interpalpebral height is suggestive of
eyes, or any other ocular problems. She has no surgical history. blepharoptosis (low-lying eyelid).
An increase in vertical interpalpebral height is suggestive of
PMHX/PDHX/Medications/Allergies/SH/FH eyelid retraction.
Lower eyelid laxity: The SNAP test is abnormal, measuring
The patient has a history of hypertension controlled with hydro- 2 seconds. (The lower eyelid normally reapproximates the globe
chlorothiazide. She has no endocrinopathies (Graves’ disease may within 1 second when it is pulled inferiorly and released; Fig. 89.4.)
present as eyelid edema, eyelid retraction, or proptosis). She has
no history of coagulopathies. She denies usage of anticoagulation Imaging
medications and herbal medications (a risk factor for increased
intraoperative bleeding and retrobulbar hematoma). Preoperative and serial postoperative photo imaging is mandatory
for cosmetic procedures. Close-up views of the eyelids in both the
Examination closed and open eyelid positions are recommended.

General. Well-developed female in no apparent distress. Labs

Ocular. The pupils are equal reactive to light and accommoda-
tion; extraocular muscles and visual fields are within normal Routine laboratory studies are normally not indicated for cos-
limits. Schirmer’s test (a measure of baseline tear production) is metic eyelid surgery. Complex medical histories may dictate spe-
normal. Minimal eyebrow ptosis noted (brow ptosis needs to be cialized workups.
differentiated from dermatochalasis). (Evaluate the distance from
the upper eyelid margin to the lower edge of the eyebrow – 10 mm. Assessment
Suspect eyebrow ptosis if measurement is ,10 mm. If this is the
case, eyebrow lift is indicated to restore eyebrow height and A 61-year-old female desiring bilateral upper and lower eyelid
eliminate eyelid hooding.) blepharoplasties to address excess eyelid skin (dermatochalasis).
Eyelids. Evaluation of frontal and glabellar lines is performed
(Fig. 89.1). Treatment
Skin laxity can be measured using forceps to capture redun-
dant tissue and evaluate excess (Fig. 89.2). A robust mastery of facial structures, specifically orbital anatomy
The patient has no ectropion (everted eyelid), entropion and fascial layers, is critical to performing blepharoplasty.
(inverted eyelid), or lagophthalmos (eyelid incompetence). The Fig. 89.5 illustrates some of the key anatomic landmarks.
patient does not have Bell’s phenomenon (also called palpebral- For this patient, bilateral upper and lower eyelid blepharoplasty
oculogyric reflex, a protective mechanism, defined as an upward with resection of orbicularis oculi and resection of prolapsed fat
rotation of the eyeballs when the eyelid is closed). pads is indicated to address her chief complaint of dermatochalasis.
Lower eyelid skin evaluation should be done with the patient This treatment will re-create her upper eyelid shelf. It is important
in an upward gaze (Fig. 89.3). to keep in mind that each patient requires a presurgical workup
Lateral canthal rhytids, or crow’s feet, should also be evaluated. with a tailored treatment plan to achieve optimal cosmesis.

462
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 CHAPTER 89 Upper and Lower Blepharoplasty 463

Frontal lines
Glabellar lines

Eyebrow ptosis
Dermatocholasis (upper eyelid)
Lateral canthal rhytids
(crow’s feet)
Herniated orbital fat (lower eyelid)
Palpebromalar groove
Actinic lentigines
Tear trough eyelid deformity
Prominent nasolabial fold

• Fig. 89.1 Evaluation of frontal and glabellar lines.

• Fig. 89.4 Snap-back test performed to evaluate lower eyelid laxity.

Although blepharoplasty surgery can be performed under

local anesthesia in a cooperative patient, the authors recommend
general anesthesia for patient comfort and a predictable working
environment.
The eyelids are marked with the patient upright before the
administration of sedatives of local anesthetics (Fig. 89.6).
The upper eyelid crease should be identified before making any
incision. Care must be taken to maintain a minimum distance of
1 cm from the upper eyelid margin.
The upper eyelid crease is slightly higher in females ( 8–
10 mm from the eyelid margin; it is 6–8 mm in males).
Medially, the ends are marked above the lacrimal punctum;
• Fig. 89.2 Redundant skin capturing with forceps. Ensure that the eyelid further extension of the incision beyond the punctum leads to
remains fully closed while pinching tissue to avoid lagopthalmos. webbing and poor cosmesis.
The superior incision line is marked as the excess skin is
pinched with smooth forceps and the forehead and eyebrow is
stabilized. (Excessive skin capture increases the risk of lagophthal-
mos; ,1 mm of lagophthalmos is acceptable.) A minimum of
20 mm of skin must remain between the upper eyelid margin and
the eyebrow to prevent postoperative lagophthalmos.
If upper and lower eyelid blepharoplasty is planned, a minimum
of 5 mm of skin must be maintained between the two incisions.
Local anesthetic is then injected, and the surgeon may proceed
with incision with various options, including blade, electrocau-
tery, or CO2 laser.
The skin is sharply excised from the underlying muscle while
gentle superior lateral traction is applied. Upper eyelid skin is the
thinnest skin in the body; this is especially true in the older adult
patient population.
It is possible to resect a myocutaneous segment as a single unit.
• Fig. 89.3 Lower eye eyelid laxity evaluated with the patient in upward The authors recommend identifying and resecting the skin and
gaze. orbicularis oculi layers separately.

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464 S E C TI O N XI I I Facial Cosmetic Surgery

Orbital fat
Levator palpebrae
superioris Orbital globe
Levator aponeurosis
Orbital spetum Superior tarsus

Superior lacrimal canaliculi

Lacrimal gland

Medial canthal tendon

Lateral canthal tendon Inferior lacrimal canaliculi

Arcuate expansion of
lockwood’s ligament Lacrimal sac

Inferior rectus m.

Inferior tarsus

Infraorbital foramen Nasolacrimal duct

Inferior nasal concha

• Fig. 89.5 A highlight of some key anatomic landmarks pertinent to blepharoplasty surgery. m, Muscle.

• Fig. 89.6 The upper eyelid marked with the patient in an upright position.

Removal of a 3-mm strip of orbicularis oculi muscle with

curved scissors is often required to achieve optimal cosmesis in
most patients.
The next layer encountered deep to orbicularis oculi is
the orbital septum. If fat herniation is present, yellow fat glob-
ules will be visible herniated through the orbital septum. Gen-
tle globe pressure can help exacerbate fat herniation for easy
identification.
The orbital septum is incised, and the fat is pulled with very • Fig. 89.7 Excision of 3-mm thick orbicularis oculi strip with curved scis-
gentle traction. The herniated fat is then excised with electrocau- sors in a curvilinear fashion while superior lateral traction is applied.
tery. (Overzealous excision should be avoided here.)
Not all patients require fat excision. The skin is closed using The lower blepharoplasty is approached through a subciliary
6-0 Monocryl suture in a subcuticular fashion for optimal cosme- incision in the natural subciliary crease. Care is taken to maintain
sis. (6-0 nylon suture in running fashion may also be used.) 5 mm between the upper and lower eyelid incisions.
Ophthalmic antibiotic ointment is applied to the wound. Cold The orbital septum is incised, revealing the underlying perior-
compress may be used for the first 24 hours to minimize edema. bital fat pads. The fat pads are gently teased and removed with
A postoperative steroid course may also be prescribed to aid with electrocautery. An optional excision of skin and muscle in the
postoperative edema (Fig. 89.7). lower eyelid is seldom indicated to restore periorbital vitality.

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 CHAPTER 89 Upper and Lower Blepharoplasty 465

• Fig. 89.9 Documentation exhibiting skin, muscle, and fat resections in

the upper and lower eyelids. This establishes a reference to aid with a
symmetric outcome.

blood flow is irreversible. First-line treatment includes the

• Fig. 89.8 Excision of lower eyelid periorbital fat with electrocautery. removal of sutures to relieve pressure and provide an outlet to
evacuate the hematoma and reduce intraocular pressure.
Lateral canthotomy may also be indicated if suture removal is
not adequate for decompression.
High-dose steroids also play a role in reducing edema. Head of
Lower eyelid myocutaneous excision was not performed on this bed elevation and reduction in stress and strain are also vital.
patient (Fig. 89.8). Local wound care includes topical ointments, avoiding
The lower eyelid may also be approached via a transconjunc- strenuous activity, and avoiding sunlight to minimize scarring.
tival approach. Some surgeons advocate the redistribution of the Corneal abrasion is common after blepharoplasty procedures.
periorbital fat instead of excising it. The technique is surgeon The patient will endorse the sensation of sand in their eyes. Oph-
specific and dictated by preference and clinical presentation thalmic bacitracin, an eye patch, and rest are adequate, and most
(Fig. 89.9). of these resolve without intervention.
Postoperative care includes local wound care and the applica- Keratoconjunctivitis sicca (dry eyes) is common in the older
tion of antibiotic ointment. It is imperative to emphasize the adult population. Artificial tears are indicated if patients report a
prevention of overexertion for the first 48 hours after surgery be- history of dry eyes to avoid keratitis.
cause it increases the risk of hematoma formation. Some authors recommend preoperative Schirmer’s testing.
Postoperative antiemetics are commonly prescribed to avoid (Filter paper is placed on the lower conjunctiva for 5 minutes;
facial straining. Antihypertensives are to be resumed after surgery ,10 mm of wetting is considered abnormal.) However, McKinney
if held. and Byun found that Schirmer’s test was not a good predictor of
If closure was achieved with nonresorbable sutures, they are postblepharoplasty dry eye complications.
removed 5 to 7 days after surgery (Fig. 89.10). In the rare case of overzealous skin resection resulting in lag-
ophthalmos, a full-thickness skin graft may be indicated to restore
Complications eyelid length and full closure.
Periorbital edema and hematoma are common causes of tran-
The most feared postoperative complication is retrobulbar hema- sient eyelid ptosis. Consideration for surgical intervention should
toma causing loss of vision. Fortunately, retrobulbar hematoma is be delayed 4 to 6 months to allow for spontaneous resolution.
a rare occurrence (0.04%). This is usually the case in patients who Orbital cellulitis or abscess after blepharoplasty is a rare com-
are on anticoagulation and herbal medications. plication.
Adequate hemostasis after the excision of fat and before clo- If infection of abscess formation is suspected, a small opening
sure limits the risk of hematoma formation. Initial signs of he- through the incision is created to allow for drainage. Antibiotics
matoma formation are eye pain with progression to proptosis, should be started.
absent pupillary reflex, and changes in visual acuity and color Overreduction of fat may result in periorbital hallowing. This
discrimination. may be addressed by fat injections harvested from the perium-
Increased intraocular pressure can lead to occlusion of the bilical region. The fat is centrifuged and injected in areas of
central retinal artery. Nerve ischemia caused by compromised overreduction to restore a youthful look.

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A B
• Fig. 89.10 Pre- (A) and postoperative (B) photos after upper and lower eyelid blepharoplasty, fat grafting,
laser skin resurfacing, and eyebrow lift.

Discussion to the superior orbital rim. The gland should not be excised be-
cause of the increased risk of postoperative dry eye.
It is essential to take note of pertinent past medical history, and
medications. Full facial examination includes eyebrow evaluation, Additional Procedures During Upper Eyelid
nasal analysis, cheek, and mandibular asymmetries.
It is common to mistake eyebrow ptosis for excess upper eye- Blepharoplasty
lid skin. Consider an eyebrow lift in the treatment plan. The To address vertical glabellar rhytids when indicated, the corruga-
correct diagnosis is imperative to address patient concerns and tor supercilii muscle can be resected through the upper blepharo-
meet expectations. plasty incision.
Recognize that not all patients require the same treatment. Simultaneous forehead and eyebrow lifting may be performed.
Excision of skin, muscle, and fat is not always necessary to meet The upper eyelid skin resection should be more conservative in
patient expectations. Fat in the proper position can serve to re- this case. Either procedure can be carried out first depending on
store a youthful and rejuvenated look. the surgeon’s preference. Simultaneous laser skin resurfacing can
However, most patients require differential resection of a small also be performed.
strip of orbicularis oculi muscle to establish a well-defined supra-
tarsal crease.
After skin and muscle strips are excised, the fat pads are evalu-
Special Considerations in Asian Patients
ated under direct vision. Gentle pressure on the globe helps pro- More than 50% of East Asians do not have a supratarsal crease.
trude the fat pads for easy identification. This is commonly referred to as single eyelid. Asian patients com-
Hemostasis after fat pad resection is necessary to reduce the monly request the creation of a supratarsal fold to establish a
risk of postoperative bleeding and hematoma formation. This is double eyelid. In the Asian “single eyelid,” the superficial lamina
ideally achieved with electrocautery. of the levator aponeurosis does not attach and penetrate into the
orbital septum. The orbicularis oculi muscle does not attach to the
Lacrimal Gland Considerations overlying dermis as it does in the Western “double eyelid.” A well-
defined supratarsal crease may be created using supratarsal fixa-
The lacrimal glands should be properly identified and not mis- tion sutures to attach the levator aponeurosis to the pretarsal skin.
taken for fat pads. The gland should not be excised to prevent
postoperative dry eye. Prolapsed lacrimal glands may be sus- ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
pended superolaterally and attached to the periosteum posterior complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 466.e1

Bibliography McCurdy JA: Upper Lid blepharoplasty: the double eyelid operation—
external approach, Facial Plast Surg Clin North Am 4:7-23, 1996.
McKinney P, Byun M: The value of tear fi lm breakup and Schirmer’ s
Carraway JH: Surgical anatomy of the eyelids, Clin Plast Surg 14: tests in preoperative blepharoplasty evaluation, Plast Reconstr Surg
693-701, 1987. 104:566-568, 1999.
Cook BE, Lemke BN: Cosmetic blepharoplasty upper eyelid techniques, Millay DJ, Larrabee WF: Ptosis and blepharoplasty surgery, Arch Otolar-
Oral Maxillofac Surg Clin North Am 12(4):673-687, 2000. yngol Head Neck Surg 115:198-201, 1989.
Fagien S: Advanced rejuvenative upper blepharoplasty: enhancing aesthet- Niamtu J: Cosmetic blepharoplasty, Atlas Oral Maxillofac Surg Clin
ics of the upper periorbita, Plast Reconstr Surg 110:278-289, 2002. North Am 12:91-130, 2004.
Fagien S: Discussion: The value of tear film breakup and Schirmer’s tests Seckel BR, Kovanda CJ, Cetrulo CL Jr, et al: Laser blepharoplasty with
in preoperative blepharoplasty evaluation, Plast Reconstr Surg 104: transconjunctival orbicularis muscle/septum tightening and periocu-
570-573, 1999. lar skin resurfacing: a safe and advantageous technique, Plast Reconstr
Ghali GE, Lustig JH: Complications associated with facial cosmetic Surg 106:1127-1145, 2000.
surgery, Oral Maxillofac Surg Clin North Am 15:265-283, 2003. Seiff SR: Anatomy of the Asian eyelid, Facial Plast Surg Clin North Am
Holt JE, Holt GR: Blepharoplasty: indications and preoperative assess- 4:1-5, 1996.
ment, Arch Otolaryngol 111:394-397, 1985. Ullmann Y, Levi Y, Ben-Izhak O, et al: The surgical anatomy of the fat
Hughes SM: Evaluation of the cosmetic blepharoplasty patient, Oral in the upper eyelid medial compartment, Plast Reconstr Surg 99:658,
Maxillofac Surg Clin North Am 12(4):649-670, 2000. 1997.
Januszkiewicz JS, Nahai F: Transconjunctival upper blepharoplasty, Plast Walrath JD, Hayek BR, Wojno T: Blepharoplasty. In Bagheri SC, Bell
Reconstr Surg 103:1015-1019, 1999. RB, Khan HA (eds): Current Therapy in Oral and Maxillofacial
Lisman RD, Hyde K, Smith B: Complications of blepharoplasty, Clin Surgery, St. Louis, 2011, Mosby/Elsevier, p 986.
Plast Surg 15:309-335, 1988. Zukowski ML: Endoscopic brow surgery, Oral Maxillofac Surg Clin
McCurdy JA: Upper blepharoplasty in the Asian patient: the “double North Am 12(4):701-708, 2000.
eyelid” operation, Facial Plast Surg Clin North Am 10:351-368, 2002.

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90
Genioplasty
SEI E D O M I D KE Y HA N , HO UR A A S TA NE H , a n d H A M I D RE Z A FAL L A H I

CC used, muscle hyperactivity may place excessive force on the im-

plant, leading to increased bone resorption or displacement of the
A 28-year-old female complains about her nose shape and chin implant [eFigs. 90.2 and 90.3]).
appearance. She explains, “My chin has a little deviation to the On profile examination (Fig. 90.4), the patient exhibits good
right side, and I have a receding chin. Besides, I don’t like the nasal projection with a mild dorsal hump. (A large nose makes the
shape of my nose.” chin look small and vice versa.) The labiomental angle is 143 de-
grees. (Ideally, the depth of the fold or sulcus should lie 4 mm
HPI posterior to a line drawn from the lower vermilion border to the
pogonion. If the sulcus is shallow or high, augmentation results in
The patient stated that she has not been happy with the shape of enlargement of the lower face [chin and lip]; however, if the fold
her nose and the appearance of her chin, especially on profile is deep and more inferiorly positioned, augmentation predomi-
view, because of retrogenia. In addition, she thinks that these nantly accentuates the chin.) The patient demonstrates a convex
items have decreased her beauty. facial profile with a retrognathic appearance. The cervicomental
angle is obtuse at 125 degrees (normal, 110–120 degrees).
PMHX/PDHX/Medications/Allergies/SH/FH Intraoral. The patient’s oral hygiene is good. (Some clini-
cians will not place an alloplastic implant in patients with active
Noncontributory. periodontal disease. Also, this may be an indicator of the pa-
tient’s ability to keep the wound clean if an intraoral approach
Examination is to be used.) The patient has a class I molar and canine rela-
tionship. (A class II malocclusion indicates that a skeletal abnor-
General. The patient is a well-developed and well-nourished fe- mality exists; the patient should be informed of the option of
male in no apparent distress. orthodontic realignment and orthognathic surgery.) The man-
Psychiatric. The patient is in a fine and acceptable mood. Fa- dibular anterior teeth are in good position, neither retroclined
cial appearance is important to psychological well-being and so- nor proclined.
cial acceptance, and physical attractiveness may play a critical role
in the development of an individual’s self-concept or even career Imaging
goals (e.g., modeling). It is important to assess the patient’s mo-
tives and expectations for the surgery. Modern surgical interven- Standard photographs of the frontal and profile views, both in
tions can safely enhance physical appearance, which in turn ele- repose and on smiling, are recommended. A panoramic radio-
vates self-confidence and personal well-being. graph and a lateral cephalogram are recommended for the workup
Maxillofacial. Chin deformities can manifest in any of the of patients requiring a genioplasty.
three dimensions (vertical, horizontal, and transverse) in isolation The panoramic radiograph is used to delineate the proximity
or in combination; however, the vast majority are in the horizontal of the mandibular canal and mental foramen and the apices of the
plane only. Therefore, evaluation of the chin in three dimensions mandibular anterior dentition in anticipation of a genial osteot-
is necessary for proper diagnosis and genioplasty treatment plan- omy. In addition, it provides a general overview of any mandibu-
ning. A wide range of factors can cause chin asymmetry, such as lar osseous pathology.
developmental, pathological, traumatic, and functional factors. Lateral cephalometric evaluations have been used to help de-
Although genioplasty is one of the safest interventions in or- termine the desired horizontal and vertical dimensions of the
thognathic surgery, careful scrutiny of the skeletal, dental, and chin. Information gained from the cephalometric tracings in-
soft tissue structures is required to obtain a good result. cludes the relationship of the maxilla and mandible to the skull
On the frontal view (eFig. 90.1), the patient exhibits an asym- base and to each other. It is important to identify any skeletal or
metric face with chin deviation to the right side. The patient does occlusal disparities that can be corrected before or concomitant
not have tooth show at rest. Chin pad tissue thickness is 9 mm with a genioplasty procedure. Ideally, the chin (the soft tissue
(normal, 8–11 mm). On smiling, the lower lip is symmetrical. On pogonion) should rest slightly posterior to the lower lip, and the
elevation of the lower lip, there is no mentalis muscle hyperactiv- lower lip should be posterior to the upper lip. Increasing sagittal
ity or chin pad fasciculations. (If alloplastic augmentation is to be projection beyond these relations may risk an unesthetic result.

467
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 CHAPTER 90 Genioplasty 467.e1

A B
• eFig. 90.1 A Preoperative frontal view of the patient demonstrating facial asymmetry caused by chin
deviation to the right side. B, Preoperative frontal view of the patient while smiling highlights facial
asymmetry due to chin deviation to the right side.

A B
• eFig. 90.2 Preoperative downward (A) and upward (B) head tilt views of the patient.

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A B
• eFig. 90.3 Preoperative three-quarters view of the patient.

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A B
• Fig. 90.4 A, Preoperative profile view of the patient demonstrating retrogenia and dorsal hump. B, Preop-
erative profile view of the patient while smiling, showing retrogenia and dorsal hump.

The lateral cephalogram for the current patient demonstrates the

deficiency of the chin in the anteroposterior (AP) dimension (ret-
rognathic appearance) and a class I molar relationship (Fig. 90.5).
Cone-beam computed tomography facilitates appreciation of
the three-dimensional (3D) anatomy of the mandible and preop-
erative planning.

Labs
No routine laboratory testing is indicated for genioplasty proce-
dures unless dictated by the medical history. The current patient
reports normal medical history and routine laboratory tests before
the surgery were normal.

Assessment
Retrogenia and facial asymmetry caused by chin deviation in a
patient who desires chin augmentation.

Treatment
Genioplasty refers to a horizontal osteotomy of the anterior man-
dible as a facial cosmetic surgery procedure. It is a surgical proce-
dure used to enhance the shape and appearance of the chin. The
procedure could be either isolated or in combination with other
facial cosmetic procedures such as rhinoplasty. The most common
methods of genioplasty include osteotomy of the chin (also known
as osseous genioplasty) and implant placement. Chin implant refers
to either an alloplastic or autogenous implant. Osseous genioplasty
is more versatile than alloplastic implants in improving 3D chin • Fig. 90.5 Preoperative lateral cephalogram showing the retrogenia and
position. It can be used to manage vertical and AP excess or a class I molar relationship.

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 CHAPTER 90 Genioplasty 469

TABLE Comparison of the Two Currently Accepted dimension. If vertical shortening is desired, the angle should be
90.1 Methods of Chin Augmentation more acute. The midline should be marked with a bur (fissure
type) to prevent postoperative iatrogenic asymmetries. The oste-
Osseous Genioplasty Alloplastic Augmentation otomy is completed with a reciprocating saw. The orientation of
Can correct deformities in vertical Indicated only for correction of a this saw should remain constant to ensure a symmetrical cut
transverse and sagittal planes mild to moderate sagittal through the buccal and lingual cortices to prevent interferences
Useful in the correction of a deficiency that may hamper the proposed movement. After the osteotomy
failed alloplastic genioplasty Relatively straightforward has been completed and the fragment repositioned, it can be se-
More technically demanding Can be performed via an intraoral or cured through a variety of methods, including the use of wires,
No extraoral scarring extraoral approach prebent chin plates, or lag screws. The wound should be closed in
Precision increases with com- Precision increases with CAD-CAM– layers; it is essential that the mentalis muscle be accurately reposi-
puter-assisted surgery designed implants
tioned. A pressure dressing is applied to facilitate soft tissue reat-
CAD-CAM, Computer-aided design and computer-aided manufacture. tachment (supporting mentalis muscle repairment) and prevent
hematoma formation.
Alloplastic augmentation can also be considered for the treat-
ment of a genial deficiency. Alloplastic implants are limited to the
correction of a vertical or transverse chin deficiency. A wide range
deficiency and correct midline asymmetries. Injection of dermal of materials can be used. Those most commonly used include
fillers can also be considered as a temporary method of correcting high-density polyethylene (Medpor, Porex Surgical Products
mild to moderate chin retrusion and resorption. Group), hard tissue replacement polymer, polyamide mesh (Supra-
There are various osteotomy designs in augmentation genio- mid, S. Jackson, Inc.), polydimethyl-siloxane (Silastic, Dow Corn-
plasty techniques such as sliding genioplasty, sagittal genioplasty, ing), and fibrillated expanded polytetrafluoroethylene (ePTFE;
3D printing genioplasty template system, and alloplastic genio- Gore-Tex, W.L. Gore & Associates). Before the removal of Proplast
plasty. Alloplastic chin implants and sliding genioplasty are the two from the American market, various forms of Proplast (Vitek) was
currently accepted methods of chin augmentation (Table 90.1). used for genial augmentation, such as Proplast I (PTFE and graph-
In genioplasty surgery, the soft tissue response to hard tissue ite), Proplast II (PTFE and alumina), and Proplast hydroxyapatite.
movements is quite variable. In general, advancement movements Many surgeons believe that polydimethyl-siloxane (Silastic) meets
horizontally tend to show 80% to 100% soft tissue response. most of the criteria for an ideal alloplastic implant.
Vertical augmentation demonstrates 80% to 90% soft tissue re- Preformed implants, such as “off-the-shelf ” implants, are read-
sponse. The response to reduction genioplasty is most variable and ily available and cost-effective, although they may not be ideal for
depends on the technique. Vertical reduction is predictable, but those with specific facial profile or particular facial goals.
the amount of preoperative soft tissue redundancy is important. Three-dimensional computer-aided design and computer-
Careful treatment planning, meticulous surgical technique, aided manufacture of customized-designed implants reduces the
and the surgeon’s artistic sense are three important factors for suc- need to carve or shape stock implants during surgery. In patients
cessful and predictable chin surgery. undergoing genioplasty, custom implants are usually used to cor-
For intraoral access, it is important to plan an incision that rect contour irregularities from previous unsuccessful attempts.
achieves the following goals: The ideal characteristics of an alloplastic implant include the
• Ease of wound closure, ensuring that movable mucosa, rather following:
than attached gingiva, forms the wound margin • Anatomic configuration that has a posterior surface that con-
• Avoidance of periodontal problems after wound contraction tours to the external surface of the mandible and an external
and scar formation implant shape that imitates the desired outcome
• Prevention of mental or inferior alveolar nerve severance • Readily implantable and nonpalpable
• Ability to resuspend the mentalis muscle to prevent chin (men- • Margins of the implant blend onto the bony surfaces
talis) droop • Easily removable
An incision in the depth of the vestibule results in excessive scar • Malleable, comfortable, and inert
formation and should be avoided. A U-shaped incision extending • Easily modifiable by the surgeon during the procedure
from canine to canine that leaves 10 to 15 mm of mucosa anterior Alloplastic augmentation can be performed via extraoral sub-
to the depth of the vestibule is ideal. The mentalis muscle is incised mental incision and intraoral incision. Placement of alloplastic
in an oblique fashion, leaving an ample amount superiorly to allow implants via an extraoral submental incision can be combined
for closure. The mentalis muscle is stripped in a subperiosteal with other procedures, such as rhytidectomy submental liposuc-
plane, exposing the symphysis. The mental nerves are identified tion or platysmal placation. The surgeon’s experience is usually the
bilaterally, and the periosteum is freed circumferentially around deciding factor in whether an implant or an osteotomy is per-
the foramen. Careful dissection in this area allows the surgeon to formed. It is generally accepted that mild to moderate abnor-
preserve all branches of this nerve. The planned osteotomy should malities can be corrected with either alloplastic implantation or
lie a minimum of 5 mm below the longest tooth root (usually the genioplasty. (Some clinicians recommend alloplastic augmenta-
canine) and a minimum of 10 to 15 mm superior to the inferior tion for deficiencies up to 5 mm because mandibular resorption
border. The osteotomy should also extend 4 to 5 mm below the beyond an augmentation of 5 mm is a concern.) However, for
lowest point of the mental foramen. It should be remembered that severe abnormalities, sliding genioplasty should be performed.
the angle of the osteotomy can influence vertical and horizontal Genioplasty is a more versatile procedure because it can address
changes. An osteotomy that is more parallel with the occlusal abnormalities in any of the three dimensions. There is some de-
plane allows a greater vector of advancement in the horizontal bate on the superiority of either procedure for augmentation.

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Computer-assisted osseous genioplasty involves performing

the osteotomy virtually. From this a model can be fabricated and
plates prebent. In addition, a surgical guide can be made to trans-
fer the osteotomy line’s screw positions and a jig to accurately
position the genial segment intraoperatively. Evaluation of the
accuracy of this technique has shown that it is promising.
The application of digital design technology compared with
conventional techniques can provide various benefits for both the
surgeon and patient. Significant advantages that are certainly of
particular importance to surgeons are more accurate and more
predictable surgical outcomes and reduction in operating time.
Injectable soft tissue filler substances such as hyaluronic acid
fillers can play an important role in the aesthetic treatment to
improve facial areas such as the chin shape and the mandibular
line and can also be selected as an alternative treatment for chin
augmentation and has the advantage of simple operation and few
complications. Because the skin on the chin is quite thick, con-
tour irregularity with supraperiosteal injection is often not of
particular concern.
For the current patient, computer-assisted horizontal transla-
tional osseous genioplasty, minimally invasive rhinoplasty, and
septoplasty were performed simultaneously. This is a new com-
puter-assisted genioplasty technique for the correction of chin
asymmetries. Before surgery the 3D computed tomography of
the lower jaw area was obtained (Fig. 90.6). To accurately design • Fig. 90.8 Intraoperative views of the customized clear surgical guide. For
the virtual chin osteotomy, raw data were input into software. accurate adaptation with the chin anatomy, a clear surgical guide was
Eventually, a customized module was exclusively designed for fabricated.
the patient deformity (eFig. 90.7 and Fig. 90.8). First the pa-
tient was intubated through the nose and underwent advance-
ment genioplasty of 7 mm, and the chin was transferred 4 mm The advantages of horizontal osteotomy are stable results, for-
to the left side to correct deviation using a chin osteotomy surgi- eign material absence, less chance of infection, more predictable
cal guide and through computer-assisted horizontal transla- soft tissue response, and 3D movement potential of the chin.
tional osseous genioplasty (Fig. 90.8, eFig. 90.9, and Fig. 90.10). eFigs. 90.11–13 and Fig. 90.14 show postoperative facial views
Afterward the patient was intubated through the mouth, and of the patient.
septorhinoplasty was accomplished through minimally invasive
rhinoplasty and dorsal preservation using piezoelectric. Com- Complications
puter-assisted horizontal translational osseous genioplasty is a
simple and reliable technique for patients with facial asymmetry Given a very low complication rate, genioplasty is considered one
caused by chin deviation. of the most successful operational activities in the facial cosmetic

A B
• Fig. 90.6 A, Three-dimensional computed tomography of the lower jaw area. Frontal view. B, Three-
dimensional computed tomography of the mandibular area. Profile view.

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 CHAPTER 90 Genioplasty 470.e1

A B
• eFig. 90.9 A Intraoperative view of the dissected genial segment. Genial
segment is retracted. B, Intraoperative view of the genial fragment while
genial segment is placed in its new position (before fixation).

• eFig. 90.7 Digital design of chin osteotomy surgical guide for the current
patient.

A B
• eFig. 90.11 A Postoperative frontal view of the patient. B, Postoperative frontal view of the patient while
smiling.

A B
• eFig. 90.12 Postoperative downward (A) and upward (B) head tilt of the patient.
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A B
• eFig. 90.13 A, Postoperative three-quarters view of the patient. B, Postoperative three-quarters view of
the patient with a smile.

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 CHAPTER 90 Genioplasty 471

hemorrhage causing lingual hematoma and possible airway com-

promise, and avascular necrosis of the mobilized segment are pos-
sible but rare complications of this procedure.
Up to 50% of patients complain of temporary postoperative
paresthesia or anesthesia owing to stretching from the retractors
or edema. Only about 3.5% of patients suffer from permanent
neurosensory disturbances secondary to nerve injury.
Injury rates to the mental nerve have been reported to range
from 0% to 20% at 1 year after surgery. The causes of nerve in-
jury include inadequate exposure, poorly designed flaps, inade-
quate protection during osteotomy, excessive stretching, and
compression. The majority of patients undergoing genioplasty
experience a transient neurosensory deficit, probably secondary
to neuropraxia. However, most studies show resolution of any
neurosensory deficit after several months. To avoid damage to the
mental nerve, the osteotomy should be placed 5 to 8 mm below
the apices of the canines and approximately 4 to 6 mm below the
mental foramen. A reduction in the response to light touch (a
• Fig. 90.10 Intraoperative view of fixation of the genial segment in the sensitive marker for neurosensory deficit) has an incidence of
corrected position using four titanium screws.
3.4%. This complication is associated with no adverse effect on
the quality of life.
Temporary paresthesia of the lower lip is common in osseous
surgery. The most common complication after genioplasty surgery genioplasty owing to edema; stretching from retraction; and,
is a neurosensory disturbance followed by hematoma and infection. rarely, transection. This appear in almost 40% to 70% of patients
Soft tissue changes, such as chin ptosis, excessive lower tooth dis- and resolves within 12 months.
play, damage to the anterior mandibular teeth (this apprehension is The inferior alveolar nerve travels inferiorly and anteriorly past
especially important in adolescent patients because of incomplete the mental foramen before looping back and exiting the mental
mandibular growth until the late teens or early 20s because the foramen (Fig. 90.15). It is recommended that the osteotomy line
tooth roots may be close to the mandibular canal) such as devital- remain 5 mm (4.5 mm minimum) below the mental foramen to
ization of teeth, creation of mucogingival problems, asymmetry, avoid injury to the inferior alveolar nerve. If the nerve runs low in
infection, neurosensory disturbance, relapse, bone resorption, over- regard to the inferior border of the mandible and the condition is
or underaugmentation, overall patient dissatisfaction, and unes- not perceived preoperatively and adjusted for during surgery, in-
thetic results are also known complications. Mandibular fracture, ferior alveolar nerve injury can occur.

A B
• Fig. 90.14 A, Postoperative profile view of the patient. B, Postoperative profile view of the patient smiling.

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472 S E C TI O N XI I I Facial Cosmetic Surgery

should avoid excessive stripping of the mentalis muscle to avoid chin

ptosis. The mentalis muscle is the only muscle of significance when
performing a genioplasty. It is the sole elevator of the lower lip, provid-
ing the majority of the lip’s vertical support. During dissection for
both osseous genioplasty and implant placement, the mentalis muscle
is incised and reflected to approach the anterior mandible. To avoid
G shortening of the muscle, it is prudent during closure to reapproxi-
mate the mentalis muscle. If the muscle is not precisely reattached at
the end of the surgery, chin ptosis, lip ptosis and increased exposure of
I the lower incisors, drooling, and skin dimpling can occur. A study has
reported that chin ptosis, as well as lip incompetence, could be seen
H because of improper soft tissue redraping. Advocates of alloplastic
augmentation report that if the implant is placed through a submental
• Fig. 90.15 Terminal mandibular canal in relationship to the mental fora- approach, the mentalis muscle can be left attached. If asymmetric
men demonstrating the looping of the nerve before exiting at the foramen. ptosis is present, botulinum toxin A can be injected on the unaffected
Looping terminal mandibular canal and mental forarnen. G, Distance from side to lend temporary symmetry as muscle function recovers.
terminal mandibular canal to mental foramen; H, Advanced anterior dis-
Although alloplastic implants are facile techniques and faster
tance from terminal mandibular canal to mental foramen; I, Distance from
the terminal mandibular canal to inferior border of body near the mental
and easier to perform than advancement genioplasty, they can
foramen. The average distances of G, H, and I were 4.5 6 1.9 mm, 5.0 6 produce complications, including risk of infection, erosive osse-
1.8 mm, and 9.2 6 2.7 mm, respectively. (From Hwang K: Vulnerability of ous changes, extrusion, chronic inflammation, variable bone re-
the inferior alveolar nerve and mental nerve during genioplasty: an ana- sorption, capsular contraction, displacement, and chin ptosis. The
tomic study, J Craniofac Surg 16:10-14, 2004.) most common complications of alloplastic augmentation are in-
fection, bone resorption under the implant (although some stud-
ies have shown that in the majority of patients, this has no clinical
To minimize the risk of nerve transection, the osteotomy consequences, including esthetic changes in the soft tissue pro-
should be at least 7 mm below the mental foramen, and careful file), extrusion, malpositioning or displacement of the implant,
presurgical imaging should be done. and improper sizing of the implant.
Sensory innervation of the chin is divided into three territories: The main theories on the cause of resorption under an alloplas-
the labial territory (the mental nerve supplies this area), mental ter- tic implant include the following:
ritory (cutaneous branch of the mylohyoid nerve), and submental •ressPure of the implant against bone. (Studies have shown that
territory (cervical branches of the cervical plexus). Neurosensory the implant’s location with respect to the periosteum is irrele-
deficits of the skin overlying the chin, without involvement of the vant in the prevention of resorption; also, implants placed over
mental nerve, can occur with injury to the mylohyoid nerve. When alveolar bone tend to cause more resorption, and there is the
a horizontal osteotomy is performed using a reciprocating saw and risk of erosion into the roots of the mandibular anterior teeth.
sectioning involves not only bone but also some soft tissue of the In addition, lower lip strain and an overactive mentalis may
floor of the mouth in this area, the potential for injury to the my- place additional pressure on an implant.)
lohyoid muscle exists, along with injury to the mylohyoid nerve. •ascuLloasrsitoy.f (vPreserving the lingual soft tissue has been
This can result in neurosensory deficits of the skin overlying the shown to be beneficial in preventing resorption.)
chin without involvement of the mental nerve. Other anatomic •icroMmotion. (A precise pocket, excellent contact between the
structures at risk include the submental and sublingual arteries. implant and mandible, and consideration of the use of rigid
Bone drills and oscillating saws are more aggressive cutting fixation and porous implants that allow ingrowth have been
instruments and are almost difficult to control (e.g., caused by the shown to reduce micromotion.) Long-term follow-up of pa-
generation of macrovibrations) and cause more damage to soft tients who have implants is recommended. In patients who
tissues. The piezoelectric is an ultrasonic device that produces demonstrate resorption, consideration can be given to removal
microvibrations that allow a selective linear and curvilinear cut of of the implant and placement of a smaller implant or conver-
only mineralized structures, creating only minimal damage to soft sion to an osseous genioplasty.
tissues; it is easier to control and much less aggressive. Therefore, Implant malposition usually arises when the implant is too low
to protect soft tissue and critical structures, such as nerves, vessels, on the chin or when it migrates superior to the pogonion. An
and mucosa, piezosurgery is recommended to increases the safety intraoral approach may more frequently lead to superior move-
of osteotomies. ment of implant after surgery, and it can be treated by replacing
Aggressive stripping of the soft tissue pedicle attached to the the implant via a submental approach, securing it in place with
inferior and medial aspect of the mandibular symphysis can also sutures or screws.
involve the cutaneous branch of the mylohyoid nerve. Relapse in It is contraindicated to use an alloplastic implant in an even-
the immediate postoperative period is uncommon except in the tual edentulous mandible, principally because of the risk of supe-
case of fixation failure. There is generally good stability of the seg- rior displacement of the implant or to interference with the dental
ment after genioplasty. prosthesis in patients with mandibular alveolar ridge resorption.
Postoperative infections are rare, and oral antibiotic treatment There are some advantages and disadvantages of alloplastic aug-
is generally effective. This infection can often arise because of mentation materials. For instance, porous high-density polyethylene
bone debris remaining in the wound after osteotomy. Abundant or Medpor’s disadvantage when used for chin augmentation is its
saline irrigation before soft tissue closure is generally preventive. lack of pliability and handling relative to other alloplastic implants,
“Witch’s chin deformity” is a term coined by Gonzales-Ulloa in but it is inert material with very low tissue reactivity. It also causes
1971 to describe chin ptosis. Loss of mentalis muscle origination plays minimal inflammatory foreign body reactions, forms no capsules,
an important role in the pathogenesis of this problem, and surgeons and yields no observable systemic or cytotoxic effects.

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 CHAPTER 90 Genioplasty 473

Reports revealed that although autogenous cartilage and bone the orthodontist extracts the lower premolars followed by
provide the benefit of tissue compatibility, they were associated retroclining of the mandibular incisors. This results in normal oc-
with donor site morbidity, restricted availability, difficulty of clusal and lip relationships; however, the patients usually exhibit
shaping the graft, unpredictability of remodeling, and resorption. macrogenia. Macrogenia can be classified into three subgroups,
Although chin augmentation with supraperiosteal filler injec- depending on the vectors of growth: anterior, vertical, or a combi-
tion is often not of particular concern, superficial injection of nation. This can be corrected using either reduction of the mental
fillers may produce irregularity, especially with mentalis contrac- protuberance with a bur or a horizontal sliding osteotomy. Re-
tion and incitement. There is also a problem of limitations when moval of excess bone with a bur does not result in appreciable
a lot of augmentation is needed. In addition, vascular compro- improvement of the soft tissue contour. The soft tissues drape
mise is quite rare but has been reported. poorly over the newly contoured bone, resulting in a double-chin
The current patient underwent computer-assisted horizontal appearance. Lower lip ptosis can also be seen if the periosteum
translational osseous genioplasty using surgical guide printed does not attach to the newly contoured bone. Lip incompetence
from 3D-printing technology. This technique has well-known and a lack of cervicomandibular definition can also be associated
complications of genioplasty. There were no new complications with this technique. Submental ostectomy (burring) of the promi-
after this new technique and no increase in the rates of complica- nence is acceptable when only a small amount of reduction is
tion are described in articles. The supposed disadvantages of hori- needed. Posterior repositioning with an osteotomy has been shown
zontal osteotomy include a higher incidence of paresthesias, to produce a better result. However, this technique has the poten-
complexity and need for use of power tools, postoperative dis- tial for mental nerve injury not only from the procedure but also
comfort, and the possibility of tooth devitalization. because of the need to dissect around the inferior border to reduce
the projecting wings. Submental ostectomy with soft tissue exci-
Discussion sion via an extraoral approach has been shown to prevent the
negative sequelae of excessive submental tissue and chin ptosis.
Horizontal sectioning of the anterior mandible (genioplasty) was In patients with macrogenia and a class I relationship, an orth-
first described by Hofer (Hofer O, 1957) in the German literature odontic history should be obtained to determine whether premo-
in 1957 for correction of microgenia. An extraoral cutaneous (sub- lar extraction has been performed. In these patients, there usually
mental) incision was used. This initial operation was performed on is a normal lip relationship with overprojection of the chin.
a cadaver, with pre- and postoperative photographs demonstrating Although microgenia may be a component of either retrognathia
the results. Subsequently, Trauner and Obwegeser (Trauner R, or micrognathia, most adult cases with microgenia have normal
1957) introduced the intraoral approach. Since then a number of dentoalveolar relationships or mild malocclusion of the class II type
technical variations have been described. Riley and Powell (Riley that orthognathic surgery may not be suitable for them. Patients
RW, 1986) first described the adaptation of genioplasty to achieve with microgenia can have altered neck aesthetics. Traditionally, the
functional reconstruction of the upper airway through genioglos- microgenia treatment includes using grafts, alloplastic implants, or
sus advancement. Despite the versatility of the horizontal man- osteotomies. Genioplasty is mainly indicated in patients with very
dibular osteotomy, the biologic basis was not studied until the severe microgenia and retrogenia. Guyuron and Raszewski proposed
mid-1980s. Ellis and colleagues (Ellis E, 1984) demonstrated that that implants are more appropriate for older patients (.50 years
maintaining the soft tissue pedicle (the digastric musculature and old), with a pure slight microgenia and a proper cervicomental an-
the periosteum on the inferior and lingual border) is associated gle. Implants offer several advantages, including ease of placement,
with less osseous resorption in the postoperative period. Bell and shorter surgical time, and structural stability.
Gallagher (Bell, 1984) believed that undisturbed lingual soft tissue Alantar and colleagues (Alantar A, 2000) have shown that the
not only maximizes blood supply but also avoids chin drooping. mean number of branches of the mental nerve as it exits the fora-
Storum (Storum KA, 1988) demonstrated that close apposition men is two. However, the number of branches can range from one
of the margins of the osteotomy is important for vascular bridging to four. The branches of the mental nerve are known to run in an
and early osteogenesis. In patients with skeletal discrepancies who oblique direction; the mean angle between the most medial branch
would benefit from conventional orthognathic surgery, Proffit and and the long axis of the orbicularis oris muscle is 36 degrees. Based
colleagues (Proffit WR, 1981) suggested three specific indications on this, it is recommended that an incision not be made parallel to
for an isolated genioplasty as a camouflage procedure: the fibers of the orbicularis oris muscle. Damage can be avoided if
•derA
linbeoerxtraction patient with a good nasolabial angle, the incision is made with an angle of 36 degrees to the long axis of
protruding mandibular incisors, and a deficient chin the lip. Labial incisions should thus have a U shape. The two sides
• A patient with a short mandibular ramus in whom advance- of the U should be as parallel as possible to the lower labial branches
ment may lead to an unstable result (36 degrees). Limiting the proximal extension of the incision to the
• A patient with asymmetry that does not involve a significant canine region also reduces the incidence of neuronal injury.
malocclusion
Advancement genioplasty represents a reproducible, safe, and ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
overall effective technique for surgeons. In a systematic review Jans- complete set of bibliography.
sens et al. concluded that isolated advancement genioplasty is a
predictable and stable procedure. None of the included studies re-
ported a clinically significant skeletal relapse of more than 2 mm. Further readings
The amount of relapse was not only related to the fixation method
but also to the amount of movement of the osseous segment. Alantar A, Roche Y, Maman L, et al: The lower labial branches of the
Macrogenia can be seen in isolation or associated with man- mental nerve: anatomic variation and surgical relevance, J Oral
dibular hyperplasia. Some patients who are under the care of an Maxillofac Surg 58:415–418, 2000.
orthodontist and would benefit from a mandibular setback are Proffit WR, Turvey TA, Mariarty JD: Augmentation genioplasty as an adjunct
never referred to a surgeon for a variety of reasons. In these cases, to conservative orthodontic treatment, Am J Orthod 79:473–491, 1981.

t.me/Dr_Mouayyad_AlbtousH
 473.e1

Bibliography Keyhan SO, Poorian B, Fallahi HR: Piezoelectric technology in rhino-

plasty, Oral Maxillofac Surg Clin North Am 33(1):23-30, 2021.
Khan M, Sattar N, Erkin M: Postoperative complications in genioplasty
Bagheri SC, Jo C: Clinical Review of Oral and Maxillofacial Surgery E- and their association with age, gender, and type of genioplasty, Int J
book, 2013, Elsevier Health Sciences. Dent 2021:8134680, 2021.
Bell WH: The versatility of genioplasty using a broad pedicle, J Oral Maas C, Merwin G, Wilson J, et al: Comparison of biomaterials for facial
Maxillofac Surg 42:637-645, 1984. bone augmentation, Arch Otolaryngol Head Neck Surg 116(5):
Bertossi D, Galzignato PF, Albanese M, et al: Chin microgenia: a clinical 551-556, 1990.
comparative study, Aesthetic Plast Surg 39(5):651-658, 2015. Moradi A, Shirazi A, David R: Nonsurgical chin and jawline augmenta-
Brandon G, Kern E, Neel B: Autografts of uncrushed and crushed bone tion using calcium hydroxylapatite and hyaluronic acid fillers, Facial
and cartilage, Arch Otolaryngol Head Neck Surg 105:75-80, 1979. Plast Surg 35(2):140-148, 2019.
Burcal RG, Laskin DM, Sperry TP: Recognition of profile change after Oth O, Durieux V, Orellana MF, et al: Genioplasty with surgical guide
simulated orthognathic surgery, J Oral Maxillofac Surg 45(8): using 3D-printing technology: a systematic review, J Clin Exp Dent
666-670, 1987. 12(1):e85, 2020.
Chan D, Ducic Y: A simplified, reliable approach for advancement ge- Peter B: Piezosurgery-assisted sliding genioplasty: a method for reduction
nioplasty, JAMA Facial Plast Surg 18(2):114-118, 2016. of complications. Review and case report, Eur J Plast Surg 33(4):
Chaushu G, Blinder D, Taicher S, et al: The effect of precise reattach- 183-187, 2010.
ment of the mentalis muscle on the soft tissue response to genioplasty, Rho NK, Chang YY, Chao YY, et al: Consensus recommendations for
J Oral Maxillofac Surg 59(5):510-516, 2001. optimal augmentation of the Asian face with hyaluronic acid and
Chen JX, Koch A: Genioplasty. In Ferneini EM, Goupil MT (eds): Office- calcium hydroxylapatite fillers, Plast Reconstr Surg 136(5):940-956,
Based Maxillofacial Surgical Procedures, 2019, Springer, pp 367-373. 2015.
Choe KS, Stucki-McCormick SU: Chin augmentation, Facial Plast Surg Richard O, Ferrara J, Cheynet F, et al: [Complications of genioplasty],
16(1):45-54, 2000. Rev Stomatol Chir Maxillofac 102(1):34-39, 2001.
Santos Junior JF, Abrahão M, Gregório LC, et al: Genioplasty for genio- Riley RW, Powell NB, Guilleminault C: Inferior sagittal osteotomy of
glossus muscle advancement in patients with obstructive sleep apnea- the mandible with hyoid myotomy‐suspension: a new procedure for
hypopnea syndrome and mandibular retrognathia, Braz J Otorhino- obstructive sleep apnea, Otolaryngology–Head and Neck Surgery
laryngol 73(4):480-486, 2007. 94(5):589–593, 1986.
Ellis E, Dechow PC, McNamara JA, et al: Advancement genioplasty with Shokri T, Rosi-Schumacher M, Petrauskas L, et al: Genioplasty and man-
and without soft tissue pedicle, J Oral Maxillofac Surg 42:637–645, dibular implants, Facial Plast Surg 37(6):709-715, 2021.
1984. Sood A, Caldemeyer C, Ferneini EM: Complications of genioplasty,
Fallahi HR, Keyhan SO, Fattahi T, et al: Comparison of piezosurgery and Complications Maxillofac Cosmet Surg 229-235, 2018.
conventional osteotomy post rhinoplasty morbidities: a double-blind Stanton DC: Genioplasty, Facial Plast Surg 19(1):75-86, 2003.
randomized controlled trial, J Oral Maxillofac Surg 77(5):1050-1055, Storum KA: Microangiographic and histologic evaluation of revascular-
2019. ization and healing after genioplasty by osteotomy of the inferior
Ferneini EM, Goupil MT: Office-Based Maxillofacial Surgical Procedures, border of the mandible, J Oral Maxillofac Surg 48:210–216, 1988.
2019, Springer. Trauner R, Obwegeser H: Surgical correction of mandibular progna-
Guyuron B, Raszewski RL: A critical comparison of osteoplastic and alloplas- thism and retrognathism with consideration of genioplasty, Oral Surg
tic augmentation genioplasty, Aesthetic Plast Surg 14(1):199-206, 1990. 10:677, 1957.
Hofer O: Die osteoplastiche Verlaengerung des Unterkiefers nach Vo- White JB, Dufresne CR: Management and avoidance of complications in
neiselber bei Mikrogenia, Dtsch Zahn Mund Kieferheilkd 27:81, 1957. chin augmentation, Aesthet Surg J 31(6):634-642, 2011.
Janssens E, Shujaat S, Shaheen E, et al: Long-term stability of isolated Wilson MJV, Jones IT, Butterwick K, et al: Role of nonsurgical chin
advancement genioplasty, and influence of associated risk factors: a augmentation in full face rejuvenation: a review and our experience,
systematic review, J Craniomaxillofac Surg 49(4):269-276, 2021. Keyhan Dermatol Surg 44(7):985-993, 2018.
SO, Azari A, Yousefi P, et al: Computer-assisted horizontal Zide BM: The mentalis muscle: an essential component of chin and
translational osseous genioplasty: a simple method to correct chin lower lip position, Plast Reconstr Surg 105(3):1213-1215, 2000.
deviation, Maxillofac Plast Reconstr Surg 42(1):36, 2020.
Keyhan SO, Fattahi T, Bagheri SC, et al: Integrated Procedures in Facial
Cosmetic Surgery, 2021, Springer Nature.

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91
Endoscopic Eyebrow Lift
K EI T H A . S O NNE V E L D a n d EL I E M. F E R NE I N I

CC indicated is actually an eyebrow lift. Dermatochalasis and eye-

brow ptosis can exist together and often are treated together, but
A 61-year-old female presents to your office for evaluation of her eyebrow ptosis alone may give the appearance of dermatochalasis.
“droopy and sad-looking eyes.”
Imaging
HPI
No imaging studies are indicated for this evaluation.
This patient presents for cosmetic consultation because for about
the past 10 years, she has been receiving injected neuromodula- Labs
tors in her forehead and dermal fillers in her face, but she has
noticed that her upper eyelids are beginning to droop around the No routine lab studies are indicated for this condition.
sides and are giving her somewhat of a tired appearance that she
would like corrected. Assessment
PMHX/PSHX/Medications/Allergies/SH/FH Age-related eyebrow ptosis.

The patient’s current medical status is only significant for mild Treatment
hypertension and hyperlipidemia, which are currently treated
with lisinopril and simvastatin, respectively. Past surgeries include This patient underwent an endoscopic eyebrow lift. There are
two cesarean sections, a hysterectomy, and bunion removal. She several approaches to an eyebrow lift— transblepharoplasty, di-
does not use tobacco or alcohol. Her only reported allergy is rect, trichophytic, endoscopic, and coronal—which all have dif-
codeine, which she said makes her nauseous. ferent advantages and disadvantages (Fig. 91.1).
Transblepharoplasty is usually done in conjunction with a
Examination blepharoplasty and is only capable of modest improvement in
eyebrow position, but it spares a second incision.
She is a well-developed, well-nourished female with appropriate age- Direct eyebrow lift is performed with an incision on the superior
related changes to her facial appearance. She has Fitzpatrick II and aspect of the eyebrow and can be done with or without a midfore-
Glogau 2 skin. Evaluation of her face shows gross facial symmetry head eyebrow lift to treat the medial eyebrow. These are generally
with even vertical facial thirds. She has mild jowling with no signifi- done more in males because their thicker eyebrow hair and mid-
cant platysmal banding. She has a slightly accentuated nasolabial forehead rhytids can better hide the incision. The ease of the proce-
fold with early downturn of the lateral labial commissures. The dure as well as the 1:1 change in position are the main advantages;
malar region shows appropriate volume and no significant nasojugal the disadvantage is that the incisions may be more visible.
groove, likely an indication of under-eye dermal filler placement. Trichophytic eyebrow lift is a subcutaneous dissection that can
There are no significant lower eyelid fat pockets visible. Evaluation be used in a patient with a longer forehead to shorten the forehead
of the eyelid and eyebrow shows that there is not a peak in her eye- while maintaining the hairline position (Fig. 91.2). The main dis-
brow and it sits along the superior orbital rim. There is mild derma- advantage is that the incision may be visible, especially in a patient
tochalasis apparent in the upper eyelid, which resolves on manual with lowered density of the anterior hairline. Other variations of
elevation of the eyebrow. Her Marginal Reflex Distance (MRD) 1 the trichophytic eyebrow lift can also advance the hairline.
and 2 are both normal. The distance from her eyebrow to the Coronal eyebrow lift is a powerful lift and allows access to the
trichion is approximately 5 cm and has dense hair along the hairline. bony structures to allow for recontouring, but the main disadvan-
The normal position of the eyebrow in a female lies above the tage is the large incision, which may be evident and can also result
superior orbital rim, with a peak at approximately the lateral third in cicatricial alopecia.
of the eyebrow. It generally begins as a thicker strip of hair, taper- Endoscopic eyebrow lift is a good mixture of effective results
ing as it moves laterally. It is highly important to evaluate the and smaller incisions, but the technical difficulty and inability
eyebrow position for anyone concerned with their upper eyelid to change the dimensions of the forehead are disadvantages. It
because patients may expect a blepharoplasty when the treatment is relatively contraindicated in a patient with an already large

474
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 CHAPTER 91 Endoscopic Eyebrow Lift 475

A
• Fig. 91.1 The various eyebrow-lifting approaches: transblepharoplasty
(white dotted line), direct (pink line), midforehead (white solid line), pretri-
chial (red line), trichophytic (green line), endoscopic (yellow lines), and
coronal (blue line). (Used with permission from Niamtu J, Cuzalina A: Brow
and forehead lift: form, function, and evaluation. In: Niamtu J, ed. Cos-
metic Facital Surgery. 3rd ed. Elsevier; 2023:272-344.)

forehead because the superior repositioning of the forehead and

eyebrow tissue will elongate it even more.
The endoscopic eyebrow lift includes five incisions: one
midline incision, two parasagittal incisions, and two temporal
incisions. The midline and parasagittal incisions are in an antero-
posterior orientation and placed just behind the hairline and are
1.5 to 2 cm in length. The temporal incisions are 3 to 4 cm in
length and are placed 1 to 2 cm posterior to the temporal hairline
running parallel. Inside the temporal crest, the plane of dissection
is subperiosteal, and any of the three incisions can be used to in-
sert the endoscope. The dissection is carried out to release eye-
brow tissue to the level of the superior orbital rim, and medially,
it can be dissected to a desired level depending on the amount of
medial lift desired. Laterally, the plane of dissection is deep to the
temporoparietal fascia and just superficial to the superficial layer
of the deep temporal fascia. This dissection is carried out to release
the arcus marginalis in the area of the lateral canthus, and the
conjoint tendon is also dissected to connect the forehead and the
temporal surgical sites.
After all of the tissue release is completed, the periosteum is B
incised 1.5 to 2 cm superior to the arcus marginalis to allow for a
more powerful lift of the eyebrow tissue. Through this incision, • Fig. 91.2 A, Preoperative photograph in a patient requesting periocular
the procerus and corrugator supercilii muscles can be accessed and rejuvenation. B, Early postoperative photograph after pretrichial eyebrow
myotomies performed to reduce the eyebrow depressor actions, lift and concomitant upper blepharoplasty. (Courtesy of Dr. Mo Banki.)

t.me/Dr_Mouayyad_AlbtousH
476 S E C TI O N XI I I Facial Cosmetic Surgery

although this is a more advanced maneuver. After adequate release in an exaggeration of dermatochalasis. Often concurrent blepharo-
has been achieved, the lift must be secured. The temporal lift areas plasty with some eyebrow lifting procedure is performed, but careful
may be repositioned superiorly and can be secured to the superfi- patient examination should reveal situations when a blepharoplasty
cial layer of the deep temporal fascia. The parasagittal incisions are alone will not be enough to provide a rejuvenated appearance to the
lifted and secured to the bone through a variety of bone anchors, periocular area. The surgeon who performs solely a blepharoplasty in
bone tunnels, or plates and screws as per the surgeon’s preference. someone who would likely benefit from an eyebrow lift as well
will likely result in overresection of redundant skin and significantly
Complications compromise the results if the patient has an eyebrow lift done
elsewhere.
The most immediate complication is a hematoma, which can There are several drawbacks to the procedure, including the
form in any of the surgical areas, but often the most at-risk area is initial setup investment, technique difficulty, and questionable
in the temporal area, where the sentinel vein often traverses the long-term stability. The instrumentation needed for this proce-
plane of dissection as it is carried out to the lateral canthus area. dure requires an endoscope and all of the equipment necessary to
This vein is important because its presence indicates proximity to use the endoscope in addition to special endoscopic instrumenta-
the frontal branch of the facial nerve, which will be in the tempo- tion. The various open eyebrow lifting techniques require similar
roparietal fascia superficial to the plane of dissection. Care should instrumentation to that which is used for a facelift. With the
be taken to avoid injury to the sentinel vein because the limited different perspective of using an endoscope and specialized instru-
exposure through the endoscopic incisions may make obtaining mentation, the learning curve on performing an endoscopic eye-
hemostasis quite difficult and increase potential of injury to the brow lift can be high. The concepts behind the procedure are easy
frontal branch of the facial nerve. to understand, but the actual hands-on ability to perform the
An injury to the frontal branch of the facial nerve is also a po- procedure does take time to develop, and this is without the more
tential risk during the procedure. The risk of this can be minimized advanced techniques briefly mentioned earlier.
by careful dissection to the appropriate plane and maintaining the There is some controversy in the cosmetic world regarding the
plane during the development of the plane. Mild injuries to the long-term results of the endoscopic eyebrow lift and which patients
nerve result in an asymmetry of eyebrow movement after the pro- are good candidates for the procedure. The minimally invasive na-
cedure, which resolve with time, but in rare cases, long-term or ture of the procedure is a large draw to patients who do not wish to
even permanent injury can occur with significant asymmetry in have skin incisions on their face or large incisions in their hair, but
eyebrow movement or even an inability to close the eyelids. some surgeons believe that its results look good in the short term,
Neurosensory disturbances of terminal branches of the trigemi- and tissue may return to the original position after only several
nal nerve (supraorbital nerve, supratrochlear nerve) are common months. It stands to reason that a skin dissection with excision of
after the procedure because of the dissection along the superior redundant skin has a lower likelihood of relapse to a ptotic position.
orbital rim. It is important to avoid overaggressive dissection in A counter argument to this is similar to that made when discussing
this area to minimize the severity of neurosensory dysfunction after different facelift techniques: a skin flap-only technique will indeed
the procedure. stretch and reduce redundant skin, but the results may be compro-
During the fixation process, it is extremely important to ensure mised if the deeper layers of tissue are not addressed through the
adequate and stable fixation through whichever the surgeon surgical procedure, as is the case in an endoscopic eyebrow lift.
chooses. Loss of one point of fixation will result in an asymmetric With many procedures, especially in the cosmetic realm, there
result. The loss of both points of fixation will result in a total are several options in procedures and techniques used to achieve
failure of the procedure, and the loss of either one or both points an outcome. The choice in treatment and technique should
of fixation will result in an unhappy patient. be patient centered with a multitude of both objective criteria and
patient desires. The endoscopic eyebrow lift is a versatile tool in
Discussion an experienced surgeon’s hands and enhances rejuvenation of the
periocular area.
Overall, the endoscopic eyebrow lift is a powerful tool for facial
rejuvenation because the effect of eyebrow ptosis is well understood ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
to have major effects on the creation of pseudodermatochalasis or complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 476.e1

Bibliography Perenack JD: The endoscopic brow lift, Atlas Oral Maxillofac Surg Clin
North Am 24(2):165-173, 2016. doi:10.1016/j.cxom.2016.05.005.
Rohrich RJ, Cho MJ: Endoscopic temporal brow lift: surgical indica-
Bagheri SC, Khan HA: Facial cosmetic surgery. In Bagheri SC, Khan HA tions, technique, and 10-year outcome analysis, Plast Reconstr Surg
(eds): Clinical Review of Oral and Maxillofacial Surgery: A Case-Based 144(6):1305-1310, 2019. doi:10.1097/PRS.0000000000006238.
Approach, 2nd ed, St. Louis, 2014, Elsevier Mosby, pp 411-455. Saltz R, Lolofie A: My Evolution with endoscopic brow-lift surgery, Fa-
Fattahi T: Brow lifting. In Kademani D, Tiwana PS (eds): Atlas of Oral & cial Plast Surg Clin North Am 29(2):163-178, 2021. doi:10.1016/j.
Maxillofacial Surgery, St. Louis, 2016, Elsevier Saunders, pp 1378-1383. fsc.2021.02.007.
Graham DW, Heller J, Kirkjian TJ, et al: Brow lift in facial rejuvenation: Terella AM, Wang TD: Technical considerations in endoscopic brow lift,
a systematic literature review of open versus endoscopic techniques, Clin Plast Surg 40(1):105-115, 2013. doi:10.1016/j.cps.2012.06.004.
Plast Reconstr Surg 128(4):335-341, 2011. doi:10.1097/PRS.0b013e Zins JE, Coombs DM: Endoscopic brow lift, Clin Plast Surg 49(3):
3182268d41. 357-363, 2022. doi:10.1016/j.cps.2022.02.003.
Niamtu J, Cuzalina A: Brow and forehead lift: form, function, and evalu-
ation. In Niamtu J (ed): Cosmetic Facial Surgery, 3rd ed, Philadelphia,
2023, Elsevier, pp 272-344.

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92
Cleft Lip and Palate
MA R SH A L L F. N E W M A N , C H R I S J O, a n d S H A H ID R. A Z I Z

CC PMHX/PSHX/Medications/Allergies/SH/FH
As a member of the multidisciplinary cleft and craniofacial anom- Except for the CLP, the child has no other medical problems. He
alies team, you are asked to evaluate a male infant born with a right was born with Apgar scores of 8 and 9 at 1 and 5 minutes, respec-
unilateral complete cleft lip and palate (CLP) Veau class III. tively. There are no facial or systemic anomalies characteristic of
Cleft lip is a unilateral or bilateral gap in the upper lip that any known syndromes (see Discussion later in this section), in-
forms during the 3rd through 7th weeks of embryonic develop- cluding any associated cardiac, respiratory, renal, ophthalmologic,
ment. It develops from failure of fusion of the medial nasal pro- or musculoskeletal abnormalities. There is no family history of
cess and the maxillary process. Clefting of the lip is generally de- CLP or isolated cleft palate.
scribed as either complete or incomplete. A complete cleft lip is a
cleft of the entire lip with discontinuity of the orbicularis oris and Examination
usually the alveolar arch or premaxilla; an incomplete cleft lip
involves only the lip to varying degrees and often spares the soft General. Male infant is in the 25th percentile for weight and
tissue of the associated alar base of the nose. A cleft palate is a gap height (potentially because of difficulty with feeding).
in the hard or soft palate (or both) that forms during the 5th Maxillofacial. The cleft lip (cleft lip) is complete, penetrating
through 12th weeks of development. Cleft palate forms as a result the entire thickness of the lip, alveolus, nasal tip cartilages, and
of failure of attachment and alignment of the levator veli, tensor floor of the nose (Fig. 92.1). The cleft is unilateral, right of mid-
veli palatini, uvular, palatopharyngeus, and palatoglossus muscles. line, and continuous with the palate (CLP is most commonly
There are both ethnic and racial variations in the incidence of expressed unilaterally, with a 2:1 predilection for the left side).
CLP. It is most common in Asians (3.2 in 1000) followed by Intraoral. The cleft continues through the hard and soft pal-
Whites (1.4 in 1000), and individuals of African descent (0.43 in ates. (Structures anterior to the incisive foramen form the primary
1000). CLP occurs more often in males and on the left side. Iso- palate and posterior to the incisive foramen form the secondary
lated cleft palate is a different genetic entity with no racial predi- palate.) Throughout the cleft, the nasal cavity, nasal conchae, and
lection. It is more common in females and when present is sig- posterior pharyngeal wall are readily visible. The nasal mucosa
nificantly associated with underlying sequence or syndromic appears inflamed and ulcerated (because of irritation of the fragile
genetic alterations or further midline developmental anomalies
These may include Pierre Robin sequence, Stickler syndrome, van
der Woude syndrome, or 22q deletion.

HPI
The CLP was known prenatally. Using high-resolution ultraso-
nography, cleft lip can be diagnosed reliably as early as 14 weeks
of gestation, though a diagnosis of cleft palate may be more dif-
ficult until closer to 20 to 21 weeks of gestation. The infant was
born at a community hospital with no obstetric complications.
His presentation is consistent with a nonsyndromic CLP. The
pregnancy was uncomplicated. Parents report no known environ-
mental exposures, and there is no family history of cleft lip or
palate. Potential environmental contributors to the development
of CLP may include maternal alcohol or tobacco use, vitamin
deficiencies, or exposure to medications such as corticosteroids
and antiseizure treatments. If a single parent has CLP, the likeli-
hood of an infant having CLP is 4% to 6%. If neither parent has
a history of CLP and one child has CLP, the likelihood of a • Fig. 92.1 Preoperative photograph of patient showing unilateral cleft lip
second child having CLP is 2% to 8%. and palate.

479
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480 S E C TI O N XIV Syndromes of the Head and Neck

tissue from feeding). Bidigital palpation identifies solid supportive Presurgical dentofacial orthopedics are increasingly used to
bone along the palatal shelves bordering the cleft site. This presen- optimize primary CLP repair. These techniques are commonly
tation would be consistent with a Veau class III cleft of the palate known as nasoalveolar molding (NAM). As the name implies,
involving the complete primary, secondary, and soft palate areas. such dentofacial orthopedics can be used to improve lip soft tis-
The Veau classification is commonly used, in which Veau class I sue, nasal tissue and projection (particularly in bilateral CLP), and
represents soft palate clefting only, Veau class II the soft and hard the palatal shelves. Patient growth and socioeconomic concerns
palate but not the alveolus area, and Veau class IV representing must always remain critical factors when deciding whether to use
complete bilateral clefting of all oral structures. It is important to NAM because the devices may require frequent clinic visits for
palpate the hard palate of any infant. Even when an obvious de- alterations.
fect is not readily visible, palpation may detect a notch at the
posterior border of the hard palate, which together with a zona
pellucida along the mid soft palate and notching of the uvula cre-
Timing Considerations
ates a clinical triad indicating submucous cleft palate. Table 92.1 outlines the sequence of management of patients
with CLP. Cleft lip repair is usually addressed at 10 to 14 weeks
Imaging of age. It is essential to take into account if a patient was born
prematurely because the necessary growth preoperatively may
No imaging studies are indicated for the diagnosis and manage- require waiting longer before performing primary cleft repairs.
ment of routine isolated CLP. Depending on the physical exami- An additional advantage of waiting until this age is to allow for
nation findings, further workup may be indicated. For example, a thorough medical evaluation to determine whether the infant
if ear abnormalities exist, a screening renal ultrasound examina- has any congenital defects or additional medical considerations.
tion may be indicated. When midline defects such as isolated The surgical procedure is generally easier to perform when the
cleft palate are present, examination of other structures such child is slightly larger because anatomic landmarks are more
as the heart with an echocardiogram are important. When prominent and well defined. It has historically been accepted
orbital or cranial bony anomalies exist, computed tomography is that the safest anesthesia time period for infants is based on the
indicated. “rule of 10s”—surgery can be performed when the child is at
least 10 weeks of age, weighs at least 10 lb, and has a minimum
Labs hemoglobin value of 10 mg/dL. (However, there is no current
scientific rationale to support this rule.) With modern intraop-
Baseline hemoglobin and hematocrit levels are indicated before erative pediatric monitoring techniques, general anesthesia can
surgical correction of any cleft. In general, a hemoglobin level of be performed safely at an earlier age as needed, although there is
10 mg/dL often correlates with sufficient growth and develop- little literature to support performing cleft lip repair before
ment of the infant patient to facilitate safer administration of 3 months of age because severe growth restriction of the maxilla
general anesthesia. Any family history of bleeding diatheses may occur. Excessive scarring and inferior esthetic results have
should be thoroughly investigated before surgery. also been documented when surgery is performed earlier than
age 3 months.
Assessment Cleft palate repair is usually performed between 9 and 18 months
of age. It is intended to coincide with the progression of natural
Newborn male infant with nonsyndromic right unilateral complete speech development and growth. In deciding on the timing of
CLP Veau class III. repair, the surgeon must consider the delicate balance between
facial growth restriction after early surgery and early speech devel-
Treatment opment, which requires an intact palate. It is important to avoid
compensatory misarticulations that may result if speech develop-
Preoperative Considerations ment continues without an intact palate. Most children require an
intact palate to produce certain sounds by 18 months of age.
There is no consensus regarding the timing and techniques used If developmental delay is present and speech is not anticipated to
for CLP surgery. Individual cleft and craniofacial centers and develop until later, cleft palate repair can be delayed. A high per-
surgeons follow various protocols according to their own experi- centage of patients with CLP have severe and recurrent enough
ence, rationale, and preferences. The functional needs, esthetic middle ear infections that if there exists middle ear disease at the
concerns, and ongoing growth of affected individuals all create time of palatal repair, myringotomy tubes are typically placed as
specific concerns that complicate the treatment process. All agree, well. There is alteration of the eustachian tube anatomy in pa-
though, that feeding, growth, and development are of primary tients with CLP, and in addition to a flatter angle relative to the
importance. It is essential for such patients to be treated in a mul- skull base as pediatric patients develop, inadequate middle drain-
tidisciplinary team manner to allow for continued proper growth age is common.
and development, particularly patients with clefting of the palate. There is very little evidence to support cleft palate repair before
Patients who have orofacial clefts that involve the palate cannot 9 months of age. Surgical repairs before this time are associated with
generate the appropriate suction seal with their mouths to feed a higher incidence of maxillary hypoplasia later in life and show no
properly. This leads to excessive effort when feeding and can lead improvement in speech. However, this pertains to repairs involving
to an imbalance between the nutrition an infant is able to con- the hard palate. At some centers, the soft palate is repaired first to
sume versus the energy expended by the body in consuming it. facilitate appropriate speech development and the hard palate re-
Although specialized feeding bottles help tremendously in this paired later to allow less effect on maxillary growth. Most centers,
endeavor, the input of multiple specialists is necessary for infants though, repair the hard and soft palate defects at the same time.
with CLP to grow appropriately. After initial cleft palate repair, 15% to 20% of children develop

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 CHAPTER 92 Cleft Lip and Palate 481

TABLE
92.1 Sequence of Management of Cleft Palate

Procedure Age or Timing Comments

Dentofacial orthopedics First few weeks of life Improves tension-free lip closure
Lip adhesion (two-stage repair) After dentofacial orthopedics and before definitive Some centers prefer one-stage closure and do
nasolabial repair not perform lip adhesions
Definitive nasolabial repair Traditionally done at 10 weeks (no scientific basis) Timing may vary based on cleft type
Centers now advocate lip closure at 3–6 months
Cleft palate repair Before 1–2 years Earlier repair (before 1 year) is advocated to im-
Some centers advocate closure at 8–10 months prove speech development
Some centers advocate two-stage repair using an Maxillary growth should be monitored with ear-
obturator to delay palate closure lier repairs
Correction of VPI (pharyngeal flap or Speech assessment begins at 1.5–2 years VPI may occur after maxillary advancement and
sphincter pharyngoplasty) can be corrected 6–12 months later
Nasolabial revisions Before 3 years —
Phase 1 orthodontics Before alveolar cleft bone grafting Differentially expands the anterior maxilla
Alveolar bone grafting At 8–12 years (when maxillary canine root is half Bone graft from anterior ilium is usually preferred
to two-thirds formed)
Phase 2 orthodontics Permanent dentition phase —
Correction of maxillary hypoplasia (orthognathic After completion of growth Distraction osteogenesis should be considered
surgery, distraction osteogenesis, or both) when maxillary advancement is .10 mm
Rhinoplasty At 6–12 months after maxillary advancement —

VPI, Velopharyngeal insufficiency.

Modified from Kaban LB, Troulis MJ (eds): Pediatric oral and maxillofacial surgery, St. Louis, 2004, Saunders.

inadequate closure of the velopharyngeal mechanism (velopharyngeal reconstruction. Considerable literature now exists for the use of
insufficiency [VPI]). This is usually diagnosed at 3 to 5 years of age, allogeneic bone graft materials as well as adjuncts such as bone
when a more detailed speech examination can be performed because morphogenetic protein, which may be considerations in older
of patient participation. It is important to have both objective (endo- patients or those requiring repeat operations.
scopic nasendoscopy or video fluoroscopy) as well as subjective Orthognathic reconstruction of maxillary and mandibular
(speech-language pathology evaluation) assessments of a patient with discrepancies is generally performed between 14 to 18 years of age
VPI when considering the most appropriate intervention. Surgery based on individual growth characteristics. A combined approach
may be performed to correct an anatomic defect at the velopharynx with both orthodontics and surgery is necessary for optimal pa-
with the goal of improving closure between the palatal and nasopha- tient outcomes. Orthognathic surgery before this time frame is
ryngeal tissues to reduce nasal air escape during the production of performed only for severe cases of dysmorphology and for certain
certain sounds. Multiple types of VPI surgery exist, and not all pa- severe psychosocial concerns.
tients require surgical intervention when speech therapy can treat the Lip and nasal revisions are best completed after orthognathic
primary issue if the diagnosis is accurate from the start. surgery is finished if planned and usually at least 1 year after jaw
Approximately 75% of patients with any type of cleft present surgery. Correction of the skeletal facial discrepancy allows for the
with clefting of the maxilla and alveolus. Bone graft reconstruc- appropriate foundation for cleft rhinoplasty or otherwise.
tion of the alveolus is performed during the mixed dentition be-
fore eruption of the permanent canine or permanent lateral inci- Surgical Techniques for Cleft Lip Repair
sor. The timing of this procedure is based on dental development
and not chronologic age. Reconstruction of the alveolus before Many techniques for cleft lip repair exist, each with multiple
the mixed dentition stage has been associated with a high degree modifications. The technique most commonly used for unilateral
of maxillary growth restriction and potential need for additional cleft lip repair is the Millard rotation-advancement technique. A
bone graft reconstructions at a later age. Autogenous bone grafted three-layer closure of skin, muscle, and mucosa is performed to
from the iliac crest has provided the best results for reconstruction reposition the superiorly inserted orbicularis oris muscle into its
of alveolar or maxillary cleft defects. Most commonly in the normal circular orientation. The medial cleft lip is rotated inferi-
United States, the alveolar grafting is completed when the associ- orly as well, and the lateral lip segment is advanced to meet it. A
ated canine root is two-thirds formed, that is, typically at 9 to separate C-flap along the medial margin of the cleft aids in closure
11 years of age. Before grafting, orthodontic expansion of the maxilla and creation of the nasal sill. The small flap can also be positioned
is indicated to maximize the amount of graft placed in the alveo- medially in part to lengthen the rotation side of the reconstruc-
lus and to facilitate elevation of soft tissues for nasal and oral tion. A critique of this technique is the potential for shortening of

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482 S E C TI O N XIV Syndromes of the Head and Neck

the repair or the need for longer backcutting incisions with larger oral and nasal cavities in the production of speech. The tensor and
advancements. Hypoplastic tissue along the cleft margins is ex- levator veli palatini and uvularis muscles, which usually join at the
cised and discarded. The Mohler repair is similar to the Millard midline to form a continuous sling, are separated and insert along
repair but may be more useful for more vertically oriented unilat- the posterior edge of the hard palate. The velum, or soft palate,
eral cleft lips. The medial incision is carried more vertically at the must be closed before the development of speech. If repair occurs
base of the columella to gain vertical length as the small curved after this time, compensatory speech articulations may result.
superior aspect becomes straight. An approach used to address the speech issues with growth-
The Randall-Tennison technique is a Z-plasty technique used related concerns involves staging the closure of the secondary
by some surgeons for unilateral cleft lip repair. This technique palate with two procedures. This involves repair of the soft palate
allows for less scar contracture because of its Z-plasty design but early in life followed by closure of the hard palate later during
places the incision in a potentially less cosmetic location than infancy. The intent of this approach is to accomplish timely repair
other repairs. of the soft palate, which is critical for speech, while delaying hard
Increasing in use is the geometric subunit repair created by palate repair until further growth has occurred. This technique
Fisher. This repair uses aspects of a straight-line repair as well as offers the advantage of less growth restriction, easier repair of
triangular insertions to lengthen the lip in a very specific manner larger clefts, and less chance for fistula formation.
in which the lengths of each repair segment are precisely measured The basic premise of cleft palate repair involves mobilization of
and marked. This is in contrast to the rotation-advancement tech- multilayered flaps to close the defect created caused by the failed
nique in which modifications can be easily created as a repair fusion of the palatal shelves. The nasal mucosa is first closed fol-
proceeds if more length is needed. The repair avoids less cosmetic lowed by repositioning and reconstruction of the levator veli
backcuts around the lateral crural footplate but requires discard- palatini and palatopharyngeus muscles. Closure of the oral mu-
ing a more significant amount of soft tissue. cosa completes the repair.
Primary nasal reconstruction is often performed at the time of Many techniques have been devised for cleft palate repair. The
lip repair to reposition the displaced lower lateral cartilages and Bardach technique involves creation of two large, full-thickness
alar tissues. Various techniques have been advocated, each with flaps on each palatal shelf, which are brought to the midline for
considerable variation. The repair essentially involves releasing the closure (Fig. 92.2A and B). This technique allows for preserva-
alar base, augmenting the area with allogenic subdermal grafts, or tion of the palatal neurovascular bundle, which is contained
proceeding with open rhinoplasty with minimal dissection to within the pedicle of each flap. The Von Langenbeck technique
avoid scar formation. is similar to the Bardach technique, but it preserves an anterior
Bilateral cleft lip repair is a very challenging technical proce- pedicle (attachment to the anterior maxilla) for increased blood
dure, primarily because of the lack of quality tissue present and supply to the flaps. It also involves elevation of large mucoperi-
the manner of separation of the tissues caused by the clefting. The osteal flaps from the palate with midline approximation of the
typically shortened columella and rotation of the premaxillary cleft margins. Long lateral releasing incisions are made at the
segment make achieving acceptable aesthetic results difficult, and border of the palatal and alveolar bone for both repairs to allow
preoperative NAM can be helpful. Most bilateral cleft lip repairs mobilization. The levator muscles are detached from their abnor-
create orbicularis oris continuity across the prolabium (Millard, mal insertion along the hard palate, and the palatopharyngeus is
Mulliken, cutting) or simply attach the lateral lip segments to the intimately associated.
prolabium medially without creating orbicularis oris direct conti- The Furlow double-opposing Z-plasty technique involves two
nuity (Manchester). Z-plasties, one on the oral mucosa and one in the reverse orienta-
Variations to surgical approaches range from aggressive length- tion on the nasal mucosa (Fig. 92.2C). The levator muscle on one
ening of the columella with preservation of hypoplastic tissue to side is included in the posteriorly based oral mucosa Z-plasty,
conservative primary nasal reconstruction as performed with Mc- whereas the levator muscle from the opposite side is included
Comb’s unilateral cleft lip technique. McComb’s technique in- within the posteriorly based nasal mucosal Z-plasty flap. This
volves release and repositioning of the lower lateral cartilages and procedure produces palatal lengthening and reorients and pro-
alar base on both sides without aggressive degloving of the entire vides overlap of the malpositioned levator muscles. The Furlow
nasal complex. Aggressive corrective techniques often produce Z-plasty has been reported to be associated with a higher rate of
initial results that are very good. Long-term results, however, are fistula formation at the junction of the soft and hard palate.
not so favorable because of the progression of natural growth The Wardill-Kilmer-Veau technique is a V-Y advancement of
processes. Excessive angulations and lengthened structures pro- the mucoperiosteum of the hard palate and is intended to
vide a less-than-optimal esthetic effect. Revision of these deformi- lengthen the palate in the anteroposterior plane at the time of
ties is usually very difficult and sometimes impossible. In general, palatoplasty. Bone is left exposed in the area where the flaps were
if hypoplastic tissue is excised and incisions within the medial advanced. These areas granulate and epithelialize within 2 to
nasal base and columella are avoided, long-term esthetic results 3 weeks but form excessive scar tissue that may contribute to
are excellent. maxillary growth disturbances. The vomer flap is used to achieve
closure of the hard palate. A wide, superiorly based flap of nasal
Surgical Techniques for Cleft Palate Repair mucosa is elevated from the vomer and attached to the palatal
shelf to close the defect. The vomer flap eliminates the need to
Successful cleft palate repair during infancy depends on two objec- elevate large mucoperiosteal flaps from the hard palate, thus
tives. The first involves watertight closure of the oronasal commu- avoiding possible maxillary growth disturbances.
nication involving the hard and soft palate except for the area of the For very wide clefts, a pharyngeal flap may be used. This
alveolus. The second involves anatomic repair of the musculature technique allows the central portion of the cleft to be filled with
within the soft palate, which is critical for the creation of normal posterior pharyngeal wall tissue, making the closure of the nasal
speech. The soft palate functions in coupling and decoupling of the and palatal mucosa easier. Patients with Pierre Robin sequence

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 92 Cleft Lip and Palate 483

A B

C
• Fig. 92.2 A, Complete cleft palate. B, Immediate postoperative photograph showing cleft palate closure
using the Bardach technique. C, Postoperative photograph demonstrating nasal symmetry of patient in
Fig. 92.1 at 1 year of age.

Complications
The complications associated with CLP repair are essentially re-
lated to the technique used for treatment. The overall goals in-
clude nasal lining closure, adequate exposure, and release of soft
tissue attachment along the bony borders of the cleft from the
alveolar crest to the pyriform rim and closure of the oral mucosa
with well-vascularized tissue that contains attached mucosa at the
alveolar crest. Failure to address these concerns during treatment
ultimately leads to complications that include wound infection
with fistula formation, mucosal dehiscence, hypertrophic scar
formation, and hemorrhage.
It is also important to note that many patients with CLP have
coexisting systemic abnormalities that may negatively affect the
outcome of the treatment provided. Patients who present with
systemic abnormalities in general are expected to have a higher
incidence of complications compared with healthy patients. With
• Fig. 92.3 Postoperative photograph of patient in Fig. 92.1 after lip and surgical correction of CLP, Lees and Pigott observed a high inci-
palate repair at 1 year of age. dence of intraoperative and postoperative complications related to
the respiratory system.
The most significant complication or unfavorable result of pal-
(malformation) or Treacher Collins syndrome have exceptionally ate closure is the development of velopharyngeal insufficiency.
wide clefts that are difficult to close without tension. The pharyn- This is manifested as a resonance problem, with creation of hyper-
geal flap seems to address the concerns for cleft palate repair with nasal or hyponasal speech. VPI can arise following maxillary or-
these patients. Pharyngeal flaps, however, pose an increased risk of thognathic (advancement) surgery or the use of pharyngeal flaps
bleeding, snoring, obstructive sleep apnea, and hyponasality, and such as the superiorly based posterior pharyngeal flap. Abnormal
cautious airway evaluation and management in such instances is resonance can occur from the modification of oronasal portals
encouraged. that are either too large or too narrow. Correction of this problem
Fig. 92.3 shows the 1-year postoperative view of the patient involves reconstructive surgery with revision or creation of a new
seen in Fig. 92.1. pharyngeal flap, accompanied by aggressive speech therapy.

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484 S E C TI O N XIV Syndromes of the Head and Neck

A common complication of lip repair is the “whistle” defor- 3 months. Feeding sessions may be prolonged because of an
mity, which occurs because of vertical retraction of the scar or inability to create an appropriate suction seal for feeding. In
from inadequate advancement and rotation of the skin flaps. general, feeding sessions should be less than 30 minutes if pos-
Various lip-lengthening procedures can be performed secondarily, sible. Some infants also have increased metabolic needs be-
such as the V-Y advancement, which corrects the deformity and cause of congenital heart disease or airway obstruction. Height
creates a normal lip seal. and weight progressions are monitored closely.
In cases of complete bilateral CLP, collapse of the alveolar seg- • Speech and language development. Even after the palate has
ments posterior to the premaxilla is a common occurrence when been repaired, children are still at risk for subsequent speech
orthodontic or palatal retention devices are not used. Correction disorders. It is reported that 25% of children with CLP develop
of segment collapse is very complex, involving multiple surgeries normal speech after primary surgery, but the remaining 75%
over an extended period. require various surgical interventions throughout childhood
and adolescence depending on the cause of abnormal speech.
Discussion Speech problems arise from VPI, dental and occlusal problems,
oronasal fistulas, and hearing problems. Approximately 15% to
Cleft lip and cleft palate malformations are the most common 20% of patients who have cleft palate repair within the first 12
congenital abnormalities in the facial region. Worldwide, the in- to 15 months of life have VPI. As mentioned earlier, surgical
cidence of cleft lip is approximately 1 in 700 live births. The inci- intervention must be coordinated with input from both surgi-
dence of cleft palate is approximately 1 in 2000 live births. Pa- cal and nonsurgical providers. The monitoring of speech con-
tients with CLP routinely have impaired facial growth, dental tinues into adolescence and adulthood in conjunction with
anomalies, speech disorders, conductive hearing deficits, psycho- active orthodontic and surgical management.
logical difficulties, and unique social constraints. Specialized • Hearing. Patients with cleft palate are at increased risk of
multidisciplinary teams are essential for comprehensive care of middle ear effusions and subsequent infections. The attach-
these patients. The involvement of the team often starts during ment of the levator veli palatini muscle around the eustachian
the prenatal period and continues through completion of growth tube is abnormal and leads to poor aeration and drainage of
and adolescence. The multidisciplinary team is composed of a the middle ear. Regular assessment by an otolaryngologist and
craniofacial surgeon, pediatrician, otolaryngologist, pediatric den- audiologist is recommended to ensure that permanent hearing
tist, orthodontist, audiologist, speech and language pathologist, damage does not occur and that hearing deficits are not con-
geneticist, psychologist, and social worker. tributing to speech difficulties.
Palatal defects may go undetected during infancy, only to be • General dental welfare. Children with CLP are at great risk
identified later during childhood when the resultant anomaly be- for developing malocclusion. When the cleft involves the al-
comes very apparent with the emergence of speech, feeding, and veolar process, odontogenic structures within this region are
growth complications. It is therefore very important to accurately routinely absent or malformed. Phase 1 orthodontics are often
assess the palatal anatomy of any infant before such deficiencies initiated after the primary maxillary first molars have erupted.
create significant problems. During the initial inspection and ex- Phase 2 orthodontics to facilitate potential orthognathic sur-
amination of the palatal anatomy of infants, the presence of a gery are undertaken closer to the time of skeletal maturity.
submucous cleft is quite frequently missed. On visual inspection, • Genetics. There are three types of genetic risk groups for CLP:
the palate appears intact; however, the overlying oral and nasal the syndromic group, identified by physical examination; the
mucous membranes are expanded against the cleft area, giving the familial group, identified by history; and isolated defects, iden-
illusion of an intact palate. Digital palpation identifies a notch or tified by exclusion of the first two groups. As mentioned ear-
discontinuity along the posterior aspect of the bony hard palate. lier, the incidence of cleft lip is approximately 1 in 700 live
The submucous cleft still has a deficiency in the musculature of the births, and the incidence of cleft palate is approximately 1 in
palate caused by failed midline fusion of the palatal muscles, 2000 live births. With one parent and one child affected, the
namely, the levator veli palatini, tensor veli palatini, uvula, palato- chance of a second child having a cleft can approach 10%.
glossus, and palatopharyngeus muscles. A bluish midline streak is When both parents are without clefts and two children have
often present over the soft palate, which indicates the splitting of clefts, the chance of a third child having a cleft is 19%. When
the muscle layers. This clinical entity is important to differentiate one parent has a cleft and two offspring are normal, the chance
from the others because the vast majority of patients with submu- of the third child being born with a cleft is closer to 2.5%.
cous cleft palate will not require surgery, and interventions should • Environment. Epidemiologic studies have demonstrated a
be delayed until definitive evaluation of function both objectively relationship between maternal exposure to environmental fac-
and subjectively can be carried out by all team members. tors or teratogens during pregnancy and the development of
Particularly in infancy and during initial discussions with fam- CLP. These factors or teratogens include alcohol consumption,
ily members, but at any point in the clinical course of treating a cigarette smoking, folic acid deficiency, corticosteroids, benzo-
patient with CLP, the following are key areas to evaluate and op- diazepines, and anticonvulsants.
timize:
• Feeding. Approximately 25% of infants with CLP have early ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
feeding difficulties, with poor weight gain for the first 2 to complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 484.e1

Bibliography Marsh JL: Craniofacial surgery: the experiment on the experiment of

nature, Cleft Palate Craniofac J 33:1, 1996.
McComb H: Primary correction of unilateral cleft lip nasal deformity: a
Bryne PJ, Sands NR: Secondary bone grafting of residual alveolar and ten year review, Plast Reconstr Surg 75:791-799, 1985.
palatal clefts, J Oral Surg 30:87-92, 1972. Murray JC: Gene/environment causes of cleft lip and/or palate, Clin
Carici F: Recent developments in orofacial cleft genetics, J Craniofac Surg Genet 61(4):248-256, 2002.
142(2):130-143, 2003. Padwa BL, Sonis A, Bagheri SC, et al: Children with repaired bilateral
Chung K, Kowalski C, Kim HM, et al: Maternal cigarette smoking dur- cleft lip/palate: effect of age at premaxillary osteotomy on facial
ing pregnancy and the risk of having a child with cleft lip/palate, Plast growth, Plast Reconstr Surg 105:1261, 1999.
Reconstr Surg 105(2):485-491, 2000. Posnick JC: Cleft orthognathic surgery: the unilateral cleft lip and palate
Copeland M: The effect of very early palatal repair on speech, Br J Surg deformity. In Posnick JC (ed): Craniofacial and Maxillofacial Surgery in
43:676, 1990. Children and Young Adults, Philadelphia, 2000, Saunders, pp 860-907.
Costello BJ, Ruiz RL, Turvey T: Surgical management of velopharyngeal Posnick JC: The staging of cleft lip and palate reconstruction: infancy
insufficiency in the cleft patient, Oral Maxillofac Surg Clin North Am adolescence. In Posnick JC (ed): Craniofacial and Maxillofacial Sur-
14:539-551, 2002. gery in Children and Young Adults, Philadelphia, 2000, Saunders,
Costello BJ, Shand J, Ruiz RL: Craniofacial and orthognathic surgery in the pp 785-826.
growing patient, Select Readings Oral Maxillofac Surg 11(5):1-20, 2003. Ruiz RL, Costello BJ, Turvey T: Surgical correction of midface deficiency
Dorf DS, Curtin JW: Early cleft repair and speech outcome: a ten year in cleft lip and palate malformation, Oral Maxillofac Surg Clin North
experience. In Bardach J, Morris HL (eds): Multidisciplinary Manage- Am 14(4):491-507, 2002.
ment of Cleft Lip and Palate, Philadelphia, 1990, Saunders, pp 341-348. Spritz RA: The genetics and epigenetics of orofacial clefts, Curr Opin
Fisher D: Unilateral cleft lip repair: an anatomical subunit approximation Pediatr 13(6):556-600, 2001.
technique, Plast Reconstr Surg 116:61-71, 2005. Takato T, Yonohara Y, Mori Y: Early correction of the nose in unilateral
Bessell A, Hooper L, Shaw WC, Reilly S, Reid J, Glenny AM: Feeding cleft lip patients using an open method: a ten year review, J Oral
interventions for growth and development in infants with cleft lip, Maxillofac Surg 53A:28-33, 1995.
cleft palate or cleft lip and palate, Cochrane Database Syst Rev Tse R, Siebold B: Cleft palate repair: description of an approach, its
2011(2):CD003315, 2011. evolution, and analysis of postoperative fistulas, Plast Reconstr Surg
Habel A, Sell D, Mars M: Management of cleft lip and palate, Arch Dis 141:1201-1214, 2018.
Child 74(4):360-366, 1996.
Lees VC, Pigott RW: Early postoperative complications in primary cleft
lip and palate surgery: how soon may we discharge patients from
hospital? Br J Plast Surg 45:232-234, 1992.

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93
Nonsyndromic Craniosynostosis
MA R SH A L L F. N E W M A N a n d S H A H R O K H C . B AG H E R I

CC Examination
A 7-month-old male infant is referred by his pediatrician for General. The patient is a well-developed and well-nourished
evaluation of a cranial dysmorphology. pleasant child in no apparent distress.
Maxillofacial. Examination of the skull reveals a mild dysmor-
HPI phology (the exact dysmorphology varies greatly and depends on
which portion or portions of the sagittal suture are involved) in
The mother of this 7-month-old, otherwise healthy male (cranio- which the cranial vault is narrow in the bitemporal and biparietal
synostosis has a male predilection) has been concerned about the dimensions and abnormally elongated in the anteroposterior (AP)
abnormal shape of his head, which was noticed immediately after dimension. (This is called scaphocephaly, meaning “long and nar-
birth. (Craniosynostosis is the premature fusion of the cranial row.”) Frontal and occipital bossing is apparent (described as a
sutures during intrauterine life. The deformity is often noticeable “keel-like” appearance).
early [Fig. 93.1].) The pediatrician has been closely observing There are no midfacial or mandibular hypoplasia or asymmetry
this skull deformity for changes and resolution. It was initially and no orbital dystopia (a relative discrepancy in globe position in
assumed to be deformational plagiocephaly (a skull deformity the vertical and/or horizontal planes) or exophthalmos (anterior
caused by vaginal delivery or early fetal descent into the pelvis) position of the globe relative to the orbital rims).
and later was thought to be secondary to a positional plagio- The fundoscopic examination is normal, with no evidence of
cephaly, an acquired skull deformity caused by a repetitive head papilledema (edema of the optic disc, which is indicative of ele-
position during sleep. (Nonsynostotic posterior plagiocephaly vated intracranial pressure [ICP]).
has increased since the American Academy of Pediatrics issued a Intraoral. The results of the examination are within normal
recommendation that infants be placed on their backs during limits (nonsyndromic craniosynostosis is not associated with an
sleep to reduce the risk of sudden infant death syndrome.) De- increased incidence of cleft lip and cleft palate).
spite conservative management, the child continued to exhibit Extremities. There are no deformities. (Nonsyndromic craniosyn-
the cranial deformity, which appeared to slightly worsen over ostosis does not have any associated abnormalities of the extremities.)
time. He is otherwise in good health, and the mother denies any
behavioral abnormalities. He is referred for craniofacial evalua- Imaging
tion. (The rate of detectable cranial abnormalities secondary to
craniosynostosis has been reported to be as high as 1 in 1700 to Plain film complete skull series comprise a potential initial diagnos-
1 in 1900 births.) tic radiographic workup. (The clinical diagnosis of craniosynostosis
must be confirmed radiographically.) In the current patient, the
PMHX/PDHX/Medications/Allergies/SH/FH radiographs showed the absence of the entire sagittal suture. (Sagit-
tal suture synostosis can involve the entire suture, the anterior por-
Noncontributory. The patient is up to date with all childhood tion only, or the posterior portion only. If the sutures appear patent
immunizations, and there is no previous surgical history. The pa- on a radiographic study of diagnostic quality, craniosynostosis can
tient had an otherwise uneventful vaginal delivery. be ruled out.)
There is no significant family history. (Mendelian inheritance Craniofacial axial and coronal (or reformatted) cut computed
patterns are rare for nonsyndromic craniosynostosis and are usu- tomography (CT) scans and three-dimensional reconstructions
ally associated with other abnormalities except for metopic suture provide more detailed morphologic information, which is very
craniosynostosis, which has a 5% positive family history.) useful during surgical planning. (CT scans are also indicated when
With the exception of metopic craniosynostosis (which has a plain films are nondiagnostic.) In the current patient, CT scans
43% incidence of associated malformations with no clear syn- showed a scaphocephalic skull deformity, which is consistent with
dromic diagnosis), patients with nonsyndromic craniosynostosis synostosis of the sagittal suture. CT scans of the head showed no
are typically healthy and do not show other malformations com- masses (the possibility of an intracranial mass should be included
monly present in syndromic craniosynostosis. in the differential diagnosis of cranial vault abnormalities) and no

485
t.me/Dr_Mouayyad_AlbtousH
486 S E C TI O N XIV Syndromes of the Head and Neck

of the fused cranial suture to allow unrestricted growth of the

brain and subsequent correction of the cranial dysmorphology
with natural brain growth and (2) a reconstructive type of proce-
dure that addresses the skeletal dysmorphology directly to restore
an appropriate anatomic form. The surgical team should be com-
posed of a pediatric craniofacial surgeon and a pediatric neurosur-
geon for optimal results.
To use the first type of surgical management, strip craniectomy
of the prematurely fused suture, it is important to use postopera-
tive orthotic (helmet) therapy to shape the skull. Such techniques
rely on the intrinsic growth potential of the brain, and experience
has demonstrated that the best results for correction of the skeletal
dysmorphology must incorporate helmet therapy postoperatively.
Removal of the affected suture can be done endoscopically or un-
der direct visualization with minimal incisions required for access.
This typically allows for less blood loss and is completed between
A 2 to 6 months of age to take advantage of growth potential. Vari-
ous modifications, including barrel staving of the surrounding
cranial bone, may assist with cranial molding and expansion post-
operatively. It should be noted that postoperative helmet therapy
is needed generally 23 hours a day and typically requires 9 to 12
months of use, which can be cumbersome for families.
A similar approach that allows for removal of the fused suture
but assists in selective expansion of the skull and molding postop-
eratively is the use of springs placed at the craniectomy site. Such
springs mold the cranial bones in an “active” manner rather than
a “passive” manner as is the case with helmet therapy. The use of
spring-assisted cranial vault expansion allows for a less invasive
approach to cranial reconstruction and allows for expansion in
patients who are slightly older than the typical age range for en-
doscopic techniques and postoperative helmet therapy. Patients
may be treated at the ages of 3 to 8 months more reliably than
with endoscopic techniques. However, the use of springs can be
technique sensitive and requires a second general anesthetic for
removal of the springs. Displacement of the springs during treat-
ment can be a significant problem.
Modern reconstructive-type procedures to address nonsyn-
B dromic craniosynostosis include a formal craniotomy performed
by a neurosurgeon and simultaneous skeletal reconstruction by
• Fig. 93.1 Sagittal synostosis. Top of head (A) and frontal view (B) before the craniofacial surgeon. Reconstruction and reshaping include
treatment. (From Bagheri SC, Bell RB, Khan HA: Current Therapy in Oral
and Maxillofacial Surgery, St. Louis, 2012, Saunders.)
the removal, dismantling, and reassembly of all dysmorphic skel-
etal components into an anatomically desirable shape. The extent
of the surgery depends on the suture or sutures involved and the
hydrocephalus. (This is usually not encountered in single-suture resultant skeletal deformity. The choice of surgical technique may
craniosynostosis but may occur independently; hydrocephalus is often be dictated by the timing of patient presentation as well as
seen in approximately 10% of cases in which multiple sutures are family desires. If a patient presents initially at the age of 7 months
involved.) of age, for example, with isolated sagittal suture craniosynostosis,
endoscopic techniques with postoperative helmet therapy would
Labs be less predictable for correction of the skeletal dysmorphology.
Cranial vault reconstruction therefore should be a consideration
In an otherwise healthy, 7-month-old patient, the preoperative for such patients. When reconstructive-type procedures are per-
laboratory evaluation should include hemoglobin and hematocrit formed, the patient should be older during the first year of life to
levels as well as coagulation studies. allow for more predictable long-term results. Growth potential
and healing capacity are at their best during the first year of life,
Assessment but it should be noted that there is essentially no significant in-
creased risk of increased ICP that has been demonstrated in pa-
Nonsyndromic craniosynostosis involving the entire sagittal suture. tients with isolated nonsyndromic craniosynostosis before 1 year
of life, so waiting until that time may be helpful for some patients.
Treatment All patients with craniosynostosis should undergo evaluation with
neuro-ophthalmology for any signs of potential increased ICP
There are two primary types of surgical management for nonsyn- that may be related in part to the premature closure of cranial
dromic isolated craniosynostosis: (1) a resective type of treatment sutures. Older patients generally tolerate anesthesia better and

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 CHAPTER 93 Nonsyndromic Craniosynostosis 487

have a larger blood volume, which is important because the need

for blood transfusion during cranial vault reconstruction is com-
mon. Slightly older patients also allow for more stable cranial
bone fixation, which is usually completed with the use of resorb-
able plates and screws or sutures.
There are various methods for cranial vault reconstruction. To
treat nonsyndromic sagittal suture craniosynostosis in the exam-
ple presented, a common management strategy involves treating
the posterior two-thirds of the cranial vault to provide expansion
and allow appropriate brain growth and potentially improve cere-
brospinal fluid (CSF) and venous dynamics. It is important to
note that the dysmorphology of sagittal suture craniosynostosis is
primarily biparietal narrowing, AP elongation, loss of posterior
cranial vertical height, and compensatory bifrontal bossing. For
many patients, a reconstructive plan that focuses primarily on the
posterior cranial vault for biparietal expansion, improvement of
posterior vertical cranial height, and to a lesser degree decreases
the AP elongation is sufficient for addressing the cranial dysmor-
phology. Frontal bone compensatory bossing often improves
significantly throughout cranial growth, which continues until
approximately 6 years of age when it is more than 90% complete.
Thus, treating the posterior two-thirds of the cranial vault may
optimize the risks and benefits of other techniques such as total • Fig. 93.3 The occipital bone, bilateral parietal bones, and bandeau are
shown prior to reconstruction.
calvarial reconstruction, which may involve more significant
blood loss, longer surgery, and potentially increased morbidity for
the patient. Some centers elect to treat both the anterior and pos-
terior cranial vaults in two separate surgeries separated by a short
period of time. Such general risks are inherent to any cranial vault
reconstruction, and one method is not suitable for all patients
who present with craniosynostosis. A potential method for such
cranial vault reconstruction is presented in Figs. 93.2 to 93.4.
Biparietal and occipital craniotomies have been performed by
pediatric neurosurgeons and reconstruction by pediatric cranio-
facial surgeons. Bony segments are commonly secured with re-
sorbable plates and screws or sutures. With expansion of the
cranial vault, gaps between the bony segments will exist without
split-thickness grafting of the cranial bone. This is difficult in
very young patients but can be done. However, when the cranial

• Fig. 93.4 The posterior cranial vault is reconstructed for expansion,

adding both width and height while shortening the anteroposterior
dimension of the cranium. Gaps between the bony segments will exist
without split-thickness grafting of the cranial bone.

vault reconstruction is completed before 2 years of age, almost all

bony gaps, including full-thickness defects, will completely fill in
with bone given the osteogenic potential of the periosteum and
dura mater, and grafting is generally not necessary. Complete
bony healing is less predictable in patients aged 2 to 4 years and
likely to require grafting or augmentation if completed after
4 years of age.

Complications
Despite the very low complication rates associated with craniofa-
cial surgery, both intraoperative and postoperative complications
• Fig. 93.2 Sagittal suture craniosynostosis with elongation of the skull is can occur. Massive blood loss and postoperative infection are
demonstrated with the patient in a prone position. Subgaleal and subperi- the most common and most feared complications (Box 93.1).
osteal flaps have been elevated and planned craniotomies marked. There is a high likelihood that blood transfusion will be required

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488 S E C TI O N XIV Syndromes of the Head and Neck

• BOX 93.1 Intraoperative and Postoperative Complications in Craniofacial Surgery

Intraoperative Complications 100% of patients undergoing cranial vault reconstruction. However, this is
Venous air embolism. Neonatal and pediatric calvaria have a large number of not universally accepted by all craniofacial surgeons. Major blood loss re-
diploic and emissary channels that become exposed during a craniotomy sulting in hypovolemic shock has a reported incidence of 0.3% to 4.6%. Ap-
procedure. Because the operative field is typically above the level of the propriate fluid resuscitation with crystalloid, colloid, and blood and replace-
heart, air could enter these exposed vascular channels and travel to the right ment of coagulation factors (fresh frozen plasma) should be anticipated.
atrium. A symptomatic air embolus could lead to profound hypoten- sion and Death. Reported mortality rates for craniofacial surgery range from 0% to 4.3%.
cardiovascular collapse. If venous air embolism is suspected, sur- gery Massive intraoperative bleeding, postoperative bleeding, intracranial bleed-
should be stopped, the head of the bed lowered, and the surgical field ing, cerebral edema, infection, inadequate volume replacement, respiratory
irrigated and covered with a wet sponge; bone wax can be applied to the obstruction, and anesthetic complications are the most common causes.
osteotomized bony edges. Nitrous oxide should be discontinued. Closed Postoperative Complication
cardiac massage may be indicated in a severely compromised patient to Infection. Infection can develop in the form of osteitis or osteomyelitis, men-
force the air into the pulmonary circulation. A thoracotomy and direct mas- ingitis, or intracranial abscess. It is the most common postoperative com-
sage with aspiration of intracardiac air are the last resort in failed attempts. plication (infection rates range from 1% to 14%). Separation of the nasal
Oculocardiac reflex. Transcranial and fronto-orbital surgery can trigger the oc- and paranasal sinuses from the intracranial cavity is paramount in reduc-
ulocardiac reflex in response to orbital manipulation and pressure, leading ing the incidence of infection. The use of appropriate perioperative antibi-
to bradycardia and hypotension. Care must be taken to prevent excessive otics, intraoperative antibiotic irrigation (or saline with dilute iodine), and
orbital pressure and flap retraction. The anesthesia team should be notified reduction of surgical time also reduce infection rates. Monobloc advance-
during such maneuvers. Severe bradycardia and hypotension require the ment procedures have a higher rate of infection compared with other
administration of atropine. intracranial procedures.
Dural lacerations. David and Cooter reported a 31% incidence of iatrogenic Extradural and subdural hematomas. These are relatively rare occurrences.
dural tears in a series of 53 patients. Others have reported an incidence of Poole reported less than a 1% incidence of hematoma. Suction drainage is
5% to 60%. Direct repair usually has no detrimental sequelae. not advocated because of concern that it can cause bleeding, cerebrospinal
Major blood loss. The continual oozing of blood from the vascular osteotomy fluid leakage, or infection or draw nasal or sinus contamination intracrani-
sites over several hours of surgical time can amount to loss of a large por- ally. Close neurologic observation is needed to look for signs of an evolving
tion of the patient’s blood volume. The incidence of perioperative blood intracranial hemorrhage.
transfusions is variable and has been reported to be as high as 80% to

during cranial vault reshaping. This is in part because of the Discussion

low effective blood volume in infants and children. Acute nor-
movolemic hemodilution is a technique commonly performed Virchow coined the term craniostenosis in 1851. The word cranio-
intraoperatively to reduce the need for transfusion. Additional synostosis describes the process of premature fusion of cranial sutures
techniques include intraoperative blood salvage. Maintaining a (six major suture areas and seven minor sutures), which results in
“safe” hematocrit level, between 28% and 35%, is recommended. craniostenosis (outdated terminology). The craniofacial deformity
However, the incidence of transfusion has been estimated to be is directly proportional to the area of sutures fused. Many classifica-
as high as 90%. tion systems have been developed to describe various subtypes
Other complications include ocular complications (diplopia, of craniosynostosis. Three broad categories of craniosynostosis
temporary ptosis, strabismus, corneal abrasion and, rarely, visual have been identified: simple (single suture) or compound (two or
loss), seizures (rare), CSF leakage, elevated ICP, electrolyte distur- more sutures), primary or secondary (related to another disorder),
bances (syndrome of inappropriate antidiuretic hormone secretion and isolated (nonsyndromic) versus syndromic (Crouzon, Apert,
or cerebral salt-wasting syndrome, resulting in hyponatremia), Carpenter, Pfeiffer, Saethre-Chotzen, and other syndromes). In
airway embarrassment, fixation failure, translocation or migration, approximately 85% of patients, craniosynostosis is nonsyndromic
damage to the lacrimal drainage apparatus, and residual deformity, in origin.
requiring secondary procedures. There are several different types of craniosynostosis. Sagittal su-
Particularly in patients who undergo posterior cranial vault ture craniosynostosis is the most common form of nonsyndromic
procedures and who are placed in a prone position, maintaining single-suture synostosis, with a prevalence of approximately 1 in
no pressure on the eyes during the procedure is paramount. Other 5000 live births and a three-to-one male predilection. It is charac-
positions have been used such as the sphinx position with the terized by a scaphocephalic deformity (long and narrow cranial
head extended. This can potentially lead to compression of the vault) because of premature fusion of the entire sagittal suture or
spinal cord and negatively affect venous outflow drainage during part of it. Absence or premature fusion of the sagittal suture results
the procedure. An additional late potential complication can arise in no growth perpendicular to the suture and arrested development
from the use of resorbable materials for fixation of the cranial of the two parietal bone plates, causing bitemporal and biparietal
bone. Resorbable plates and screws can take many months to re- narrowing. There is compensatory growth at the major sutures that
sorb depending on the specific manufacturing materials used and remain patent (i.e., coronal, lambdoid, and metopic sutures) as the
their proportions. The body can develop a granulomatous-type brain continues to expand, causing an abnormal, AP elongation of
reaction to the materials as they resorb. This manifests generally the cranial vault. This results in frontal and occipital bossing, often
late in the 9- to 12-month range after surgery and may appear to described as “keel-like.” Portions of the sagittal suture (anterior or
be an abscess but is not a true infection, hence the clinical entity posterior portions) or the entire suture can be fused and determine
being referred to as a “sterile abscess.” Local wound care measures the extent of the cranial deformity. The least common form of cra-
are usually sufficient treatment. niosynostosis is lambdoid suture synostosis.

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 93 Nonsyndromic Craniosynostosis 489

Several theories have been proposed for the cause of craniosyn- suture is the most common type. Table 93.1 lists the major types
ostosis. Virchow believed that the primary event was craniosynos- of nonsyndromic craniosynostosis, along with their characteristic
tosis and that the associated cranial base deformity was secondary features and incidence.
to that event. Moss theorized that the cranial base deformity was Coronal suture craniosynostosis is the second most common
the primary malformation, resulting in premature fusion of the type of nonsyndromic synostosis. Mutation of the FGFR3 gene
cranial sutures. Others theorized that mesenchymal defects re- has been implicated in its pathogenesis. Because of early fusion
sulted in both craniosynostosis and an abnormal cranial base. of the coronal suture (either right or left), there is hypoplasia of
Growth of the midfacial skeleton also is restricted if sutures along the frontal and parietal bones on the affected side, resulting in
the anterior cranial base are prematurely fused. A positive family flattening of the forehead (anterior plagiocephaly). Compensa-
history is a risk factor. This identifies the genetic relationship in tory overgrowth of the unaffected sutures, including the contra-
craniosynostosis. lateral coronal suture, results in frontal bossing of the unaffected
Maternal and environmental factors resulting in nonsyn- side. Also, orbital dystopia (superior, posterior position of the
dromic craniosynostosis include advanced maternal age, maternal affected orbit), ipsilateral zygomatic hypoplasia, and nasal asym-
cigarette smoking, alcohol use, and use of clomiphene for infertil- metry commonly occur. Midfacial hypoplasia and orbital dysto-
ity. However, these risk factors have been inconclusive because of pia are seen because of the involvement of the anterior cranial
the lack of large-scale studies. base along the frontoethmoidal, frontosphenoidal, and spheno-
Regardless of the pathogenesis, the prematurely fused suture or ethmoidal sutures. This results in a “harlequin eye” deformity on
sutures inhibit growth of the neurocranium perpendicular to the an AP skull film. Surgical correction similarly may involve en-
fused suture or sutures. There is compensatory overgrowth at the doscopic strip craniectomy of the affected suture with postop-
normal (open) sutures to accommodate the growing brain. (Brain erative helmet therapy or involves a bifrontal craniotomy, orbital
volume triples during the first year of life.) Thus, a unilateral syn- osteotomies, fronto-orbital advancement, and anterior cranial
ostosis results in a bilateral deformity. This phenomenon is known vault reshaping depending on many factors such as patient age
as Virchow’s law. Despite this compensatory growth, an increase in and growth potential as mentioned earlier. When treating pa-
ICP (.15 mm Hg) may still be seen. tients with craniosynostosis, such factors as well as the surgical
Neurologic impairment is rare with single-suture craniosynos- technique are often tailored to the patient at the time of their
tosis (the single-suture type is most common, and the sagittal presentation and given their specific cranial dysmorphology.
suture is most often affected), especially when the condition is Follow-up is essential because patients even with isolated single
treated before the age of 1 year. (Elevated ICP is seen in 14% of suture craniosynostosis can potentially develop increased ICP
children with untreated single-suture craniosynostosis and in and craniocerebral disproportion requiring secondary interven-
42% of those in whom two or more sutures are involved.) How- tion. One of the best ways to monitor a patient is for a neuro-
ever, if elevated ICP is left untreated, it may lead to irreversible ophthalmologist to evaluate for any signs of papilledema on
neurologic and cognitive damage. fundoscopic examination. This underscores the importance of
The major cranial sutures are the sagittal, metopic, coronal treating patients with craniofacial anomalies in a multidisci-
(right and left), and lambdoid (right and left) sutures. The minor plinary team setting.
sutures are the temporosquamosal, frontonasal, and frontosphe-
noidal sutures. In most patients with nonsyndromic craniosynos- ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
tosis, only one suture is involved. Involvement of the sagittal complete set of bibliography.

TABLE
93.1 Types of Nonsyndromic Craniosynostosis

Elevated Intracranial Central Nervous System

Sutures Affected Head Shape Name Incidence Pressure (Mental Retardation)
Sagittal Long and narrow Scaphocephaly 1 in 5000 Absent Slight
Coronal One hemicranium smaller Anterior plagiocephaly 1 in 10,000 Infrequent Slight to moderate
than the other
Metopic Triangular forehead Trigonocephaly 1 in 15,000 Usually absent Slight to moderate
Lambdoidal One hemicranium smaller Posterior 1 in 150,000 Infrequent Slight to moderate
than the other plagiocephaly
Bilateral coronal Short, broad, and tall Brachycephaly Rare Infrequent Slight to moderate
(acrobrachycephaly)
Sagittal and coronal Short and narrow Oxycephaly Rare Usually present High

Modified from Dufresne CR: Classifications of craniofacial anomalies. In Dufresne CR, Carson BS, Zinreich SJ (eds): Complex Craniofacial Problems, pp 63-71, New York, 1992, Churchill Livingstone.

t.me/Dr_Mouayyad_AlbtousH
 489.e1

Bibliography Gerety P, Basta M, Fischer J, et al: Operative management of nonsyn-

dromic sagittal synostosis: a head-to-head meta-analysis of outcomes
comparing 3 techniques, J Craniofac Surg 29:632-635, 2018.
AAP Task Force on Infant Positioning and SIDS: positioning and SIDS, Golabi M, Edwards MSB, Ousterhout DK: Craniosynostosis and hydro-
Pediatrics 89(6):1120-1126, 1992. cephalus, Neurosurgery 21:63, 1987.
Ardalan M, Rafati A, Nejat F, et al: Risk factors associated with cranio- Greensmith AL, Meara JG, Holmes AD, et al: Complications related to
synostosis: a case control study, Pediatr Neurosurg 48(3):152-156, cranial vault surgery, Oral Maxillofac Surg Clin North Am 16:465-473,
2012. 2004.
Carson BS, Dufresne CR: Craniosynostosis and neurocranial asymmetry. Jones BM, Jani P, Bingham RM, et al: Complications in paediatric cra-
In Dufresne CR, Carson BS, Zinreich SJ (eds): Complex Craniofacial niofacial surgery: an initial four year experience, Br J Plast Surg
Problems, New York, 1992, Churchill Livingstone, pp 167-194. 45:225-231, 1992.
David DJ, Cooter RD: Craniofacial infection in 10 years of transcranial Meyer P, Renier D, Arnaud E, et al: Blood loss during repair of cranio-
surgery, Plast Reconstr Surg 80:213-223, 1987. synostosis, Br J Anaesth 71:854-857, 1993.
Dufresne CR: Classifications of craniofacial anomalies. In Dufresne CR, Moss ML: The pathogenesis of premature craniosynostosis in man, Acta
Carson BS, Zinreich SJ (eds): Complex Craniofacial Problems, New Anat (Basel) 37:351-370, 1959.
York, 1992, Churchill Livingstone, pp 63-71. Phillips RJL, Mulliken JB: Venous air embolism during a craniofacial
Eaton AC, Marsh JL, Pilgram TK: Transfusion requirements for cranio- procedure, Plast Reconstr Surg 82:155-159, 1988.
synostosis surgery in infants, Plast Reconstr Surg 95:277-283, 1995. Pietrini D: Intraoperative management of blood loss during craniosynos-
Faberowski LW, Black S, Mickle JP: Incidence of venous air embolism tosis surgery, Pediatr Anesth 23:278-284, 2013.
during craniectomy for craniosynostosis repair, Anesthesiology 92:20- Poole MD: Complications of craniofacial surgery, Br J Plast Surg 41:608-
23, 2000. 613, 1988.
Fearon J, McLaughlin E, Kolar J: Sagittal craniosynostosis: surgical out- Renier D, Sainte-Rose C, Marchac D, et al: Intracranial pressure in cra-
comes and long-term growth, Plast Reconstr Surg 117:532-541, 2006. niosynostosis, J Neurosurg 57:370, 1982.
Fishman MA, Hogan GR, Dodge PR: The concurrence of hydrocephalus Ruiz RL, Ritter AM, Turvey TA, et al: Nonsyndromic craniosynostosis:
and craniosynostosis, J Neurosurg 36:621-629, 1971. diagnosis and contemporary surgical management, Oral Maxillofac
Fitzpatrick DR: Filling in the gaps in cranial suture biology, Nat Genet Surg Clin North Am 16:447-463, 2004.
45:231-232, 2013. Virchow R: Über den kretinismus, namentlich in Franken und über pa-
Gault DT, Renier D, Marchac D, et al: Intracranial pressure and intra- thologische Schädelformen, Verhandlung der physikalischen-medizinischen
cranial volume in children with craniosynostosis, Plast Reconstr Surg Gesellschaft Würzburg 2:231-284, 1851.
90:230-271, 1992.

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94
Syndromic Craniofacial Synostosis
MA R SH A L L F. N E W M A N a n d S H A H R O K H C . B AG H E R I

CC pyloroplasty. The family history reveals that his two brothers and
one sister are healthy. (Most cases of Apert syndrome are sporadic
A 14-year-old male previously diagnosed with Apert syndrome in nature, although autosomal dominance inheritance has been
presents to the multidisciplinary cleft and craniofacial team for reported.) Cognitive assessments at school have revealed that the
evaluation of his anterior open bite (apertognathia) with a chief patient is slightly developmentally delayed for his age. (About
complaint of “difficulty chewing.” 65% of patients have an intelligence quotient of less than 70, and
attention-deficit hyperactivity disorder is also common.)
HPI
Examination
The patient was diagnosed with Apert syndrome shortly after
birth. Craniosynostosis is one of the many clinical characteristics General. The patient is moderately cooperative. He has a poor
of Apert syndrome, and the patient underwent a fronto-orbital attention span (secondary to developmental delay) but is able to
advancement at 9 months of age. At age 2 years, he underwent follow simple commands. He has a short stature for his age and
craniofacial advancement to address the midface hypoplasia in the compared with his parents. (Megalocephaly [large head] results in
form of a monobloc frontofacial advancement. The parents report the weight and height being above the 50th percentile early, but
moving frequently and have had difficulty establishing long-term this decreases with age.)
follow-up at times. Currently, the parents are unhappy with the Maxillofacial. Examination of the skull reveals a steep frontal
child’s appearance because children at his school continually bone (Fig. 94.1A), flat occipital region, and bulging temporal re-
mock him about his appearance, particularly his open bite. The gion. (Bitemporal enlargement is characteristic of Apert syndrome
parents believe that this has affected their son’s self-confidence and and has surgical implications when considering osteotomies such
performance. The patient’s mother indicates that the child has as a fronto-orbital advancement.) He exhibits mild ocular esotro-
difficulty biting hard foods, such as steak and pizza, and must use pia (cross-eyed) and hypertelorism (diverging and widely spaced
only his posterior teeth for chewing. He is currently undergoing pupils, respectively). There is underdevelopment of the maxilla
presurgical orthodontic treatment in preparation for combined and zygomas bilaterally (midface hypoplasia; Fig. 94.1B).
surgical–orthodontic correction of the skeletal malocclusion. The Intraoral. The patient has an anterior open bite (apertognathia)
parents are also concerned about their son’s continued “sunken” with a narrow, high (V-shaped) maxillary arch (Fig. 94.1C) and a
face appearance (midface hypoplasia), which has persisted despite class III molar relationship. (Class III malocclusion with an ante-
his corrective surgery at age 2 years. The parents and patient deny rior open bite is almost universal for Apert syndrome.) Only two
any changes in vision, headaches, seizures, or loss of consciousness posterior molars are in contact on either side. There is no apparent
but do note that he wakes frequently at night and is often tired hard or soft tissue clefting of the palate (this is seen in 30% of
throughout the day. patients with Apert syndrome).
Extremities. The index, middle, and ring fingers are fused, and
PMHX/PDHX/Medications/Allergies/SH/FH there is a common nail in both hands (symmetrical syndactyly)
(Fig. 94.1D). The thumb and small fingers are not affected in either
The patient was diagnosed with a heart murmur at birth and hand and show normal strength and mobility. The feet are normal
subsequently had corrective surgery without complications. and are not affected. (The lower extremities may be involved.)
(Cardiovascular and valvular abnormalities, such as patent ductus Skin. The child has yellow, raised papules on the dorsum of
arteriosus, are seen in 10% of patients with Apert syndrome.) He the hands. (Acne vulgaris involving the hands is seen in 70% of
is physically active without significant restrictions. In addition, patients with Apert syndrome.)
the patient had a history of hydronephrosis at birth, which re-
solved without surgery. (Genitourinary abnormalities are seen in Imaging
about 10% of patients.) At age 4 weeks of age, he was diagnosed
with pyloric stenosis, thickening of the pyloric valve that results A panoramic radiograph and periapical radiographs are required to
in gastric obstruction (gastrointestinal abnormalities are seen in evaluate for supernumerary teeth, root crowding, and morphology
1.5% of patients) and successfully underwent a laparoscopic and to detect caries. When impacted teeth are present (excluding

490
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 CHAPTER 94 Syndromic Craniofacial Synostosis 491

A B

C D
• Fig. 94.1 A, Frontal view showing the general appearance of the patient. B, Profile view showing severe
midfacial hypoplasia and frontal bossing. C, Intraoral view showing apertognathia. D, Syndactyly (seen in
both hands).

third molars), periapical films from various angles can be obtained Magnetic resonance imaging is not required but can be useful in
to evaluate the buccolingual position of the tooth (Clark’s rule). A select cases for evaluation of soft tissue anatomy, such as brain pa-
cone-beam computed tomography (CBCT) scan is often beneficial renchyma, orbital tissue, or pharyngeal structures. Obstructive
for determining the spatial relationship of the maxillomandibular sleep apnea is commonly seen in patients with Apert syndrome, and
complex. It is also an efficient initial screening tool to evaluate the the mentioned imaging modalities may be used to assess the poste-
orbits and cranium, and residual full- or partial-thickness defects of rior airway anatomy.
the skull should be appreciated preoperatively. A lateral cephalo- In the current patient, a panoramic radiograph, lateral cepha-
metric radiograph, along with cephalometric analysis, is used for lometric radiograph, initial CBCT scan, and subsequent medical-
evaluation and treatment of the skeletal facial deformity. A conven- grade CT scan were obtained and used in treatment planning. No
tional helical CT scan is not required but can be used for evaluation teeth crowding, impactions, or supernumerary teeth were found;
of opacified sinuses (which are common in maxillary hypoplasia) therefore, no periapical radiographs were obtained.
and for visualization of the three-dimensional anatomy as an aid in
treatment planning. This is important for appreciation of vascular Labs
and foramina proximity to potential osteotomies and for evaluation
of additional bone formation in the midface or orbital region result- Preoperative laboratory testing includes a complete blood count
ing from prior surgeries. For more complex cases requiring orthog- and a basic metabolic panel. For the current patient, neither of
nathic surgery, CT-guided treatment planning is generally used. these demonstrated any abnormalities.

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492 S E C TI O N XIV Syndromes of the Head and Neck

Assessment surgical treatments (three) early in life is a notable number, when

fronto-orbital advancement and anterior cranial vault reconstruc-
Apert syndrome with maxillary hypoplasia and apertognathia requir- tion is performed early, patients with syndromic craniosynostosis
ing combined surgical orthognathic and orthodontic treatment. frequently require a second fronto-orbital advancement and ante-
rior cranial vault expansion procedure for protection of the globes
Treatment several years later by around the age of 3 or 4 years. Repeating this
surgery can be quite difficult, and if a posterior cranial vault re-
It is important to understand, to the best of one’s ability, what pro- constructive procedure is undertaken before this age of repeating
cedures exactly a patient with syndromic dysostosis has previously the anterior cranial surgery, then the total number of surgeries
undergone. This is true for all patients, but particularly for these would be the same. Surgical outcomes vary significantly from
patients, there is significant variability of surgical treatments and surgeon to surgeon and team to team.
more importantly variability of the timing during development that When a more definitive initial fronto-orbital advancement and
such craniofacial surgical treatments may be rendered. The initial anterior cranial vault reconstruction is performed later than ear-
evaluation of patients with Apert syndrome at birth focuses on the lier, the potential secondary correction may be incorporated
airway, central nervous system (CNS) malformations, and feeding within a monobloc or facial bipartition procedure. This treatment
assessment. A retruded maxilla and limited nasopharyngeal airway sequence cannot be assumed and must incorporate frequent re-
increases the work of breathing and may require advanced airway evaluation with neuro-ophthalmology, neurosurgery, and cranio-
interventions. This may include tracheostomy. An inability to pass facial surgery specialists. Cranial growth is mostly complete
a nasogastric tube may indicate nasopharyngeal obstruction. Most around 6 years of age, and orbital growth mostly complete around
often these infants compensate with obligate mouth breathing and 8 or 9 years of age. When performed at earlier ages, some of the
hence have an “open mouth” appearance, but the effort expended significant complications such as infection or bony or soft tissue
by an infant to breathe in this manner as well as feed may ultimately wound problems are often lessened for significant procedures
outweigh the energy and nutrition obtained by feeding. The CNS such as a monobloc frontofacial advancement and facial biparti-
symptoms may manifest as seizures, hypotonia or hypertonia, and tion. Earlier performance of these procedures often does not re-
apnea. The high-arched palate and possible clefting may also add to quire managing the frontal sinus as well. These may be followed
difficulties with feeding and obtaining appropriate nutrition. These by definitive Le Fort I level surgery and potential mandibular
patients may need a nasogastric or orogastric feeding tube or place- surgery in coordination with orthodontics later in life.
ment of a percutaneous gastrostomy tube. A patient with craniofacial dysostosis despite all of these earlier
The primary craniofacial surgical management of patients with interventions should still be expected to require definitive orthog-
Apert syndrome early in life centers on treatment of craniosynos- nathic and orthodontic treatment of their skeletal facial discrep-
tosis. Cranial dysmorphology varies greatly between the multiple ancy later in life in the majority of cases. For this reason, a patient
craniosynostosis syndromes, and treatment is based on the present- may opt for a Le Fort III level advancement slightly later as an
ing craniofacial anomaly. Patients with Apert syndrome present alternative, assuming sufficient fronto-orbital advancement for
with severe turribrachycephaly. Both coronal sutures are typically protection of the globes followed by Le Fort I advancement and
fused early, but the anterior fontanelle is usually quite large. As potential mandibular surgery. Overall, the goals are to minimize
noted previously, enlargement of the temporal lobes of the brain is the number of surgical interventions, protect the eyes and brain
common. Sleep apnea is also common along with posterior cranial growth, and minimize the effect of surgery on growing structures
vault constriction, and hydrocephalus is a less frequent finding such as the midface as much as possible.
than in patients with Crouzon syndrome, for example. Surgical The current patient’s initial treatments in infancy and childhood
management of the craniosynostosis involves a staged reconstruc- deviated significantly from these suggested treatment sequences.
tive approach. There is no clear consensus on the most appropriate When a craniofacial procedure such as a monobloc advancement is
timing and technique for each reconstructive stage. performed at 2 or 3 years of age, significant midface and orbital
It is important to evaluate syndromic craniofacial patients in a growth restriction and abnormalities should be expected. Before
team setting for these reasons. For Apert syndrome, a potential considering any surgical treatment in this patient, an evaluation
surgical approach frequently advocated is an initial decompressive with neuro-ophthalmology is indicated for fundoscopic evaluation
craniectomy of the fused coronal sutures bilaterally. This allows of any signs of papilledema or optic nerve atrophy that could be the
continued growth of the anterior cranial vault in particular when result of a craniocerebral disproportion, increased intracranial pres-
performed around 2 to 3 months of life but may have variable sure being present in up to 43% of young patients with syndromic
results. This approach also relies on the growth potential of the craniosynostosis. A preoperative sleep study should be considered to
underlying brain and presumes that there is no significantly con- evaluate the extent of sleep apnea. The current patient was treated
tributing abnormality of the skull base that could contribute to with a Le Fort III level advancement. Mounted models with lateral
craniocerebral disproportion in syndromic patients, which may cephalometric analysis as well as virtual surgical planning were used
not be the case. However, assuming such initial interventions were to evaluate the extent of surgical movement. A custom-made,
reasonably successful, consideration could be given to the neuro- prefabricated occlusal splint was used to guide the position of
logic and cranial dysmorphology of the posterior cranial vault. the maxilla intraoperatively. Using a bicoronal incision, it is possible
Surgical interventions involving the posterior cranial vault be- to complete the desired osteotomies without requiring transcon-
tween 6 and 10 months of age may help significantly with sleep junctival (or subtarsal) or circumvestibular maxillary incisions. Os-
apnea if it is present and should be tailored to the patient’s respira- teotomies were made along the roof on the orbit and lateral orbital
tory status. This type of surgical sequencing allows for potentially wall, extending laterally and inferiorly to the pterygomaxillary
a more definitive correction of the orbits and anterior cranial vault fissure. The medial orbital wall osteotomy was connected to the
with a fronto-orbital advancement that could be completed at a inferior orbital fissure. This can be done by lifting the lacrimal sac
later age, such as 12 to 18 months. Although this group of without interruption of the medial canthal ligament or by placing

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 CHAPTER 94 Syndromic Craniofacial Synostosis 493

osteotomies more posterior in the orbit. The nasofrontal osteotomy severe or total midface hypoplasia and conditions affecting the
was extended laterally and inferiorly (behind the lacrimal groove) to orbit can be extremely close and are more easily appreciated on
meet the inferior cut. Then Rowe disimpaction forceps were used three-dimensional reconstructions preoperatively.
to mobilize and advance the midface. The position of the maxillary Various modifications of maxillary osteotomies at the pterygo-
unit is dictated by the prefabricated splint. Bone grafts, or distrac- maxillary junction can be done to prevent an unfavorable frac-
tion osteogenesis, or both may be used in select patients. The deci- ture. A straight osteotome can be used at the tuberosity rather
sion for which advancement method may largely depend on the than the pterygomaxillary fissure. Swann-shape osteotomes,
extent and type of prior surgeries performed and subsequent scar which are designed to direct force anteriorly and use various saws
tissue formation. In patients with a normal occlusion, a Le Fort III or endoscopic techniques, have also been discussed. However,
with concurrent Le Fort I can be used. If the bizygomatic promi- most surgeons use a curved osteotome directed anteriorly, medi-
nence is appropriate, Le Fort II osteotomy may be sufficient, ally, and inferiorly as a measure to prevent an unwanted fracture
though this is not common for patients with Apert syndrome spe- and to avoid the internal maxillary artery.
cifically. Malar deficiencies may be addressed with augmentation Relapse of the surgical move and development of an anterior
bone grafts at the same time if indicated. open bite are more frequently seen with larger moves. Overcorrec-
tion may be appropriate, especially in younger patients. Another
Complications strategy to address this complication is to plan the surgical procedure
in two stages, with an initial higher level advancement followed by a
There are few reports in the literature on complications of Le Fort Le Fort I level osteotomy later to close the anterior open bite.
II and III orthognathic procedures. Complications of Le Fort I Disruption or transection of the lacrimal system is a potential
osteotomy have been extensively studied in the orthognathic sur- complication, and some recommend prophylactic stenting of the
gery population and reported at a rate of about 6% to 9%. Most lacrimal drainage tract during osteotomies around the orbits and
severe complications of Le Fort osteotomy (I, II, or III) result larger advancements. Potential complications of monobloc or fa-
from an unwanted pterygomaxillary separation, with fractures cial bipartition procedures include intracranial abscess formation,
extending to the skull base, orbital wall, and pterygoid plates. This loss of bone flaps, cerebrospinal fluid leak, significant blood loss,
is seen with a higher frequency in patients with craniosynostosis. intracranial hemorrhage, and potentially death. For these reasons,
Skull base fractures can result in a subarachnoid hemorrhage; performance of such procedures at a younger age in patients with
there have been seven reported cases of skull base fracture in pa- fewer operations can help to mitigate these risks.
tients with craniosynostosis (Box 94.1). It is prudent to discuss
this complication before surgery. Other complications include Discussion
increased frequency of intracranial aneurysms, seen in patients
with Crouzon syndrome. Sporadic cases of blindness have also Craniosynostosis, or abnormal premature fusion of cranial su-
been reported after Le Fort I osteotomies. The proximity of the tures, was first described by Hippocrates in 100 bc. It may present
pterygomaxillary fissure and pterygoid plates in patients with as an isolated finding (Table 94.1) or in combination with other

• BOX 94.1 Intraoperative and Postoperative Complications in Craniofacial Surgery

Intraoperative Complications patients undergoing cranial vault reconstruction. However, this is not univer-
Venous air embolism. Neonatal and pediatric calvaria have a large number of sally accepted by all craniofacial surgeons. Major blood loss resulting in hy-
diploic and emissary channels that become exposed during a craniotomy povolemic shock has a reported incidence of 0.3% to 4.6%. Appropriate fluid
procedure. Because the operative field is typically above the level of the resuscitation with crystalloid, colloid, and blood and replacement of coagula-
heart, air could enter these exposed vascular channels and travel to the right tion factors (fresh frozen plasma) should be anticipated.
atrium. A symptomatic air embolus could lead to profound hypoten- sion and Death. Reported mortality rates for craniofacial surgery range from 0% to 4.3%.
cardiovascular collapse. If venous air embolism is suspected, sur- gery Massive intraoperative bleeding, postoperative bleeding, intracranial bleed-
should be stopped, the head of the bed lowered, and the surgical field ing, cerebral edema, infection, inadequate volume replacement, respiratory
irrigated and covered with a wet sponge; bone wax can be applied to the obstruction, and anesthetic complications are the most common causes.
osteotomized bony edges. Nitrous oxide should be discontinued. Closed Postoperative Complication
cardiac massage may be indicated in a severely compromised patient to Infection. Infection can develop in the form of osteitis or osteomyelitis, men-
force the air into the pulmonary circulation. A thoracotomy and direct mas- ingitis, or intracranial abscess. It is the most common postoperative com-
sage with aspiration of intracardiac air are the last resort in failed attempts. plication (infection rates range from 1% to 14%). Separation of the nasal
Oculocardiac reflex. Transcranial and fronto-orbital surgery can trigger the oc- and paranasal sinuses from the intracranial cavity is paramount in reduc-
ulocardiac reflex in response to orbital manipulation and pressure, leading ing the incidence of infection. The use of appropriate perioperative antibi-
to bradycardia and hypotension. Care must be taken to prevent excessive otics, intraoperative antibiotic irrigation (or saline with dilute iodine), and
orbital pressure and flap retraction. The anesthesia team should be notified reduction of surgical time also reduce infection rates. Monobloc advance-
during such maneuvers. Severe bradycardia and hypotension require the ment procedures have a higher rate of infection compared with other
administration of atropine. intracranial procedures.
Dural lacerations. David and Cooter reported a 31% incidence of iatrogenic Extradural and subdural hematomas. These are relatively rare occurrences.
dural tears in a series of 53 patients. Others have reported an incidence of Poole reported less than a 1% incidence of hematoma. Suction drainage is
5% to 60%. Direct repair usually has no detrimental sequelae. not advocated because of concern that it can cause bleeding, cerebrospinal
Major blood loss. The continual oozing of blood from the vascular osteotomy sites fluid leakage, or infection or draw nasal or sinus contamination intracrani-
over several hours of surgical time can amount to loss of a large portion of the ally. Close neurologic observation is needed to look for signs of an evolving
patient’s blood volume. The incidence of perioperative blood transfu- sions is intracranial hemorrhage.
variable and has been reported to be as high as 80% to 100% of

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494 S E C TI O N XIV Syndromes of the Head and Neck

TABLE
94.1 Types of Nonsyndromic Craniosynostosis

Elevated Intracranial Central Nervous System

Sutures Affected Head Shape Name Incidence Pressure (Mental Retardation)
Sagittal Long and narrow Scaphocephaly 1 in 5000 Absent Slight
Coronal One hemicranium smaller Anterior plagiocephaly 1 in 10,000 Infrequent Slight to moderate
than the other
Metopic Triangular forehead Trigonocephaly 1 in 15,000 Usually absent Slight to moderate
Lambdoidal One hemicranium smaller Posterior plagiocephaly 1 in 150,000 Infrequent Slight to moderate
than the other
Bilateral coronal Short, broad, and tall Brachycephaly Rare Infrequent Slight to moderate
(acrobrachycephaly)
Sagittal and coronal Short and narrow Oxycephaly Rare Usually present High

Modified from Dufresne CR: Classifications of craniofacial anomalies. In Dufresne CR, Carson BS, Zinreich SJ (eds): Complex Craniofacial Problems, New York, 1992, Churchill Livingstone.

physical findings; in the latter case, it is designated “syndromic In contrast, Crouzon syndrome was first described in 1912 by
craniosynostosis.” Apert, Crouzon, Pfeiffer, and Saethre-Chotzen O. Crouzon and later in a series of 86 cases published by Atkinson
syndromes are well-known syndromes that include craniosynosto- in 1937. The reported prevalence in the literature is 15 to 16 per
sis with the most common being Muenke syndrome. Variable 1 million births, accounting for 4.5% of all cases of craniosynos-
degrees of dysmorphology, including varying degrees of midface tosis. The syndrome follows an autosomal dominant mode of
hypoplasia, are often present. These are generally referred to as distribution, although reports of sporadic cases from new muta-
craniofacial dysostosis syndromes. tions occur. Variability of expression characterizes this syndrome.
Apert syndrome was first described in 1894 by S.W. Wheaton Abnormalities of the CNS may include progressive hydrocepha-
and later by Eugene Apert in 1906. This acrocephalosyndactyly lus, chronic cerebellar herniation, and stenosis of the jugular foramen
(deformity of the skull, face, and extremity) presents with a distinc- with venous obstruction. An increased frequency of cerebellar hernia-
tive cranial vault shape, midface hypoplasia, and limb abnormali- tion has been attributed to earlier patterns of suture closure in Crou-
ties, such as symmetrical syndactyly, acne vulgaris, and nail abnor- zon syndrome compared with Apert syndrome. Differences in skull
malities. There have been more than 300 cases reported. Most cases development between Apert and Crouzon syndromes have been
are sporadic, but an autosomal dominance inheritance has also been suggested, including earlier closure of sutures, fontanelles, and syn-
observed. Advanced paternal age and parental consanguinity (seen chondroses in Crouzon syndrome. This leads to marked differences
in two patients) have been associated with an increased risk. in shape and the cranial volume of the skull in patients with Crouzon
Early fusion of the coronal sutures, along with a widely patent syndrome. Cranial malformation depends on the order and rate of
sagittal suture (extending from the glabella to the posterior fonta- progression of sutural synostosis. Brachycephaly is most common,
nelle), produces a short anterior cranial fossa and a steep, wide, flat but scaphocephaly, trigonocephaly, and cloverleaf skull may be ob-
forehead. This results in a bulging pterion and an obliquely con- served. Tailoring the overall treatment of cranial dysmorphology and
toured temporal bone bilaterally. The occiput is also flat, which later midfacial hypoplasia therefore may appear significantly different
makes for a shorter anteroposterior dimension and increases the in timing as discussed earlier, though many of the craniofacial proce-
vertical dimension. The resulting skeletal deformity of craniosynos- dures are applicable to various craniofacial dysostosis syndromes.
tosis is caused by poor skeletal development perpendicular to the Shallow orbits with ocular proptosis are an important diagnos-
prematurely fused suture. The remaining sutures widen excessively, tic feature of Crouzon syndrome. Concomitant ocular findings
producing the final cranial form. This is referred to as Virchow’s law. include exotropia, poor vision or blindness, optic atrophy, nystag-
The midface hypoplasia consists of an underdeveloped maxilla mus, exposure conjunctivitis, and keratitis, among others. Ap-
in all dimensions, total midface hypoplasia, with a reduction in proximately 50% of patients with Crouzon syndrome have lateral
the nasopharyngeal airway space. Oral examination may show a palatal swellings that resemble a pseudocleft. Cleft lip and palate
high-arched palate, cleft palate, dental crowding, and an anterior or a bifid uvula occur with less frequency overall. Conductive
open bite. Ocular abnormalities present as orbital hypertelorism hearing loss deficit is found in 55% of patients, and atresia of the
and exorbitism, which are generally not as severe as in Crouzon external auditory canals occurs in 13%. Crouzon syndrome
syndrome. Syndactyly consists of soft tissue fusion of the second, should be further distinguished from simple bilateral coronal
third, and fourth fingers or toes. This is seen with a variable extent synostosis and Crouzon dermoskeletal syndrome as well.
of bony and fingernail fusion of the involved digits.
The affected brain can include the development of progressive Acknowledgment
hydrocephalus (rare); distorted ventricle shape; agenesis of the
septum pellucidum, corpus callosum, and cavum septum pellu- The authors and publisher acknowledge Dr. Chris Jo for his con-
cidum; and possible developmental delay. Two cranial nerves can tribution on this topic in the previous edition.
be affected, independent of cranial vault shape: cranial nerve I
(9%), resulting in anosmia, and cranial nerve VIII, causing hear- ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
ing impairment (10%). complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 494.e1

Bibliography Lanigan DT, Romanchuk K, Olson CK: Ophthalmic complications as-

sociated with orthognathic surgery, J Oral Maxillofac Surg 51:480-
494, 1993.
Brookes C, Golden B, Turvey T: Craniosynostosis syndromes, Atlas Oral Lanigan DT, Tubman DE: Carotid-cavernous sinus fistula following Le
Maxillofac Surg Clin North Am 2:103-110, 2014. Fort I osteotomy, J Oral Maxillofac Surg 45:969-975, 1987.
Cohen MM Jr, MacLean RE: Craniosynostosis Diagnosis, Evaluation and Lo LJ, Hung KF, Chen YR: Blindness as a complication of Le Fort I oste-
Management, ed 2, New York, 2000, Oxford University Press. otomy for maxillary distraction, Plast Reconstr Surg 109:688-698, 2002.
Cohen MM, Kreiborg S: An updated pediatric perspective on the Apert Marsh J, Galic M, Vannier MW: The craniofacial anatomy of Apert syn-
syndrome, Am J Dis Child 147:989, 1993. drome, Clin Plast Surg 18:237-249, 1991.
David DJ, Cooter RD: Craniofacial infection in 10 years of transcranial Matsumoto K, Nakanishi H, Seike T, et al: Intracranial hemorrhage re-
surgery, Plast Reconstr Surg 80:213-223, 1987. sulting from skull base fracture as a complication of Le Fort III oste-
Fearon JA: The Le Fort III osteotomy: to distract or not to distract? Plast otomy, J Craniofac Surg 14:545-548, 2003.
Reconstr Surg 107(5):1091-1103, 2001; discussion 1104-1106. Newhouse RF, Schow SR, Kraut RA, et al: Life-threatening hemorrhage
Ferraro NF: Dental, orthodontic, and oral/maxillofacial evaluation and from a Le Fort I osteotomy, J Oral Maxillofac Surg 40:117-119, 1982.
treatment in Apert syndrome, Clin Plast Surg 18:291-307, 1991. Flores- Poole MD: Complications of craniofacial surgery, Br J Plast Surg 41:608-
Sarnat L: New insights into craniosynostosis, Semin Pediatr Neurol 613, 1988.
9(4):274-291, 2002. Erratum: Semin Pediatr Neurol. 10(2):159, 2003. Posnick JC, Ruiz R: The Craniofacial Dysostosis Syndromes: Current
Girotto JA, Davidson J, Wheatly M, et al: Blindness as a complication of Surgical Thinking and Future Directions, Cleft-Palate – Craniofacial
Le Fort osteotomies: role of atypical fracture patterns and distortion Journal 37(5):433, 2000.
of the optic canal, Plast Reconstr Surg 102:1409-1421, 1998. Renier D, Arnaud E, Cinalli G, et al: Prognosis for mental function in
Iannetti G, Fadda T, Agrillo A, et al: Le Fort III advancement with and Apert’s syndrome, J Neurosurg 85:66-72, 1996.
without osteogenesis distraction, J Craniofac Surg 17(3):536-543, Robinson PP, Hendy CW: Pterygoid plate fractures caused by the Le Fort
2006. I osteotomy, Br J Oral Maxillofac Surg 24:198-202, 1986.
Juniper RP, Stajcic Z: Pterygoid plate separation using an oscillating saw Ruiz RL: Update in craniofacial surgery, Oral Maxillofac Surg Clin North
in Le Fort I osteotomy, technical note, J Craniomaxillofac Surg Am 16(4):xi-xii, 2004.
19:153-154, 1991. Sakai Y, Kobayashi S, Sekiguchi J, et al: New method of endoscopic
Katzen JT, McCarthy JG: Syndromes involving craniosynostosis and pterygomaxillary disjunction for a Le Fort I osteotomy, J Craniofac
midface hypoplasia, Otolaryngol Clin North Am 33:1257-1284, 2000. Surg 7:111-116, 1996.
Lanigan DT, Guest P: Alternative approaches to pterygomaxillary separa- Taylor J, Bartlett S: What’s new in syndromic craniosynostosis surgery?
tion, Int J Oral Maxillofac Surg 22:131-138, 1993. Plast Reconstr Surg 140:82e-93e, 2017.

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95
Hemifacial Microsomia
M I C H A E L M ILO R O

CC the pogonion is deviated to the left by 5 mm. (Malocclusion is

prevalent in HFM, and the degree of malocclusion is proportional
A 21-year-old male patient with left-sided hemifacial microsomia to the skeletal deformity. Dental crowding, inclination of the an-
(HFM) presents for treatment of a persistent facial asymmetry. terior teeth, and unilateral crossbite on the affected side are char-
(HFM may have a male predilection and a higher occurrence on acteristic findings.)
the right side, although some studies have shown an equal lateral- The patient is not missing any adult teeth, and there is no evi-
ity and sex distribution.) dence of enamel hypoplasia. No caries or periodontal disease is
evident. (However, patients with HFM are more likely to have
HPI missing teeth compared with the general population and fre-
quently have delayed tooth development on the affected side.
The patient was diagnosed with HFM in early childhood. He was Dental agenesis and enamel hypoplasia are more likely to occur in
subsequently treated with distraction osteogenesis of the left those with severe skeletal deformities. Enamel hypoplasia of the
mandible during childhood; however, his facial proportions have primary incisors on the affected side is thought to be an additional
slowly but progressively worsened since the distraction proce- early developmental marker for HFM.)
dure. (Asymmetry in HFM usually progresses with age.) Addi- The lips and oral commissure are normal (macrostomia is seen
tionally, the patient has had persistent malar hypoplasia and in 35% of patients with HFM). The soft palate, hard palate, and
asymmetry of the left auricle. The patient denies any previous alveolar processes appear normal. (Approximately 7%–15% of
history of facial trauma. (Facial fractures in a growing child, es- patients with HFM present with cleft lip and palate.)
pecially to the mandibular condyle, can contribute to growth
disturbances.) Imaging
PMHX/PDHX/Medications/Allergies/SH/FH A panoramic radiograph is the initial radiograph obtained for
evaluating the degree of deformity of the mandible and its articu-
Noncontributory. The patient is a student in good academic lation with the zygoma. Posteroanterior and lateral cephalometric
standing at a local college. radiographs may be obtained to evaluate the degree of deformity
of the maxillomandibular complex in relation to the cranial base
Examination (Fig. 95.1A).
Computed tomography (CT) scans (with three-dimensional
General. The patient is a well-developed, well-nourished male in reformatting) provide the best understanding of the geometry of
no apparent distress. the hard tissue abnormalities and relationships. Additionally, this
Neurologic. The cranial nerves are intact, specifically the facial information may be used for virtual surgical planning and fabrica-
(N0), vestibulocochlear, and hypoglossal nerves bilaterally. tion of surgical splints.
Maxillofacial. There are mild deficits in subcutaneous tissue For the current patient, the Panorex demonstrated significant
and underlying muscle (S1). There is no perioral or palatal clefting hypoplasia of the left mandible with absence of the condyle–ra-
present. There are no distortions in orbital size and no asymmetry mus unit (orbit, mandible, ear, nerve, soft tissues [OMENS] clas-
in orbital position or dystopia (O0). The left malar eminence is sification of M3/Kaban type III).
hypoplastic. There is mild hypoplasia of the left ear with signifi- The CT scan provided further information on the severity of
cant protrusion of the pinna (E1). the left zygomatic hypoplasia in addition to the degree of occlusal
There is hypoplasia of the left mandible; the left condyle is ab- plane canting and midline discrepancy in relation to the skull base
sent, along with a portion of the mandibular ramus. The TMJ ar- (Fig. 5.1B and C).
ticulation is absent, and the zygoma is hypoplastic (M3). There is
no posterior stop to the mandible when upward force is directed at Labs
the angle. The left gonial angle is underprojected. There is canting
of the mandible (upward on the left) with reciprocal canting of the Preoperative hemoglobin and hematocrit levels were within nor-
maxilla. The maxillary midline is shifted to the left by 3 mm, and mal range for this patient. No other labs are indicated.

495
t.me/Dr_Mouayyad_AlbtousH
496 S E C TI O N XIV Syndromes of the Head and Neck

B C
• Fig. 95.1 A, Posteroanterior cephalometric radiograph of a patient with left hemifacial microsomia
(HFM). B and C, Three-dimensional computed tomography scan showing the left HFM.

Assessment the progressive nature of the deformity are the key principles that
govern the sequence of intervention. In general, treatment after
A 21-year-old male with left-sided HFM; O0M3E1N0S1 or Kaban growth cessation tends to produce the most stable results, with
type III (see OMENS classification system [Table 95.1]). completion of growth following a cranial–caudal direction. Treat-
ment for the different facial anatomic regions is discussed briefly.
Treatment
The goals of treatment are both functional (restoration of occlu-
Zygomatic and Orbital Reconstruction
sion/joint function) and esthetic (normalization of facial symmetry Surgical intervention in the orbital and zygomatic area of the face
and contour). Other functional limitations (airway compromise, may be undertaken earlier than surgery for the maxillomandibular
sleep disturbances, feeding difficulties, speech disorders, and hear- deformity, typically after 5 to 7 years of age. (Growth of the or-
ing deficits) may require earlier or additional interventions. bital and zygomatic region is complete around age 7 years.) Surgi-
Timing is an important consideration in the treatment of patients cal access may require coronal flaps with the use of calvarial bone
with craniofacial disorders, and this factor has generated the most con- grafts for orbitozygomatic reconstruction. Orbital dystopia may
troversy in the management of those with HFM. Growth cessation and be managed with facial bipartition or orbital box osteotomies.

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 CHAPTER 95 Hemifacial Microsomia 497

TABLE a Le Fort osteotomy and genioplasty. Onlay grafts may be used to

95.1 OMENS Classification of Hemifacial Microsomiaa address hard tissue asymmetries that are not correctable with or-
thognathic surgery alone. Type IIB and type III mandibular de-
Classification Description formities require reconstruction of the TMJ articulation. This
O Orbital distortion may be done with a costochondral graft (for the ramus, zygoma,
or both) or total alloplastic joint replacement in the adult.
O0 Normal orbital size and position Typically, the changes in the maxilla occur secondary to limita-
O1 Abnormal orbital size tion of growth imposed by the lack of growth of the mandible. In
the past, early intervention before growth cessation was advocated
O2 Abnormal orbital position
to mitigate these reciprocal effects. Osteotomy and repositioning
O3 Abnormal orbital size and position of the mandible during the mixed dentition phase (with or with-
out a costochondral graft) were used to create an open bite on the
M Mandibular hypoplasia
side ipsilateral to the deformity. Closing the open bite slowly, over
M0 Normal mandible 18 to 24 months, allowed for normalization of the maxillary oc-
M1 Small mandible and glenoid fossa with a short ramus
clusal plane, primarily through dentoalveolar remodeling. Long-
term stability in patients operated on before skeletal maturity has
M2 Short and abnormal shaped ramus been a concern. Patients with type IIB and type III mandibles
M3 Complete absence of ramus, glenoid fossa, and tem- after costochondral reconstruction have less successful long-term
poromandibular joint stability, and this is worse when they are operated on early. Fur-
thermore, long-term data on patients reconstructed with distrac-
E Ear anomaly tion osteogenesis in childhood and adolescence have shown that
E0 Normal ear the benefits in facial symmetry initially gained from early inter-
vention are completely lost after the patient achieves skeletal ma-
E1 Mild ear hypoplasia and cupping with all the struc-
turity. A literature review by Mommaerts and Nagy has shown
tures present
that there is no evidence to support early distraction osteogenesis
E2 Absence of external auditory canal with variable hy- in the patients with HFM. Brusati compared the vertical ramus
poplasia of the concha heights of the affected and nonaffected sides in patients with type
E3 Malpositioned lobule with absent auricle I and IIA mandibles who underwent distraction osteogenesis be-
tween the ages of 5 and 7 years. By 1 year after surgery, 16% of
N Nerve involvement the vertical correction in ramal height was lost. By 5 years, 75%
N0 Normal facial nerve of the correction was lost, and at the completion of growth, the
ratio of the affected to nonaffected sides returned to the original
N1 Upper facial nerve involvement (temporal and zygo- preoperative proportion.
matic branches)
For nongrowing patients who require restoration of the TMJ
N2 Lower facial nerve involvement (buccal, mandibular, articulation (e.g., failed costochondral grafts), combined total
and cervical branches) joint alloplastic replacement, along with simultaneous orthogna-
N3 All branches of the facial nerve affected thic surgery, is an option.
S Soft tissue deficiency
Soft Tissue Reconstruction
S0 No apparent soft tissue and muscles deficiency
Initial soft tissue abnormalities (e.g., skin tag removal, correction
S1 Minimal muscle and subcutaneous deficiency of macrostomia, eyelid deficiencies) may be addressed in early
S2 Moderate deficiency adulthood. After the osseous foundation has been addressed, final
soft tissue modifications for restoration of symmetry are under-
S3 Severe deficiency with muscles and subcutaneous taken. Microvascular tissue transfer is commonly used (e.g., para-
tissue hypoplasia
scapular flap); however, serial fat grafts are a more conservative
a
Each subdivision is graded as 0 (normal), 1, 2, or 3 (most severe); these are added to ob- option for replacing or augmenting deficient facial soft tissues.
tain the orbit, mandible, ear, nerve, soft tissues (OMENS) score (e.g., O1M2E2N3S2 5
OMENS score of 10). If the OMENS score is greater than 6, there is an increased likelihood
of extracranial comorbidities. Auricular Reconstruction
Modified from Horgan JE, Padwa BL, LaBrie RA, et al: OMENS-plus: analysis of the cranio-
facial and extracraniofacial anomalies in hemifacial microsomia, Cleft Palate Craniofac J Auricular reconstruction is performed using either autologous
32(5):405-412, 1995. grafts or implant-retained prostheses. Both procedures are per-
formed in a staged approach. The advantages of autologous graft-
ing include increased long-term stability and success, less need for
maintenance, and decreased long-term costs. Prosthetic recon-
Reconstruction of the Maxillomandibular struction results in an improved symmetry with the contralateral
Complex ear; however, it often requires a lifetime of maintenance. Com-
puter-aided design and manufacture technology has improved the
Treatment planning for restoration of the MMC must take into cosmetic outcome of the prosthetic options. Costal cartilage is
account the extent of deformities and the involvement of the usually grafted from the sixth or seventh rib. The timing of graft-
temporomandibular joint (TMJ). Type I and type IIA mandibular ing is controversial; however, in the two-stage repair, delaying the
deformities likely require a ramus osteotomy in conjunction with rib harvest until age 10 years, as suggested by Nagata, has become

t.me/Dr_Mouayyad_AlbtousH
498 S E C TI O N XIV Syndromes of the Head and Neck

increasingly common. Timing options include grafting as early as Discussion

6 years of age, as recommended by Brent, or after 10 years of age, as
recommended by Nagata. The timing of endosseous implant place- Hemifacial microsomia is a craniofacial disorder that results in
ment relates to the quality of the temporal bone; increased compli- varied malformation of the first and second branchial arch deriva-
cations have resulted in children between 5 and 12 years of age tives. Involvement of the mandible, TMJ, orbit, midface, ear,
secondary to thinner and softer temporal bone. The future of recon- cranial nerves, and overlying soft tissue is common, in addition to
struction will likely involve tissue engineering using chondrocyte extracranial abnormalities. The reported incidence ranges from 1
cells seeded onto biodegradable polymer scaffolds (Fig. 95.2). in 3500 to 1 in 5600 births, making HFM the second most com-
mon craniofacial abnormality after cleft lip and cleft palate. There
Complications is a slight predilection for the right side of the face, and some
studies have suggested a male predilection (3:2). Involvement is
Multiple interventions may be necessary for reconstruction and asymmetric and bilateral in 10% to 15% of cases.
normalization of facial symmetry in patients with HFM. Depend- The phenotypic expression is quite variable, and the disorder
ing on the modalities used, multiple variable complications are has been understood to exist along a spectrum known as the ocu-
possible. These include infection, hardware failure, relapse, non- lar-auricular-vertebral spectrum, which includes Goldenhar syn-
union, graft failure, donor site morbidity, damage to adjacent drome. Additional nomenclature applied to HFM includes lateral
structures (neurovascular), scarring, and unfavorable cosmetic facial dysplasia, craniofacial microsomia, otomandibular dysosto-
outcomes. Many of the complications depend on the treatment sis, and first and second branchial arch syndrome. Treacher Collins
and are the same as those seen in orthognathic surgery and dis- syndrome may be confused with bilateral craniofacial microsomia,
traction osteogenesis for patients without HFM. These are dis- although Treacher Collins syndrome is symmetrical and has a well-
cussed elsewhere in this book. defined inheritance pattern.

A B C

F
D E

• Fig. 95.2 A–C, Three-dimensional surgical treatment planning consisting of a Le Fort osteotomy, right
sagittal split osteotomy, and genioplasty, with plans for costochondral reconstruction of the left condyle–
ramus unit. Intraoperative views of left zygomatic arch reconstruction (D) and left condyle–ramus unit recon-
struction (E) with a costochondral graft. F, Posteroanterior cephalometric radiograph of the postoperative
result showing restoration of facial symmetry.

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 CHAPTER 95 Hemifacial Microsomia 499

G H

I J

• Fig. 95.2, cont’d G and H, Comparison of preoperative and postoperative facial appearance on frontal
view. I and J, Comparison of preoperative and postoperative facial appearance on profile view.

The mechanism of HFM is poorly understood; however, com- classification demonstrates aplasia of the ramus–condyle unit,
promise of the branchial arches from vascular insult (hemorrhage lack of an articulation, and no posterior stop with palpation. The
and hematoma) to the stapedial artery has been proposed. Although OMENS classification is used to score five anatomic structures
a 2% to 3% recurrence rate has been seen in first-degree relatives, a based on severity (orbit, mandible, ear, nerve, soft tissues). A score
well-defined inheritance pattern has not been demonstrated. is given for each category based on the degree of abnormality (see
Given the extensive variability of HFM, several classification Table 95.1), and the summation correlates with the severity of
systems have been developed. The Kaban classification is a modi- mandibular deformity. Several associated anomalies can exist in
fication of the Pruzansky system, which characterizes the degree association with HFM (Tables 95.2 and 95.3). One study re-
of mandibular involvement with particular attention to the ra- ported that more than half of patients with HFM had at least one
mus-condyle unit. extracranial anomaly.
The Kaban type I mandible has mild hypoplasia of the ramus- Goldenhar syndrome (oculoauriculovertebral spectrum) has
condyle unit; however, the TMJ functions normally. A type IIA been described as a variant of HFM. However, it appears that HFM
mandible is moderately hypoplastic with a deformed ramus–con- is within the broad range of expression of the oculoauriculoverte-
dyle unit but an intact articulation. A type IIB mandible has se- bral spectrum, which is synonymous with Goldenhar syndrome.
vere hypoplasia and deformity of the ramus–condyle unit with a
functional deficit. No articulation is present between the condyle ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
and fossa, although a posterior stop may be present. The type III complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
500 S E C TI O N XIV Syndromes of the Head and Neck

TABLE Principal Maxillofacial Defects in Hemifacial TABLE

95.2 95.3 Associated Defects in Hemifacial Microsomia
Microsomia
Location Principal Defects Craniofacial Defects Other Defects
Mandible Mandibular hypoplasia (89%–%) Velopharyngeal insufficiency Vertebral or rib defects
(35%–55%) (16%–60%)
Malformed glenoid fossa (24%–27%)
Palatal deviation (39%–50%) Cervical spine anomalies
Ear Microtia (66%–99%) Preauricular (24%–42%)
tags (34%–61%) Conductive hearing Orbital dystopia (15%–43%) Scoliosis (11%–26%)
loss (50%–66%) Ocular motility disorders (19%–22%) Cardiac anomalies (4%–33%)
Midface Maxillary hypoplasia Epibulbar dermoids (4%–35%) Pigmentation change (13%–14%)
Zygomatic hypoplasia Cranial base anomalies (9%–30%) Extremity defects (3%–21%)
Occlusal canting Eyelid defects (12%–25%) Central nervous system defects
Soft tissue Masticatory muscle hypoplasia (85%–95%) (5%–18%)

Macrostomia (17%–62%) Hypodontia or dental hypoplasia Genitourinary defects (4%–15%)

(8%–25%)
Cranial VII nerve palsy (10%–45%)
Lacrimal drainage anomalies Pulmonary anomalies (1%–15%)
(11%–14%)
Frontal plagiocephaly (10%–12%) Gastrointestinal defects (2%–12%)
Sensorineural hearing loss (6%–16%)
Preauricular sinus (6%–9%)
Parotid gland hypoplasia
Other cranial nerve defects (e.g.,
cranial nerves V, VII, IX, and XII)

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 500.e1

Bibliography Yturralde KJ, Le PB, Martinez OP, Chen E: Brent technique of repair versus
Nagata auricular reconstruction for microtia reconstruction: a systematic
review and meta-analysis, J Craniofac Surg 35(1):43-45, 2024.
Bauer BS: Reconstruction of microtia, Plast Reconstr Surg 124:14-26, Nagy K: No evidence for long-term effectiveness of early osteodistraction
2009. in hemifacial microsomia, Plast Reconstr Surg 124:2061-2071, 2009.
Birgfeld C, Heike C: Craniofacial microsomia, Clin Plast Surg 46:207- Padwa BL: Midfacial growth after costochondral graft construction of the
221, 2019. mandibular ramus in hemifacial microsomia, J Oral Maxillofac Surg
Brandstetter KA, Patel KG: Craniofacial microsomia, Facial Plast Surg 56:122-127, 1998.
Clin North Am 24:495-515, 2016. Posnick JC: Surgical correction of mandibular hypoplasia in hemifacial
Brusati R: Comparison of mandibular vertical growth in hemifacial mi- microsomia: a personal perspective, J Oral Maxillofac Surg 56:639-
crosomia patients treated with early distraction or not treated: follow 650, 1998.
up till the completion of growth, J Craniomaxillofac Surg 40:105-111, Tanna N: Craniofacial microsomia soft tissue reconstruction compari-
2012. son: inframammary extended circumflex scapular flap versus serial fat
Chen Q, Zhao Y, Shen G, et al: Etiology and pathogenesis of hemifacial grafting, Plast Reconstr Surg 127:802-811, 2011.
microsomia, J Dent Res 97:1297-1305, 2018. Wang RR: Hemifacial microsomia and treatment options for auricular re-
Kaban LB: Surgical correction of mandibular hypoplasia in hemifacial placement: a review of the literature, J Prosthet Dent 82:197-204, 1999.
microsomia: the case for treatment in early childhood, J Oral Maxil- Wolford LM: Successful reconstruction of nongrowing hemifacial micro-
lofac Surg 56:628-638, 1998. somia patients with unilateral temporomandibular joint total joint
Mommaerts MY, Nagy K: Is early osteodistraction a solution for the as- prosthesis and orthognathic surgery, J Oral Maxillofac Surg 70:2835-
cending ramus compartment in hemifacial microsomia? A literature 2853, 2012.
study, J Craniomaxillofac Surg 30(4):201-207, 2002.

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96
Obstructive Sleep Apnea Syndrome
K Y LE F R A Z IE R , MA R SH A L L F. N E W M A N , a n d S H A H R O K H C . B AG H ER I

CC inflammation and edema of the upper airway mucosa, which in-

creases airway resistance).
A 46-year-old White male is referred to your office by his primary He is a sales manager and works more than 8 hours a day.
care physician for evaluation and management of obstructive (Overworking may contribute to lack of sleep, sleep-disordered
sleep apnea syndrome (OSAS). (The reported prevalence of ob- breathing, and daytime somnolence.) More recently, his cowork-
structive sleep apnea [OSA] varies widely in different studies, with ers have noticed that he is falling asleep at his desk. (Daytime
some showing rates of 15%–30% in males and 10%–15% in fe- somnolence also contributes to decreased productivity and can be
males in North America. The risk increases significantly after age particularly dangerous for individuals operating machinery or
65 years and in up to 50% of nursing home patients.) driving motor vehicles.)
His father had similar signs and symptoms of OSAS that were
HPI untreated. (A positive family history is commonly seen because of
various genetic and environmental factors.) His father died at the
The patient presents complaining of a long history of snoring and age of 60 years of a myocardial infarction. (Untreated OSAS sig-
restless sleeping. (Sleep-disordered breathing includes hypopnea, nificantly increases the risk of cardiovascular disease and cerebro-
apnea, and respiratory effort–related arousals.) His wife of 20 vascular accident resulting in death.)
years reports that he snores loudly; frequently stops breathing
(apnea); and makes grunting, gasping, and choking sounds. Examination
(Bedroom partners are often the first to recognize the problem.)
The patient has noticed difficulty concentrating at work (OSAS Vital signs. his blood pressure is 150/95 mm Hg (stage II hyper-
decreases cognitive function) and difficulty staying awake during tension), heart rate is 75 bpm, respirations are 16 breaths per
the day (daytime somnolence is a hallmark of OSAS). The patient minute, and temperature is 37.6°C.
scored above 10 on the Epworth Sleepiness Scale. (This scale is a General. The patient is a moderately obese male in no appar-
questionnaire that subjectively assesses the level of daytime som- ent distress. (Obesity is an important risk factor for OSAS.) His
nolence. Other screening tools include the Berlin questionnaire, weight is 225 lb, his body mass index is 32 kg/m2 (class 1 obesity),
the American Society of Anesthesiology checklist, and the STOP- and his waist-to-hip ratio is 1.2. (Ideal is ,0.9 in males and
BANG questionnaire.) He also complains of morning dry mouth ,0.85 in females.)
(nasal obstruction or congestion leads to mouth breathing, result- Maxillofacial. He displays mild retrognathia. (Retrognathia is
ing in morning dry mouth), morning headaches, nocturia, and a risk factor for OSAS.) His neck measures 18 inches. (A neck
night sweats (common symptoms associated with OSAS). His circumference of $17 inches in males and $16 inches in females
primary care physician referred him to a sleep center for polysom- increases the risk of OSAS and may be the best predictor of RDI
nography (PSG) (the gold standard in diagnosis of OSAS); his in males.)
respiratory disturbance index (RDI) score was 51 (see Discussion Endonasal. The nares are equally patent bilaterally. There is no
later in this chapter). evidence of internal nasal valve collapse. The result of the Cottle
test is negative. (A positive Cottle test result may indicate internal
PMHX/PDHX/Medications/Allergies/SH/FH or external nasal valve collapse.) The nasal septum appears mid-
line, and the inferior turbinates appear normal. (A deviated nasal
The patient’s past medical history is significant for hypertension septum or turbinate hypertrophy may cause nasal obstruction.)
(there is a direct relationship between OSAS and hypertension, There are no nasal polyps.
resulting in cardiovascular morbidity), which is controlled with a Intraoral. His occlusion is class II division II. The oral tongue
beta-blocker and a diuretic. His past surgical history is significant is normal in size. The soft palate and uvula are long and not com-
for tonsillectomy and adenoidectomy as a child. (Hypertrophic pletely visible (Mallampati class III airway). The tonsils are not
tonsils and adenoids increase the risk of OSAS in children, but present. There are no tori. (Enlarged or redundant oral structures
this is more uncommon in adults.) may cause oropharyngeal obstruction.)
He admits to drinking two or three beers a day (alcohol con- Endoscopic nasopharyngoscopy in the supine position.
sumption can blunt the ventilatory response to hypercarbia and Nasopharyngoscopy can be performed in the clinic and provides
thereby worsen OSA) and occasional smoking (smoking can cause information on the presence and location of the obstruction,

501
t.me/Dr_Mouayyad_AlbtousH
502 S E C TI O N XIV Syndromes of the Head and Neck

which cannot be evaluated with PSG. The nasopharynx is clear of are additional cardiac risk factors that are commonly seen in pa-
any obstruction. The retropalatal airway space is narrow and has tients with OSAS.
redundant soft tissue, and the space completely obliterates with In the current patient, the complete blood count and electro-
Müller’s maneuver (forced inspiratory effort against a closed cardiogram (ECG) were within normal limits.
mouth and nose). The retroglossal oropharynx and hypopharynx
are narrow and partially obliterated (75%) with Müller’s maneu- Polysomnography
ver. Collapse of the lateral pharyngeal walls appears to contribute
significantly to the airway collapse. There is no pathology of the Polysomnography (“sleep study”) is the gold standard for diagnos-
endolarynx, and the vocal cords are functional. ing sleep-related breathing disorders. The electroencephalogram,
Drug-induced sleep endoscopy (DISE). Although clinical ECG, electro-oculogram, electromyogram, heart rate, oxygen
nasopharyngoscopy is limited in that it is performed on an awake saturation, airflow, and respiratory efforts are monitored and re-
patient, DISE has the advantage of being performed while the corded during sleep. The numbers of apneas and hypopneas are
patient is sleeping via intravenous conscious sedation. Nasopha- calculated. The definitions of apnea and hypopnea have been al-
ryngoscopy is then performed, allowing the practitioner to evalu- tered over time, and some sources still disagree with them. The
ate multilevel pharyngeal collapse during sleep. Techniques and current American Academy of Sleep Medicine’s definitions are as
scoring are nonstandardized, but the VOTE classification is a follows: apnea is defined as a 90% or greater reduction in airflow
useful tool for reporting results. This acronym indicates the levels for 10 seconds or more, and hypopnea is defined as a 30% or
evaluated during the procedure: velum, oropharynx, tongue base, greater decrease in airflow associated with a 3% or greater reduc-
and epiglottis. The dimensions of collapse (anteroposterior vs tion in the oxygen saturation or an arousal. Apneas and hypop-
lateral vs concentric) and degree of obstruction at each level are neas are categorized as obstructive (no airflow despite inspiratory
reported. effort), central (no airflow and no inspiratory effort), or mixed
(both central and obstructive component). The average number
Imaging of apneas plus hypopneas per hour is referred to as the apnea-
hypopnea index (AHI) and is used for scoring sleep apnea as ei-
Previously, the lateral cephalometric radiograph was the initial ther mild (AHI 5–14), moderate (AHI 15–29), or severe (AHI
diagnostic study of choice. It provides an excellent overview of $30). This scale is useful for both diagnosis and in monitoring a
the craniofacial skeleton for identifying and quantifying any patient’s response to treatment.
skeletal deformities, including the position of the maxilla and In addition, respiratory event–related arousals (RERAs) are
mandible in relation to the cranial base, and the soft tissue also sometimes measured. RERAs are events that do not meet the
anatomy. However, in modern oral and maxillofacial surgery definition for apneas or hypopneas but still produce respiratory
offices, cone-beam computed tomography (CBCT) scanners symptoms ending in arousals. When RERAs are averaged in with
are ubiquitous, and their scans provide views of the airway in apneas and hypopneas, the result is the RDI.
three dimensions. The ability to view the airway in a transverse In the current patient, the PSG showed an AHI of 51. All
plane can reveal constrictions not appreciable on lateral films. episodes of apnea were obstructive in nature. The lowest oxygen
Three-dimensional (3D) renderings display the actual shape of saturation was 81%. There were no cardiac arrhythmias. (Pro-
the airway, and imaging software can compute its total vol- longed hypoxemia can precipitate premature ventricular contrac-
ume. In addition, traditional lateral cephalometric views can tions or sinus bradycardia.)
be generated from CBCT scans to evaluate traditional mea-
surements: the distance from the hyoid bone to the mandibu- Assessment
lar plane (normal, 11–19 mm), the posterior airway space
(normal, 10–16 mm), the length of the soft palate (normal, A 46-year-old obese male with severe OSAS (also termed obstructive
34–40 mm), and the thickness of the soft palate (normal, sleep apnea-hypopnea syndrome) likely caused by obstruction at the
6–10 mm). Hospital-grade CT and magnetic resonance imag- level of the oropharynx (retropalatal and retroglossal) and hypophar-
ing also provide 3D and volumetric information on the upper ynx (Fujita type II obstruction).
airway and surrounding soft tissues, and research is continuing Upper airway obstruction can occur at different levels (naso-
to develop the clinical applications of these advanced imaging pharynx, oropharynx, and hypopharynx). The Fujita classification
modalities. divides the airway in three categories based on the anatomic loca-
In the current patient, the CBCT showed a hypoplastic man- tion of the obstruction (Table 96.1). When OSA is associated
dible causing a class II skeletal discrepancy, a retropositioned po- with daytime somnolence, OSAS is diagnosed.
gonion, a posterior airway space of 6 mm (as viewed on the lateral
cephalometric view from the CBCT), a long and thick soft palate, Treatment
and a normal hyoid–to–mandibular plane distance.
The treatment of patients with OSAS begins with a proper diagno-
Labs sis, along with recognition of the level or levels of upper airway
obstruction and severity of the disease. Nonsurgical management,
No laboratory values are needed in the initial workup of OSAS. namely lifestyle changes, should be initiated immediately regardless
Thyroid hormone or thyroid-stimulating hormone levels are rou- of the severity of disease or anticipated surgical plan. This includes
tinely ordered at some sleep centers but may not be warranted. weight loss therapy and cessation of alcohol use. Obesity is seen in
Other laboratory studies, including preoperative laboratory stud- 60% to 70% of patients with OSAS. It has been shown that
ies, are ordered based on the patient’s medical history. whereas a 10% weight loss improves the AHI by 26%, a 10%
An electrocardiogram is required for all patients with OSAS. weight gain worsens the AHI by 32%. Alcohol and any other seda-
OSAS is considered a cardiac risk factor. Hypertension and obesity tives can worsen the AHI (longer and more frequent obstructions)

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 96 Obstructive Sleep Apnea Syndrome 503

TABLE Fujita Classification: Airway Classification by tissue anteriorly, thereby opening the posterior airway space. On
96.1 Anatomic Location of the Obstruction average, oral appliances reduce the AHI by 56%.
Tricyclic antidepressants and selective serotonin reuptake in-
Type Anatomic Location Structures Involved hibitors have been tried as pharmacologic therapy for patients
I Oropharynx Palate, uvula, tonsils with OSA; however, studies have failed to show significant suc-
cess. The use of oxygen alone as the main therapy for OSA can
II Oropharynx and hypopharynx Combination of Type I and result in blunting of the hypoxic drive.
Type III structures
If CPAP or an oral appliance is not tolerated by the patient or
III Hypopharynx Base of the tongue, lingual if the oral appliance does not improve the patient’s AHI to accept-
tonsil, and epiglottis able levels, surgical options should be considered.
The current patient underwent several months of CPAP ther-
apy, but he did not tolerate this treatment and now wants to ex-
plore surgical options for OSA therapy. The decision was made to
in patients with OSAS or can cause snorers to develop OSAS. Thus, perform a DISE procedure before discussing surgical treatments.
alcohol avoidance is recommended in all susceptible patients. The DISE procedure showed complete concentric velopharyngeal
Other nonsurgical treatments include positive airway pressure collapse, tonsils causing ,50% obstruction, lateral pharyngeal
devices (e.g., continuous positive airway pressure [CPAP]) oral walls causing ,50% obstruction, and anteroposterior collapse at
appliances (e.g., mandibular advancement devices) and modified the level of the tongue base causing .50% obstruction.
sleep positions (the AHI doubles when supine compared with the A plethora of different surgical options exist for the treatment
lateral decubitus position). Upright posture during sleep, with the of OSA, and the efficacy of each varies widely. Nasal obstructions
head of the bed elevated 60 degrees, has been shown to signifi- (deviated septum, inferior turbinate hypertrophy, internal nasal
cantly reduce the AHI in some patients. CPAP or bilevel CPAP is valve collapse, nasal polyps, or bony spurs) should be corrected in
titrated to pressures sufficient to eliminate upper airway obstruc- all patients, including those managed nonsurgically. Nasal recon-
tion by preventing soft tissue collapse. It is a highly effective treat- struction may include a septoplasty, radiofrequency inferior turbi-
ment if the patient is able to tolerate the device (noncompliance nate reduction (somnoplasty), spreader grafts, or polypectomy.
is the major reason for failure of this modality). Autotitrating The soft palate (retropalatal oropharynx) can be addressed by
continuous positive airway pressure (APAP) can automatically surgical ablation or radiofrequency volumetric reduction (somno-
adjust the pressure while the patient sleeps, compensating for plasty). Uvulopalatopharyngoplasty (UPPP) was popularized by
rapid eye movement sleep and position changes. Despite these otolaryngologists as an alternative to tracheotomy and was fre-
advantages, APAP has limitations, and patient selection is impor- quently and injudiciously recommended to almost all patients.
tant when prescribing this device. Long-term compliance with When UPPP was the sole surgical modality, success rates were less
CPAP devices is much lower than the self-reported compliance, than 50%. Failures were attributed to obstructions at the level of
and the overall acceptance rate is near 50%. Several US Food and the base of tongue, which were not addressed with UPPP. Others,
Drug Administration–approved mandibular repositioning or ad- who viewed the UPPP procedure as too radical with an unaccept-
vancement appliances are available such as the Herbst appliance able incidence of velopharyngeal insufficiency and hypernasality,
(Fig. 96.1), TAP3, and SomnoDent. They work by positioning advocated for the more conservative uvulopalatoplasty or uvulo-
the mandible and tongue forward (50%–100% of maximum palatal flap procedures. More recently, soft palate pillar implants
protrusive movement as tolerated), which brings the attached soft have been introduced to stiffen the soft palate, reducing the
amount of snoring and improving sleep apnea.
The retrolingual oropharyngeal and hypopharyngeal airway
space can be improved with procedures that advance the genio-
glossus muscle and hyoid bone. The anterior mandibular osteot-
omy (genial window osteotomy, preferred when the pogonion is
in normal position) or inferior sagittal osteotomy (sliding genio-
plasty, preferred when the pogonion is retropositioned) advances
the genioglossus and geniohyoid muscles. The hyoid bone can be
further positioned superiorly and anteriorly with a hyoid myot-
omy and suspension (the hyoid bone is suspended to the anterior
mandible) or with a modified hyoid suspension technique (the
hyoid bone is secured to the thyroid cartilage). When UPPP or
uvulopalatoplasty is combined with a genial tubercle advance-
ment with or without hyoid suspension, substantially higher suc-
cess rates are reported.
Maxillomandibular advancement has been shown to improve
posterior airway space and to increase the stability of the lateral
pharyngeal wall, countering its tendency to collapse. Maxilloman-
dibular advancement may be performed in various stages of surgi-
cal treatment, depending on the surgeon’s preference and the
• Fig. 96.1 Herbst appliance. Bimaxillary appliance. Note the advancement clinical indications. The maxillomandibular complex is typically
of the mandible, which has the effect of advancing the genial tubercles and advanced 10 mm. Adjunctive procedures (UPPP, genial advance-
increasing the airway space. (Courtesy of Dr. Daniel Levy-Bercowski, DDS. ment, hyoid suspension) can be performed based on site-specific
Department of Plastic, Maxilloacial, and Oral Surgery, Duke University, principles. Success rates vary in the literature. Waite and colleagues
Durham, NC.)

t.me/Dr_Mouayyad_AlbtousH
504 S E C TI O N XIV Syndromes of the Head and Neck

reported a 65% success rate (AHI , 10) when maxillomandibular risk of velopharyngeal insufficiency is greater when UPPP is com-
advancement was the sole treatment. Prinsell reported 100% suc- bined with maxillomandibular advancement. Li and colleagues
cess (AHI , 10) in 50 consecutive patients when maxilloman- reported a less than 10% incidence of “mild” velopharyngeal in-
dibular advancement was combined with genial advancement. sufficiency with simultaneous maxillary advancement and UPPP.
Upper airway stimulation (UAS) is a relatively recent addition
to the surgical options for patients with OSA. Hypoglossal nerve Discussion
stimulators (e.g., Inspire) are implantable devices that cause selec-
tive stimulation of the hypoglossal branches that supply the muscles Although many possible surgical procedures can aid in correction
producing protrusion of the tongue while excluding branches sup- of OSA, no surgery is indicated in all circumstances, and success
plying muscles that cause tongue retrusion. When the patient turns is maximized when a surgery is chosen to address the anatomic
the device on before sleep, hypoglossal nerve stimulation begins and location responsible for the patient’s disease. In 1993, Riley et al.
is synchronized with the patient’s breathing. Indications for this released what was termed as the Stanford protocol for the surgical
therapy include adult patients with AHI from 15 to 65 with less treatment of patients with sleep apnea. They developed a site-
than 25% central apneas. Notably, the device is not approved for specific and staged algorithm for treating airway obstructions. The
patients with concentric velopharyngeal collapse. Within these pa- protocol began with presurgical evaluation, consistent with the
rameters, UAS therapy boasts a high success rate and is becoming workup outlined at the beginning of this chapter. Attention was
more popular among surgeons offering OSA treatments. specifically given to locating the level of obstruction so that the
The current patient was not a candidate for UAS therapy because surgical procedure could be prescribed based on where the ob-
of the concentric collapse of his velopharynx during DISE. Because struction was occurring. Patients then moved into phase 1 of
the patient had multilevel obstruction with retrognathia, he decided surgical treatment, which consisted of UPPP for oropharyngeal
to move straight to maxillomandibular advancement as a first-line obstructions, inferior mandibular osteotomy and genioglossal
surgical therapy. Postoperative PSG 6 months later showed a reduc- advancement with hyoid myotomy and suspension (MOHM) for
tion in his AHI to 14. The patient was happy with the result and hypopharyngeal obstructions, or a combination of UPPP and
decided not to pursue additional therapies at this time. MOHM for obstructions at both the oropharyngeal and hypo-
pharyngeal levels. After phase 1 treatment, the patient would be
Complications reevaluated with PSG 6 months after surgery. If phase 1 surgical
treatment had failed to adequately treat the OSA, then the patient
The morbidity and mortality of untreated OSAS far outweigh the would move to phase 2 treatment, which consisted of maxillo-
individual complications of nonsurgical and surgical intervention. mandibular advancement (MMA). Riley et al. revised this proto-
He and associates reported the 8-year survival rate of patients with col in 2018. Among other changes, the algorithm became less
an AHI greater than 20% to be 63%; an RDI of less than 20 cor- linear, for instance, allowing practitioners to move straight to
responded to an 8-year survival rate of 96%. Hypertension is seen maxillomandibular advancement as a first-line treatment while
in one-third to two-thirds of all OSAS cases and is a major risk still permitting multilevel treatments to be performed subsequent
factor for coronary artery disease, congestive heart failure, and cere- to MMA procedures, if necessary. They also included new treat-
brovascular accident. Untreated OSAS results in higher mortality ments to the algorithm, such as UAS.
rates from cardiovascular events. Untreated OSAS also increases the The hallmark of current practice for the surgical treatment of
incidence of transient ischemic attacks and stroke, and this correla- OSA is to match procedures to their respective indications. As
tion may be stronger than that with coronary artery disease. Studies clinical practice and research progresses, surgeons will be able to
have also shown that daytime somnolence associated with OSAS is more confidently treat patients with OSA while avoiding untow-
a major cause of traffic-related accidents and death. ard consequences of unnecessary surgeries.
Complications are specific for individual procedures, which
are beyond the scope of this section. Velopharyngeal insufficiency ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
is a well-documented postoperative complication of UPPP. The complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 504.e1

Bibliography Liu SY, Riley RW, Yu MS: Surgical algorithm for obstructive sleep apnea:
an update, Clin Exp Otorhinolaryngol 13(3):215-224, 2020.
Mannarino M, Di Filippo F, Pirro M: Obstructive sleep apnea syndrome,
Angelo J, De Dios A, Brass S: New and unconventional treatments for Eur J Intern Med 23(7):506-593, 2012.
obstructive sleep apnea, Neurotherapeutics 9(4):702-709, 2012. Morganthaler TI, Kapen S, Lee-Chiong T, et al: Practice parameters for
Carvalho B, Hsia J, Capasso R: Surgical therapy of obstructive sleep ap- the medical therapy of obstructive sleep apnea, Sleep 29(8):1031-
nea, Neurotherapeutics 9(4):710-716, 2012. 1035, 2006.
Chaples S, Rowley J, Prinsell J, et al: Surgical modifications of the airway Prinsell JR: Maxillomandibular advancement surgery in a site-specific
for obstructive sleep apnea in adults: a systemic review and meta- treatment approach for obstructive sleep apnea in 50 consecutive pa-
analysis, Sleep 33:1396-1407, 2010. tients, Chest 116(6):1519-1529, 1999.
Chung F, Yegneswaran B, Liat P, et al: STOP questionnaire: a tool to Riley RW, Powell NB, Guilleminault C: Maxillary, mandibular, and hy-
screen patients for obstructive sleep apnea, Anesthesiology 108:812- oid advancement for treatment of obstructive sleep apnea: a review of
821, 2008. 40 patients, J Oral Maxillofac Surg 48(1):20-26, 1990.
Chung F, Yegneswaran B, Liat P, et al: Validation of the Berlin question- Riley RW, Powell NB, Guilleminault C: Obstructive sleep apnea syn-
naire and American Society of Anesthesiology check list as screening drome: a review of 306 consecutively treated surgical patients, Otolar-
tolls for obstructive sleep apnea in surgical patients, Anesthesiology yngol Head Neck Surg 108(2):117-125, 1993.
108:822-830, 2008. Shirin S: Perioperative management of obstructive sleep apnea: ready for
Chung S, Hongbo Y, Chung F: A systemic review of obstructive sleep prime time? Cleve Clin J Med 76(4):98-103, 2009.
apnea and its implications for the anesthesiologist, Anesth Analg Waite PD, Wooten V, Lachner J, et al: Maxillomandibular advancement
107(5):1543-1563, 2008. surgery in 23 patients with obstructive sleep apnea syndrome, J Oral
He J, Kryger MH, Zorick FJ, et al: Mortality and apnea index in obstruc- Maxillofac Surg 47(12):1256-1261, 1989.
tive sleep apnea. Experience in 385 male patients, Chest 94(1):9-14, Yaggi HK, Concato J, Kernana WN, et al: Obstructive sleep apnea as a
1988. risk factor for stroke and death, N Eng J Med 353:2034-2041, 2005.
Lee NR, Givens CD Jr, Wilson J, et al: Staged surgical treatment of ob- Young T, Palta M, Dempsey J, et al: The occurrence of sleep-disorder breath-
structive sleep apnea syndrome: a review of 35 patients, J Oral Maxil- ing among middle-age adults, N Engl J Med 328:1230-1235, 1993.
lofac Surg 57(4):382-385, 1999. Young T, Peppard PE, Gottlieb DJ: Epidemiology of obstructive sleep
Li KK, Troell RJ, Riley RW, et al: Uvulopalatopharyngoplasty, maxillo- apnea: a population health perspective, Am J Crit Care Med 165:
mandibular advancement, and the velopharynx, Laryngoscope 111(6): 1217-1239, 2002.
1075-1078, 2001.

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97
Congestive Heart Failure
SEPIDEH SABOOREE, MICHAEL R. MARKIEWICZ , FARANGIS FARSIO, and KEVIN C. LEE

CC There are multiple risk factors for the acute decompensation of

chronic stable heart failure (HF). The most common precipitants are
A 65-year-old male presents to the emergency department after a nonadherence to fluid restriction, sodium restriction, and medica-
witnessed mechanical fall complaining of “a bad bite and short- tion regimens. Noncardiac causes of decompensated HF include
ness of breath.” systemic infections, which generate inflammation and an increased
cardiac demand. Lower respiratory infections can further produce
HPI worsening pulmonary edema and dyspnea through capillary leakage.
Cardiac arrhythmias or myocardial infarctions can rapidly impair
The patient had been unloading his groceries when he tripped on systolic function and lead to acute decompensation. In the current
the sidewalk and fell forward, hitting his chin. There was no re- case, there are multiple contributions to the patient’s acute decom-
ported loss of consciousness, and no other traumatic bodily inju- pensation, including noncompliance and a history of CAD.
ries were sustained. Upon arrival, he was noted to be in moderate
respiratory distress with oxygen saturation of 92%. Head-of-bed Examination
elevation and supplementary oxygen administration slightly im-
proved his dyspnea, but he continued to exhibit increased work of Advanced Trauma Life Support (ATLS) primary survey. Negative
breathing. The oral and maxillofacial surgery service was con- except for moderate respiratory distress. The patient was immedi-
sulted to manage his head and neck injuries. ately placed on supplemental oxygen via a face mask, however given
his persistently increased work of breathing he was escalated to high-
PMHX/PDHX/Medications/Allergies/SH/FH flow nasal canula (HFNC) with an improvement in oxygenation.
(HFNC is less invasive than continuous positive airway pressure and
The patient has a history of coronary artery disease treated with bilevel positive airway pressure and can generate low levels of posi-
an angioplasty and a drug-eluting stent 2 years earlier for which tive airway pressure, reduce respiratory dead space, and decrease
he is on lifelong aspirin therapy. On his most recent transthoracic work of breathing.)
echocardiogram, he was found to have ejection fraction of 30% General. The patient is awake; alert; and oriented to person,
(normal, 50%–70%). He is taking lovastatin (an HMG-CoA re- time, and place. (Confusion and altered mental status are signs of
ductase inhibitor [cholesterol-lowering medication]), furosemide circulatory failure and cardiogenic shock.) He appears fatigued
(a loop diuretic), lisinopril (angiotensin-converting enzyme and shows increased respiratory effort.
[ACE] inhibitor), and metoprolol (beta-blocker). He admits to Vital signs. Blood pressure is 90/75 mm Hg (hypotensive with a
poor medication compliance (risk factor for congestive heart fail- narrow pulse pressure), heart rate is 120 bpm (tachycardia), respirations
ure [CHF] exacerbation). He also has type 2 diabetes mellitus that are 28 breaths per minute (tachypnea), and temperature is 37.1°C.
is managed with metformin and canagliflozin (a sodium-glucose Maxillofacial. Anterior open bite with bilateral posterior
transport protein 2 [SGLT-2] inhibitor). The patient is a current crossbite consistent with suspected Guardsman’s fracture pattern
daily smoker with a 40-pack-year history (risk factor for coronary (mandibular symphysis with bilateral condylar neck fractures).
artery disease [CAD]). He has no known medication allergies. His Cardiovascular. Fast but regular rhythm with normal S1 sound
only prior surgery was his percutaneous coronary intervention. (closure of mitral and tricuspid valves) and S2 sound (closure of
Coronary artery disease involves varying degrees of impaired aortic and pulmonic valves). An S3 sound is auscultated at the left
blood supply (oxygen) to the myocardium (causing ischemic heart sternal border at the fifth intercostal space. (An S3 sound is heard
disease), which puts the heart at risk for ischemic events (angina, in early diastole during rapid ventricular filling phase, associated
myocardial infarction), with potential functional impairment of the with increasing filling pressures, and more common in dilated
myocardium and subsequent systolic dysfunction. The inability to ventricles.) The point of maximum impulse (generated by the left
efficiently pump blood out of the heart leads to the backup of blood ventricle as it touches the inner chest wall during systole) is later-
in the heart and lungs (congestion), which is the mechanism of ally displaced with a parasternal heave (elevation of the chest wall
CHF. Risk factors for CHF include CAD (causes 50%–75% of to the left of the sternum). The jugulovenous pressure is elevated
cases), uncontrolled systemic hypertension, valvular heart disease, at 15 cm (normal, ,9 cm) with a positive hepatojugular reflex
cardiomyopathy (dilated or hypertrophic), stress (Takotsubo), drugs (distension of the jugular veins on application of pressure in
(alcohol, cocaine, chemotherapy), and infections (viral myocarditis). the right upper abdominal quadrant). Hepatojugular reflex and

506
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 97 Congestive Heart Failure 507

elevated jugulovenous pressure are signs of venous congestion Abdominal. Nontender and nondistended with hepatomeg-
observed in association with HF and volume overload. aly. The liver was percussed at 10 cm below the costal margin
Pulmonary. Use of the accessory muscles of respiration (ster- (hepatic congestion caused by right-sided HF).
nocleidomastoid, scalenes, pectoralis major and minor, and ser- Extremity. The extremities are cool to the touch (suggesting
ratus anterior muscles). Dyspnea is exacerbated when the patient diminished perfusion). The lower extremities show 31 pitting
assumes the supine position (orthopnea). Bilateral basilar rales edema at the ankles up to the midshin (significant fluid in the
(fluid in the alveolar spaces) with dullness to percussion (caused extravascular compartments caused by venous congestion, causing
by pleural effusions) in the lung bases. (Fluid accumulation in the capillary leakage; this is usually first noted in the lower extremities
lungs is secondary to left-sided HF.) because of the added effect of gravity; Fig. 97.1).

7 Jugular venous
distension

Lungs
External
jugular
veins
4 Pulmonary congestion
(Pulmonary edema)
(Backward failure)
5 • Shortness of breath
Pulmonary
hypertension
Pulmonary Pulmonary
artery veins

3 LA hypertrophy
Mitral regurgitation
RA PV LA 2
SVC Afterload
6 MV
AV Contractility
Right heart TV
failure RV
LV
IVC 1
Heart failure Arterial
( cardiac output) circulation
“Backward failure”

8 Hepatomegaly

Liver RA: Right atrium

RV: Right ventricle
LA: Left atruim
LV: Left ventricle
AV: Aortic valve
MV: Mitral valve
PV: Pulmonic valve
TV: Tricuspid valve
IVC: Inferior vena cava
SVC: Superior vena cava

9 Capillary beds
10
Capillary Cardiac output 5 Heart rate 3 Stroke
Pedal edema
leakage Stroke volume depends on:

1. Afterload
11 2. Preload
Ascites 3. Contractility of heart

• Fig. 97.1 Congestive heart failure.

t.me/Dr_Mouayyad_AlbtousH
508 S E C TI O N X Medical Conditions

Imaging Electrocardiogram Findings

A chest radiograph is the minimum imaging modality for the The electrocardiographic findings for the current patient were as
evaluation of CHF exacerbation. This is valuable for the evalua- follows:
tion of pulmonary edema and infiltration and for the approxi- Rate. Tachycardic at 120 bpm.
mation of the heart size. Echocardiography (transthoracic or Rhythm. Regular; each P wave followed by a QRS complex; each
transesophageal) is also useful for the evaluation of ventricular QRS complex preceded by a P wave; QRS complexes occur-
and valvular function and determination of the ejection frac- ring at regular intervals.
tion. The earliest finding of left-sided HF on the chest radiogra- Axis. Positive deflection in lead I; negative deflection in lead aVF
phy is cephalization of the pulmonary vessels. Normally, the (indicative of left-axis deviation secondary to left ventricular
vessels in the lung bases are larger and more numerous than hypertrophy).
those in the lung apices. This is secondary to the effects of grav- Intervals. PR interval less than 0.20 second, or 5 small boxes on
ity and the anatomically larger volume of the lungs at the base. electrocardiograph paper (.5 small boxes is consistent with
With the progression of HF, the increased pressure is transmit- first-degree atrioventricular node block); QRS complex less
ted “backward” to the pulmonary veins and capillaries (hence than 0.12 second, or 3 small boxes (.3 small boxes indicates
the term “backward failure”). The lung bases are affected first; widened QRS complex); QT interval less than half the dis-
therefore, blood is preferentially “shunted” to the upper, or more tance from QRS complex to QRS complex (normal).
cephalad, lobes, giving the radiographic appearance of cephali- Infarctions. Q waves in leads V1 through V5 (hallmark of old
zation. If the pressure in the vessels continues to rise, the fluid anteroseptal myocardial infarction); no flipped T waves, and
in the interstitium becomes radiographically evident as intersti- no ST-segment elevation or depression (signs of acute ischemic
tial edema, bronchial wall thickening, and interlobular septa. events).
The most noticeable are the Kerley B lines. These are short, thin, Other. Loss of precordial R wave progression in leads V1 through
perpendicular lines extending to the pleura at the lung bases on V6 (suggestive of old anteroseptal MI and loss of anterior elec-
a chest radiograph. The following imaging findings were noted trical forces).
for the current patient.
Chest radiograph. Bilateral blunting of the costophrenic an- Assessment
gles with pronounced infiltrates in the lower lobes (consistent
with bilateral pleural effusions and pulmonary edema). A 65-year-old male status after a mechanical fall with a history of
Cephalization of the pulmonary vessels bilaterally. In- heart disease now presenting with acute CHF exacerbation and a
creased cardiac silhouette. (An increased cardiac silhouette, complex mandible fracture.
spanning more than one-third of the thoracic cavity on an an-
teroposterior film, is indicative of an enlarged heart or dilated Treatment
cardiomyopathy.)
Transthoracic echocardiography. Dilated left ventricle con- The cardiology service was consulted for management and preop-
sistent with dilated cardiomyopathy with decreased wall motion erative optimization, and the patient was treated with aggressive
(systolic dysfunction) and mild mitral regurgitation. The pul- fluid and salt restriction and intravenous Lasix (furosemide, a loop
monic, aortic, and tricuspid valves were without stenosis or regur- diuretic). His home metoprolol was temporarily held because of its
gitation. The ejection fraction was estimated at 25% (compro- negative inotropic effects; likewise, the home lisinopril was held
mised ventricular function). No pericardial fluid and normal wall because of the hypotension and concern for renal injury. Inotropic
thickness were seen in all four chambers. Moderate elevation of support was considered because of the relative hypotension and
the pulmonary artery pressure was noted. cool extremities on examination; however, it was not required be-
Computed tomography (CT) (maxillofacial and neck). Bilat- cause of the good urine output and mental status which argued
eral medially displaced condylar neck fractures with a mildly dis- against the presence of cardiogenic shock. The patient’s cardiovas-
placed and widened symphysis fracture. Cervical spine without any cular symptoms and findings gradually improved within 36 hours
abnormalities. (A CT scan of the chest can also be used to further (decreased shortness of breath, orthopnea, and paroxysmal noctur-
evaluate the pulmonary parenchyma and cardiac structures.) nal dyspnea; resolution of peripheral edema and pleural effusions;
decrease in cardiac biomarker BNP level). He remained chest pain
Labs free and hemodynamically and electrically stable (no arrhythmias).
After his volume status normalized, he was restarted on his home
Brain natriuretic peptide (BNP) level was 2000 pg/mL (normal, regimen of lisinopril and metoprolol. After a careful perioperative
,100 pg/mL). cardiac risk assessment, the patient was taken to the operating room
With CHF, increased pressure and workload on the heart trig- for open reduction and internal fixation of the mandibular fractures
ger the myocardial cells to secrete natriuretic peptides. Atrial myo- under general anesthesia.
cytes secrete increased amounts of atrial natriuretic peptide, and
the ventricular myocytes secrete both atrial and BNPs in response Discussion
to the high atrial and ventricular filling pressures. Both of these
peptides work as natriuretic, diuretic, and vasodilator agents and Heart failure can result from any structural or functional cardiac
help reduce both preload and afterload. The plasma concentrations disorder that impairs the ability of the heart to pump blood
of both hormones are increased in patients with asymptomatic and (Fig. 97.1). It is characterized by several symptoms, such as dys-
symptomatic CHF. Of note, natriuretic peptide levels can be nor- pnea, fatigue, edema, and weight gain. There are several causes
mal in HF with preserved ejection fracture (HFpEF) because there of HF, including myocarditis or endocarditis (viral or bacterial in-
is less myocardial stretch. fections), ischemic heart disease, infiltrative disease (amyloidosis,

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 CHAPTER 97 Congestive Heart Failure 509

sarcoidosis), peripartum cardiomyopathy, hypertension, human The ACC/AHA classification is based on the chronology of
immunodeficiency virus infection, connective tissue disorders, sub- disease progression and provides accompanying treatment guide-
stance abuse, certain chemotherapy drugs, and idiopathic origin. lines for each stage. The most recent 2022 ACC/AHA classifica-
Fluid retention in HF is initiated by the fall in cardiac output, tion and treatment guidelines can be found in Table 97.1.
leading to edema and decreased effective arterial volume. The re- Heart failure may be considered as either primarily right or left
duction of cardiac output sets into motion a cascade of hemody- sided depending on the underlying pathology; however, symp-
namic and neurohormonal derangements that provoke activation toms of both right- and left-sided HF may occur separately or
of the renin–angiotensin–aldosterone and sympathetic nervous concurrently, as in the current case. The most common cause of
systems. Although initially beneficial in the early stages of HF, right-sided HF is left-sided failure because sustained left-sided HF
these compensatory mechanisms eventually lead to a vicious cycle eventually causes right-sided HF. With right-sided HF, there are
of worsening HF, fluid retention, and volume overload. elevation of the jugulovenous pressure, peripheral edema, and
The classification systems used for the management of CHF are hepatomegaly. In left-sided HF, fluid backs up in the lungs, caus-
based on the severity of the condition, systolic versus diastolic dys- ing dyspnea, cough, pleural effusions, and rales.
function, and left-sided versus right-sided failure. The two main Among patients with primarily left-sided HF, the systolic ver-
classifications of HF are the New York Heart Association (NYHA) sus diastolic designation of HF involves determining whether
classification (most commonly used) and the American College of failure is the result of impaired contraction or inefficient relax-
Cardiology/American Heart Association (ACC/AHA) classification. ation. Systolic dysfunction is commonly defined as HF secondary
The NYHA classifies patients into one of four functional catego- to impaired or reduced ejection fraction (LVEF ,40%, HFrEF),
ries based on the amount of effort needed to elicit HF symptoms. whereas diastolic dysfunction is characterized by HF in the setting
The NYHA also includes an objective assessment to stratify the of preserved ejection fraction (LVEF 50%; HFpEF). The most
clinical extent of heart disease regardless of symptomatology. This recent 2022 diagnostic HF guidelines classify patients with LVEF
objective assessment of cardiovascular disease is determined using between 41% and 49% as having HF with mildly reduced EF
data from electrocardiograms, stress tests, echocardiograms, and ra- (HFmrEF). Causes of systolic HF include hypertension, valvular
diologic imaging. Therefore, the comprehensive classification in- disease, arrhythmias, and ischemic insults from CAD. Causes of
cludes a description of both the functional capacity and the objective diastolic dysfunction include myocardial hypertrophy and infil-
assessment (e.g., Functional Capacity IV, Objective Assessment A). trative cardiomyopathy (cardiac amyloidosis).
The pharmacotherapy of patients with HF is aimed at improv-
Functional Classification ing cardiac function (contractility and stroke volume) and reduc-
ing the workload of the heart (preload and afterload reduction).
• Class I: symptoms of HF only at levels that would limit nor- Traditionally, patients with HFrEF were managed with a three-
mal individuals drug regimen consisting of a mineralocorticoid receptor antago-
• Class II: symptoms of HF with ordinary exertion nist (MRA), an ACE inhibitor or an angiotensin receptor blocker
• Class III: symptoms of HF on less than ordinary exertion (ARB), and a beta-blocker. The most recent 2022 ACC/AHA/
• Class IV: symptoms of HF at rest HFSA guidelines on HF management now advocate for quadru-
ple therapy in the context of HFrEF. First, ACE inhibitors and/
Objective Assessment ARBs have been supplanted by angiotensin-receptor neprilysin
inhibitors (ARNis), such as Entresto (sacubitril–valsartan), for
• Class A: no objective evidence of cardiovascular disease first-line treatment. Among patients who cannot tolerate ARNis,
• Class B: objective evidence of minimal cardiovascular disease ACE inhibitors and ARBs are now considered acceptable second-
• Class C: objective evidence of moderately severe cardiovascular line alternatives. The 2022 guidelines added a fourth drug to the
disease disease modifying HFrEF regimen: SGLT-2 inhibitors. For pa-
• Class D: objective evidence of severe cardiovascular disease tients with HFpEF, the recommended regimen likewise includes

TABLE
97.1 2022 American College of Cardiology/American Heart Association Classification and Treatment Guidelines

Stage Characteristics Treatment

A At high risk for HF: patients with no current symptoms Lifestyle changes, blood pressure control, SGLT-2 inhibitor for diabetics
and no structural or functional heart disease
B Pre-HF: patients with structural heart disease or evi- ACE inhibitor or ARB 1 beta-blocker (devices such as defibrillators in appropriate pa-
dence of increased heart filling pressures but with tients)
no signs or symptoms
C Symptomatic HF: patients with current or previous Routine use of diuretics, ACEI, or beta-blockers and aldosterone antagonist, ARNi, ARB,
signs or symptoms of HF digitalis, SGLT-2 inhibitors or hydralazine or nitrates, and devices such as biventricu-
lar pacing or implantable defibrillator in selected patients
D Advanced HF: marked HF symptoms that interfere Medications from stages A–C with optional palliative care, heart transplantation,
with daily life and recurrent hospitalizations chronic inotropes, permanent mechanical support, or experimental surgery or drugs

ACE, Angiotensin-converting enzyme; ARB, angiotensin receptor blocker; ARNi, angiotensin-receptor neprilysin inhibitor; HF, heart failure; SGLT-2, sodium-glucose transport protein 2.

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510 S E C TI O N X Medical Conditions

ARNIs, SGLT-2 inhibitors, and MRA with the exclusion of beta- hypoglycemic agents were initially developed for the management
blockers. The value of ARNIs and SGLT-2 inhibitors drugs has of metformin refractory type 2 diabetes. However, since their
been established by the results of numerous large-scale clinical introduction, multiple studies have also found that SGLT-2
trials. All of the HF drugs are typically titrated based on symp- inhibitors also significantly decreased HF-related hospitalizations
tomatology to their maximally tolerated dose. regardless of diabetic status. Following the results of multiple
The MRAs, or aldosterone antagonists, inhibit the reabsorp- well-designed studies, SLGT-2 inhibitors have been added to the
tion of sodium or chloride at the collecting duct. The MRAs have standard regimens for treating all three categories of left-sided HF
been shown in long-term trials to reduce death and HF hospital- (HFpEF, HFmrEF, and HFrEF).
izations and to improve the functional class for patients with Therapy with digoxin as a fifth agent may be initiated at any
NYHA class III or class IV symptoms. Aggressive diuresis for pa- time to reduce HFrEF symptoms, prevent hospitalization, control
tients with acute decompensated HF can lead to electrolyte dis- rhythm, and enhance exercise tolerance. Digoxin is a digitalis
turbances; therefore, providers should trend serum chemistries glycoside that inhibits sodium-potassium (Na1-K1) adenosine
when attempting to restore a euvolemic state. Dietary sodium triphosphatase. Inhibition of this enzyme in cardiac cells and va-
restriction is equally important to avoid overloading the body’s gal afferent fibers results in an increase in the contractile state of
excretion capacity. the myocardium and reduction in sympathetic outflow from the
Chronic treatment with an ARNIs should be initiated and central nervous system, respectively. Unlike other medications,
maintained in patients who can tolerate them. The dual action of digoxin only provides symptomatic relief and does not reduce
inhibiting the major cardiovascular system regulators has made mortality rates among patients with HF.
ARNis the preferred option. Before the 2022 updates, ACE inhibi- Other treatments can be initiated in patients with HF. The
tors and ARBs had traditionally been used, and their mechanisms combination of hydralazine and isosorbide dinitrate reduces mor-
and benefits are well studied. These medications dilate the periph- tality rates in patients with HF who remain symptomatic despite
eral vasculature and reduce the systolic effort of the heart while si- optimal medical therapy, particularly in the African American
multaneously improving preload and cardiac output. Similarly, cohort of patients. Hydralazine and isosorbide are arterial and
ACE inhibitors and ARBs improve renal sodium waste and decrease venodilators that act by lowering systemic vascular resistance
volume retention. Importantly, they have been shown to favorably (afterload). Other advanced therapies for patients with HF include
influence long-term mortality in patients with HF through neuro- intraaortic balloon counterpulsation, cardiac resynchronization,
hormonal blockades that prevent cardiac remodeling. and left ventricular assist devices.
Beta-blockers act principally to inhibit the adverse effects of
the sympathetic nervous system in patients with HF. Sympathetic Conclusion
activation can increase ventricular volumes and pressure by caus-
ing peripheral vasoconstriction and by impairing sodium excre- Trauma patients commonly present with exacerbations of under-
tion by the kidneys. Long-term treatment with beta-blockers can lying medical conditions because of increased physiologic stress,
lessen the symptoms of HF, improve the patient’s clinical status, and attention should be given to the overall status of the patient.
and enhance the patient’s overall sense of well-being. Like with Early recognition of an acute exacerbation of a preexisting medi-
MRAs, ARNIs, ACE inhibitors, and ARBs, beta-blockers are cal condition, such as CHF, is critical for preoperative medical
beneficial in the context of long-term HF outcomes but should be optimization. A thorough physical examination and a high index
temporarily held during acute decompensated states of shock or of suspicion must be maintained to assess cardiac, pulmonary, and
hypoperfusion. volume status.
The SGLT-2 inhibitors (canagliflozin, dapagliflozin, and em-
pagliflozin) promote glycosuria by blocking the reabsorption of ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
glucose and sodium in the proximal renal tubules. These newer complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 510.e1

Bibliography A Report of the American College of Cardiology/American Heart

Association Joint Committee on Clinical Practice Guidelines, J Am
Coll Cardiol 79(17):1757-1780, 2022.
Dickstein K, Cohen-Solal A, Filippatos G, et al: ESC guidelines for the Knudsen CW, Omland T, Clopton P, et al: Diagnostic value of B-type
diagnosis and treatment of acute and chronic heart failure 2008: the natriuretic peptide and chest radiographic findings in patients with
Task Force for the Diagnosis and Treatment of Acute and Chronic acute dyspnea, Am J Med 116:363, 2004.
Heart Failure 2008 of the European Society of Cardiology. Developed The Criteria Committee of the New York Heart Association: Nomencla-
in collaboration with the Heart Failure Association of the ESC (HFA) ture and criteria for diagnosis of diseases of the heart and great vessels, ed
and endorsed by the European Society of Intensive Care Medicine 9, Boston, MA, 1994, Little, Brown & Co.
(ESICM), Eur J Heart Fail 10(10):933-989, 2008. Young JB, Gheorghiade M, Uretsky BF, et al: Superiority of “triple” drug
Grady KL, Dracup K, Kennedy G, et al: Team management of patients therapy in heart failure: insights from the PROVED and RADI-
with heart failure: a statement for healthcare professionals from the ANCE trials—prospective randomized study of ventricular function
Cardiovascular Nursing Council of the American Heart Association, and efficacy of digoxin; randomized assessment of digoxin and in-
Circulation 102:2443, 2000. hibitors of angiotensin-converting enzyme, J Am Coll Cardiol 32(3):
Heidenreich PA, Bozkurt B, Aguilar D, et al: 2022 AHA/ACC/HFSA 686-692, 1998.
Guideline for the Management of Heart Failure: Executive Summary:

t.me/Dr_Mouayyad_AlbtousH
98
Cardiac Arrest
S TA N F O R D PL AVI N, PIY U SH K U M A R P. PAT E L , a n d C L A I R E M I L L S

CC stop timeout was agreed upon by the staff present. After comple-
tion of the time-out and before the initiation of any sedation, the
A 61-year-old male undergoing extraction of carious teeth with patient reported feeling heaviness in his chest and some difficulty
deep sedation develops ventricular tachycardia (VT). in breathing. Immediate review of his ECG tracing revealed VT
(wide QRS with the absence of atrial waveforms).
HPI The procedure was aborted, and immediate treatment for the
patient’s arrhythmia and symptoms was initiated. Activation of
The patient, a 61-year-old male who denies any previous past the emergency medical services (EMS) system occurred, and con-
medical history, was referred by his dentist for extraction of mul- tinued assessment of the patient and treatment options were im-
tiple carious teeth. He was seen for a consult during which time mediately evaluated.
he was found to have carious teeth #2, #3, #4, and #5. At the time
of his consultation, he was noted to be extremely anxious and in PMHX/PDHX/Medications/Allergies/SH/FH
severe pain from his teeth, which have been symptomatically
painful off and on for the past month. Upon further questioning, the patient, who is 5 feet, 10 inches tall
The risks, benefits, options, and potential complications for and weighs 110 kg (body mass index, 34), denied any significant
removal of the carious teeth were discussed with the patient, as well past medical history but did report that he had not seen his physi-
as the anesthetic options for his proposed surgical extractions. The cian in some time. He only visited his dentist for evaluation of his
patient demonstrated a good understanding of the proposed pro- dental pain. Of note, jaw and tooth pain along with retrosternal
cedure and anesthesia options; he elected to have them performed discomfort can be seen and are common during myocardial isch-
under deep sedation as soon as possible. He was scheduled for the emia. Consequences of myocardial ischemia include silent isch-
next day. On the day of surgery, after confirming preprocedure emia, Prinzmetal angina, or acute coronary syndrome (unstable
protocols had been met (including patient factors [nothing by angina, non–ST-elevation myocardial infarction, ST-elevation
mouth status, consent, appropriate escort presence], procedure myocardial infarction). He has smoked a half of cigarettes a pack
factors [room ready, radiography and necessary instruments ready], per day for 30 years but has been trying to quit recently. He also
and emergency factors [verification that emergency equipment and reports drinking four or five beers every week. His activity is lim-
supplies are available in case the need arises]), the patient was ited because he works as a computer programmer and sits behind
brought to the procedure room. He was positioned in the chair, a desk 8 to 10 hours per day. His wife of 34 years notes that he
and standard monitors were attached. snores very heavily at night and sometimes seems to gasp for air.
The use of dynamic electrocardiogram (ECG) monitoring is Patients should be considered to have coronary artery disease
regarded as a standard of care during the provision any anesthetic (CAD) or coronary heart disease if they have at least two of the
and is recommended even in the absence of general anesthesia following risk factors: hypertension, diabetes, hyperlipidemia
cases. (This device is variably referred to as an ECG or as an EKG, with cholesterol greater than 240 mg/dL, smoking, and age older
the latter based on the Greek term “kardia” for heart. Some pro- than 60 years. Male gender, genetics, and other poor lifestyle
viders prefer EKG to ECG because it is less likely to be confused choices such as a high-fat, high-cholesterol diet and a sedentary
verbally with EEG, the abbreviation for an electroencephalo- lifestyle, are additional risk factors (Table 98.1).
gram.) In addition to three-lead ECG monitoring, pulse oximetry Coronary artery disease is hardening, narrowing, or dysfunc-
and a blood pressure cuff were also applied. The patient was ini- tion of the blood vessels that supply oxygen to cardiac muscle, thus
tially provided with 2 L/min of oxygen via nasal cannula with causing an imbalance between myocardial oxygen demand and
end-tidal CO2 monitoring capability. Intravenous (IV) access was supply. CAD is the most common type of heart disease and is the
established with a 22-gauge IV needle in the left antecubital fossa. leading cause of myocardial infarction (MI). More than 550,000
The patient was noted to be quite anxious but denied any addi- deaths per year in the United States are attributable to CAD, mak-
tional concerns at this time. Initial blood pressure was 146/94 ing it the leading cause of death in both males and females. The
mm Hg, heart rate was 99 bpm, respirations were 20 breaths per American Heart Association (AHA) estimates that every minute,
minute, and oxygen saturation was 98% on 2-L/min nasal can- one American will die from a coronary event. The diagnosis of
nula oxygen. The patient was prepped and draped in the usual CAD can be quite challenging because many individuals go undi-
manner, and the procedure was about to commence after a hard agnosed until they present with acute symptoms and heart attacks.

511
t.me/Dr_Mouayyad_AlbtousH
512 S E C TI O N X Medical Conditions

TABLE TABLE Duke Activity Status Index (DASI) Questionnaire

98.1 Revised Cardiac Risk Index 98.2 to Determine Functional Capacity
Six Independent Predictors of Major Cardiac Complications Activity Weight
High-risk type of surgery (e.g., vascular surgery and any open intraperi- Can you . . .
toneal or intrathoracic procedures)
1. Take care of yourself, that is, eating, dressing, bathing, 2.75
History of ischemic heart disease (history of MI or a positive exercise test or using the toilet?
result, current complaint of chest pain considered to be secondary to
myocardial ischemia, use of nitrate therapy, or ECG with pathological Q 2. Walk indoors, such as around your house? 1.75
waves; do not count prior coronary revascularization procedure unless 3. Walk a block or two on level ground? 2.75
one of the other criteria for ischemic heart disease is present)
4. Climb a flight of stairs or walk up a hill? 5.50
History of heart failure
5. Run a short distance? 8.00
History of cerebrovascular disease
6. Do light work around the house like dusting or wash- 2.70
Diabetes mellitus requiring treatment with insulin ing dishes?
Preoperative serum creatinine .2.0 mg/dL (177 mmol/L) 7. Do moderate work around the house like vacuuming, 3.50
sweeping floors, or carrying in groceries?
Rate of Cardiac Death, Nonfatal MI, and Nonfatal Cardiac Arrest
According to the Number of Predictors 8. Do heavy work around the house like scrubbing floors, 8.00
or lifting or moving heavy furniture?
No risk factors: 0.4% (95% CI, 0.1–0.8)
9. Do yardwork like raking leaves, weeding, or pushing a 4.50
One risk factor: 1.0% (95% CI, 0.5–1.4)
power mower?
Two risk factors: 2.4% (95% CI, 1.3–3.5)
10. Have sexual relations? 5.25
Three or more risk factors: 5.4% (95% CI, 2.8–7.9)
11. Participate in moderate recreational activities like 6.00
Rate of MI, Pulmonary Edema, Ventricular Fibrillation, Primary golf, bowling, dancing, doubles tennis, or throwing a
Cardiac Arrest, and Complete Heart Block baseball or football?

No risk factors: 0.5% (95% CI, 0.2–1.1) 12. Participate in strenuous sports like swimming, singles 7.50
tennis, football, basketball, or skiing?
One risk factor: 1.3% (95% CI, 0.7–2.1)
Total DASI score:
Two risk factors: 3.6% (95% CI, 2.1–5.6) METs [(DASI score 3 0.43) 1 9.6]/3.5:
The higher the DASI score, the more physically active the patient is. Patients who can
Three or more risk factors: 9.1% (95% CI, 5.5–13.8)
achieve ,4 METs have poor functional capacity, 4 to 10 METs suggest moderate func-
tional capacity, and .10 METs suggest excellent functional capacity. The DASI question-
CI, Confidence interval; ECG, electrocardiogram; MI, myocardial infarction.
naire is not designed to assess very high levels of physical activity. The maximum DASI
References: Lee TH, Marcantonio ER, Mangione CM, et al: Derivation and prospective valida-
score is 58.1, which would be the equivalent of 9.89 METs.
tion of a simple index for prediction of cardiac risk of major noncardiac surgery, Circulation
METs, Metabolic equivalents.
100:1043, 1999 and Devereaux PJ, Goldman L, Cook DJ, et al: Perioperative cardiac events
References: Hlatky MA, Boineau RE, Higginbotham MB, et al: A brief self-administered ques-
in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the
tionnaire to determine functional capacity (the Duke Activity Status Index), Am J Cardiol
pathophysiology of the events, and methods to estimate and communicate risk, CMAJ 173:
64:651, 1989. Reproduced with permission from Duke University. Copyright © 1989 Duke
627, 2005.
University, All rights reserved.

Sudden cardiac arrest (SCA) usually occurs in people with assess the risk of complications during and after surgery. Indi-
some form of underlying structural heart disease, most notably viduals who engage in regular physical activity at a moderate to
CAD. As many as 70% of SCAs have been attributed to CAD. vigorous intensity may have lower risk of complications during
Among patients with CAD, SCA can occur both during an acute and after surgery. A score of 4 or greater is generally accepted to
coronary syndrome and in the setting of chronic, otherwise stable imply that the patient has an adequate cardiac reserve to tolerate
coronary disease. More than 50% of cardiac arrests occur as the a well-managed low risk surgery where oxygenation is continu-
initial manifestation of previously unknown or unrecognized car- ously maintained, and tachycardia and hypotension are avoided.
diac disease. More than half of patients with SCA had some pro- During his preoperative visit, the patient denied cardiac symp-
dromal symptoms such as chest pain or dizziness. toms, and his METs score was graded to be greater than 4
Often, dental patients needing medical care do not access it, (see Table 98.2) His dental pain was consistent with his grossly
many times presenting with undiagnosed coronary disease. This carious teeth.
underscores the importance of meticulous history taking as part
of any risk assessment before scheduling a patient for any surgical Examination
procedure. An important component of this assessment is to re-
view the patient’s activity level (Tables 98.2 and 98.3). An additional examination of the patient was performed after the
A score of 4 metabolic equivalents of task (METs) is a mea- procedure was aborted prior to its start.
surement used to evaluate the intensity of physical activity and General observations. The patient continues to appear to be
to determine an individual’s overall health and fitness level. In a well-developed, well-nourished male but is now in moderate
preoperative risk assessment, this information can be used to distress and has his hands on his chest.

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 CHAPTER 98 Cardiac Arrest 513

TABLE EMS transport should be summoned immediately. Current ad-

98.3 Evaluating Functional Capacitya vanced cardiac life support (ACLS) guidelines (Fig. 98.1) suggest
procainamide, amiodarone, and sotalol as preferred agents; the
Activity Points office team should be prepared for cardiac arrest in case it occurs.
Walk around in house 1.75 The office personnel had undergone simulation training as part of
their crisis resource management (CRM) plan. (CRM is a type of
Light work: dusting washing dishes 2.7 training meant to prepare participants to manage all human factors
Personal care (dress eat, bath, toilet) 2.75 that enter into the causation, propagation, and management of
critical incidents. This training includes how to challenge authority
Walk one or two blocks (level ground) 2.75
and minimize the cause of errors [“situational awareness”].)
Moderate work: vacuuming, sweeping 3.5 Simulation of mock codes with office personnel within their
environment is also of paramount importance. This identifies
Yard work: raking, weeding mowing 4.5
knowledge gaps, equipment, and facility problems before an ac-
Sexual relations 5.25 tual emergency. In this case, 911 was called by the designated
Climb a flight of stairs 5.5
member, and a designated scribe began charting within the office
emergency record. The crash cart and automatic electronic defi-
Golf, bowling dancing, doubles tennis 6 brillator (AED) were brought into the room with the leader (sur-
Swim, singles tennis, basketball, skiing 7.5 geon) clearly communicating and controlling the response. The
ADSA Ten Minutes Saves a Life app can be engaged to use as a
Run short distance 8 cognitive aid. Drs. Jason Brady and Andrea Fonner are credited
Total Points with overseeing the development of this comprehensive medical
emergency response app that functions as a cognitive aid during
Excellent capacity .7 crisis management.
Moderate capacity 4–7 Current American Association of Oral and Maxillofacial Sur-
geons (AAOMS) resolutions indicate that members who provide
Poor capacity ,4
office-based moderate sedation, deep sedation, or general anesthesia
a
must successfully complete an AAOMS-approved anesthesia simu-
The overall functional capacity of a patient is estimated on the basis of a point scale de-
rived using metabolic equivalents (METs) calculated as 1 MET 5 3.5 mL/kg/min oxygen
lation training course every 5 years (2026). Additionally, members
utilization. who provide office-based moderate, deep, or general sedation must
From Becker DE: Preoperative medical evaluation: part 1: general principles and cardiovas- provide verification that their anesthesia assistants are certified by
cular considerations, Anesth Prog 56(3):92-103, 2009. an AAOMS-approved process, and all members must attest that
they are conducting quarterly team mock emergency drills.
Cardiac arrest is the sudden cessation of cardiac activity so the
patient becomes unresponsive, with no normal breathing and
Vital signs. His blood pressure was now reading at 88/50 mm signs of circulation. If corrective measures are not rapidly taken,
Hg (hypotension; the administration of nitroglycerin is contrain- the condition progresses to sudden cardiac death (SCD). Cardiac
dicated when the systolic blood pressure is ,90 mm Hg), heart arrest should be used to signify an event that is reversed, usually
rate is 155 bpm (tachycardia), respirations are 24 breaths per by cardiopulmonary resuscitation (CPR) or defibrillation (or
minute, and oxygen saturation is 100% on 2 L per nasal cannula. both), cardioversion, or cardiac pacing.
Neurologic. The patient’s Glasgow Coma Scale score is 15; he After the primary assessment confirms cardiac arrest, EMS
is alert and oriented 3 3 (place, time, and person) but is in pain. transport must be activated (in this case, this has already oc-
Cardiovascular. He is tachycardic at 155 bpm. He is hypoten- curred), and the office team should commence CPR and ACLS
sive with chest discomfort and does have a pulse. protocols following the AHA guidelines (see Fig. 98.1). After an
Respiratory: Nonlabored, anxious breathing, clear. Respira- advanced airway is in place, chest compressions should no longer
tions of 24 breaths per minute, tachypneic. be interrupted. A single ventilation can be provided every 6 to 8
seconds while compressions continue and ACLS protocols have
Labs been initiated.
Within 2 minutes of post-time-out assessment and activation
No laboratory tests are indicated in the current outpatient setting. of the EMS system, the patient subsequently lost consciousness,
and his rhythm was consistent with ventricular fibrillation (VF).
Imaging CPR was initiated immediately, and the AED was applied because
of the rhythm change and absence of a pulse. In the office setting,
No imaging is indicated in the current outpatient setting. the ECG status will most likely commence with VT, which dete-
riorates to VF. This can subsequently deteriorate further to asys-
Assessment tole or pulseless electrical activity. Cardiac arrest is most often
attributed to MI but may also be triggered by other factors, such
Symptomatic adult tachycardia with a palpable pulse, in gross distress. as sustained hypoxemia caused by severe respiratory depression or
airway obstruction.
Treatment This patient is experiencing what is described as witnessed
cardiac arrest. VT or VF account for the majority of episodes of
Patients can remain momentarily stable while experiencing this SCA. A bradyarrhythmia is also responsible for some cases of
dysrhythmia (VT), but it can deteriorate rapidly to cardiac arrest. SCD.

t.me/Dr_Mouayyad_AlbtousH
514 S E C TI O N X Medical Conditions

1
Start CPR CPR quality
• Give oxygen • Push hard (at least 2 inches
• Attach monitor/defibrillator [5 cm]) and fast (100–120/min)
and allow complete chest recoil.
• Minimize interruptions in
compressions.
• Avoid excessive ventilation.
Yes Rhythm No
• Change compressor every
shockable? 2 minutes or sooner if fatigued.
• If no advanced airway, 30:2
2 9 compression-to-ventilation ratio.
• Quantitative waveform capnography
VF/pVT Asystole/PEA -If PETCO2 is low or decreasing,
reassess CPR quality.

Shock energy for defbrillation

3 Shock Epinephrine • Biphasic: Manufacturer
ASAP recommendation (e.g., initial dose of
4 10 120–200 J); if unknown, use
maximum available.
CPR 2 min CPR 2 min Second and subsequent doses
• IV/IO access • IV/IO access should be equivalent, and higher
• Epinephrine every 3–5 min doses may be considered.
• Consider advanced • Monophasic: 360 J
airway, capnography Drug therapy
Rhythm No
• Epinephrine IV/IO dose:
shockable? 1 mg every 3–5 minutes
• Amiodarone IV/IO dose:
Yes Rhythm Yes First dose: 300 mg bolus
shockable? Second dose: 150 mg
5 Shock or
Lidocaine IV/IO dose: First
dose: 1–1.5 mg/kg Second
6 dose: 0.5–0.75 mg/kg
No
CPR 2 min Advanced airway
• Epinephrine every 3–5 min 11
• Consider advanced airway, • ET intubation or supraglottic
advanced airway
capnography CPR 2 min • Waveform capnography or
• Treat reversible causes capnometry to confirm and
monitor ET tube placement
• After advanced airway in place, give
Rhythm No 1 breath every 6 seconds (10
breaths/min) with continuous chest
shockable?
compressions
Yes (ROSC)
No Rhythm Yes • Pulse and blood pressure
7 Shock • Abrupt sustained increase in PETCO2
shockable?
(typically $40 mm Hg)
8 • Spontaneous arterial pressure waves
with intra-arterial monitoring
CPR 2 min
• Amiodarone or lidocaine Reversible causes
• Treat reversible causes
• Hypovolemia
• Hypoxia
• Hydrogen ion (acidosis)t
12
Go to 5 or 7 • Hypo-/hyperkalemia
• If no signs of (ROSC), go to • Hypothermia
“10 or 11” • Tension pneumothorax
• Tamponade, cardiac
• If ROSC, go to post–cardiac arrest • Toxins
care • Thrombosis, pulmonary
• Consider appropriateness of • Thrombosis, coronary
continued resuscitation

• Fig. 98.1 Adult cardiac arrest algorithm. ASAP, As soon as possible; CPR, cardiopulmonary resuscita-
tion; ET, endotracheal; IO, intraosseous; IV, intravenous; PEA, pulseless electrical activity; PETCO2, end-tidal
carbon dioxide pressure; pVT, pulseless ventricular tachycardia; ROSC, return of spontaneous circulation;
VF, ventricular fibrillation.

Mechanism of Ventricular Tachycardia arrhythmias are present for a variable period of time before the
development of VT and VF.
In approximately 80% of patients who present with VT and VF, the • Sustained monomorphic VT can accelerate to a rapid rate and
sustained ventricular arrhythmia is preceded by an increase in ven- subsequently degenerate into VF. The relationship between
tricular ectopy and the development of repetitive ventricular ar- monomorphic VT and SCD has been debated, with some
rhythmia, particularly runs of nonsustained VT. These spontaneous studies suggesting that this arrhythmia is present only in a

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 CHAPTER 98 Cardiac Arrest 515

minority of patients with SCD. As in this presentation, sus- support, mechanical ventilation, temperature management, diag-
tained monomorphic VT may simply be the same company as nosis and treatment of underlying causes, diagnosis and treatment
VF, thus presenting as recurrent coronary ischemia providing a of seizures, vigilance for and treatment of infection, and manage-
rapid wavefront that leads to VF. ment of the critically ill state of the patient. Many cardiac arrest
• A sustained polymorphic VT can degenerate into VF. This is patients who survive the initial event will eventually die because
most often the result of underlying ischemia (i.e., polymorphic of withdrawal of life-sustaining treatment in the setting of neuro-
VT without QT prolongation of the sinus QRS complex), al- logic injury. This cause of death is especially prominent in those
though it may also be the result from acquired or congenital with OHCA. Thus, much of post–cardiac arrest focuses on miti-
QT prolongation. gating injury to the brain (Fig. 98.2).
• VF can develop as the primary event.
There are limitations as to the assessment of the cause given the Discussion
ECG monitor uses a three- or five-lead reading. Conventional
ECG monitoring uses a three-lead system, commonly known as Cardiac arrest is known to have a 6- to 10-fold increase in those
limb leads based on Einthoven’s triangle. Willem Einthoven in with recognized heart disease and a 2- to 4-fold increase in those
1901 described three angles or leads in the form of a triangle with with the presence of CAD risk factors. SCA can also occur in
the heart in the middle. The three electrode arrangements are patients who have nonischemic heart disease, no structural heart
known as the primary limb leads I, II, and III. Further develop- disease, and no cardiac disease. Sixty percent of those presenting
ment led to more sophisticated ECGs that can monitor up to 12 with cardiac arrest or SCD are those with known CAD. Fifteen
leads and provide extensive information regarding ischemia, hy- percent of these patients with CAD present with SCA as their
pertrophy, and dysrhythmias. However, a three-lead device is initial clinical manifestation.
currently appropriate for monitoring heart rate and rhythms dur- When evaluating a patient’s anesthetic and procedural risk, it
ing sedation and general anesthesia. Generally, lead II tracings is important to incorporate a number of items, including site of
provide the largest complexes, especially the P wave, which allows surgery, providers (oral and maxillofacial surgery [OMS] physi-
the best assessment of rhythm. ECG monitors only electrical ac- cian and anesthesiologist), resources, type of procedure, and a
tivity. It does not assure the complexes are generating myocardial thorough preoperative assessment (including cardiac fitness and
contraction; a tracing could represent pulseless electrical activity. frailty) (see Table 98.3). AAOMS places an emphasis as part of
Thus, the pulse of an unresponsive patient must be verified by their preoperative risk stratification and patient selection process
palpation. The pulse oximeter and ECG both monitor heart rate; on evaluating cardiac history and fitness.
it is the pulse oximeter that assures pulsatile blood flow and is Prompt recognition of cardiac arrest or a life-threatening ar-
most useful for monitoring pulse. The ECG supplements this rhythmia, initiation of adequate CPR, administration of epineph-
information and adds an ability to detect rhythm disturbances. rine (if applicable), and application or use of a defibrillator when
The patient was defibrillated and returned to sinus rhythm applicable are all essential steps in achieving return of spontane-
with a stable blood pressure, heart rate, and oxygen saturation ous circulation and an optimal outcome. Definitive treatment
level. The patient was provided with a sedative to accommodate requires electrical defibrillation as soon as it is available. The
continued tolerance of the endotracheal tube. The patient was beneficial role of CPR likely rests in its modest influence on coro-
transferred immediately via EMS to the hospital and was dis- nary perfusion and minimizing hypoxemia, which may sustain
charged home 3 days later after undergoing successful treatment electrical activity until defibrillation is available. Supporting this
for his formerly undiagnosed three-vessel disease. concept are data illustrating greatest success when CPR is initi-
ated immediately and is followed by defibrillation within 5 to 8
Complications From Cardiac Arrest minutes of cardiac arrest. Interruptions in CPR should be mini-
mized as much as possible. An end-tidal CO2 level of 20 mm Hg
Outcomes can range from full recovery to anoxic brain injury and or higher during chest compressions indicates adequate CPR ef-
death despite adequate response and treatment. Regular organized forts and is associated with an improved survival rate. If CPR is
drills support a culture of safety and preparedness in case the need initiated within 4 minutes of cardiovascular collapse, the chance
ever arises. Managing an emergency effectively is a true team effort, of survival to discharge from the hospital doubles. In office-based
and the best outcomes are achieved with repetitive practice with anesthesia, particularly within OMS, adverse respiratory events
the entire staff rehearsing and practicing roles. The postresuscita- (causing hypoxemia) are the most common causes of crises that
tion phase is associated with a marked inflammatory response. In can then lead to cardiac events. It is unlikely for the respiratory
a study of 50 consecutive out-of-hospital cardiac arrest (OHCA) event to arise from a primary cardiac event because the majority
patients, a long time to return of spontaneous circulation and high of office patients are mostly American Society of Anesthesiologists
lactate values at admission were associated with increased comple- class I or II. Approximately 14% of cardiac arrests associated with
ment activation, proinflammatory cytokines (interleukin-6, inter- an anesthetic present with VF. This is in contrast to approximately
leukin-8), and endothelial injury at admission. These biomarkers 45% of the cardiac arrests caused by anesthesia are typically
were in turn significantly associated with lower mean arterial blood bradyarrhythmias or asystole, neither of which is amenable to
pressure, lower cardiac output, and lower systemic vascular resis- defibrillation. VF is a common community dysrhythmia, but it
tance, as well as increased need of early circulatory support. is not common in the perioperative setting. Preparation, recogni-
Patients with SCA in the acute phase of MI are believed to be tion, and early intervention enhance the patient’s chance at
at similar risk of death after revascularization compared with MI survival.
patients without SCA. Post–cardiac arrest care is a critical compo-
nent of the chain of survival. After initial stabilization, care of ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
critically ill post–cardiac arrest patients hinges on hemodynamic complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
516 S E C TI O N X Medical Conditions

ROSC obtained Initial stabilization phase

Resuscitation is ongoing during the

post-ROSC phase, and many of these
Manage airway activities can occur concurrently.
However, if prioritization is
Early placement of endotracheal tube
necessary, follow these steps:
• Airway management: waveform
Manage respiratory parameters capnography or capnometry to
Initial Start 10 breaths/min confirm and monitor ET placement
stabilization SpO2 92%–98% • Manage respiratory parameters:
phase PaCO2 35–45 mm Hg titrate FIO2 for Spo2 92%–98%; start at
10 breaths/min; titrate to PaCO2 of
Manage hemodynamic parameters 35–45 mm Hg
• Manage hemodynamic parameters:
systolic blood pressure .90 mm Hg
administer crystalloid and/or
Mean arterial pressure .65 mm Hg vasopressor or inotrope for goal
systolic blood pressure >90 mm Hg or
mean arterial pressure >65 mm Hg
Obtain 12-lead ECG
Continued management and
additional emergent activities
Consider for emergent cardiac intervention if These evaluations should be done
• STEMI present concurrently so that decisions on
• Unstable cardiogenic shock TTM receive high priority as cardiac
• Mechanical circulatory support required interventions.
• Emergent cardiac intervention:
early evaluation of 12-lead
ECG; consider
Follows commands? hemodynamics for decision on
Continued No Yes cardiac intervention
• TTM: if patient is not following
management
commands, start TTM as soon as
and additional Comatose Awake
possible; begin at 32°–36°C for 24
emergent • TTM Other critical care hours by using a cooling device with
activities • Obtain brain CT management feedback loop
• EEG monitoring • Other critical care management
• Other critical care - Continuously monitor core temperature
management (esophageal, rectal, bladder)
- Maintain normoxia, normocapnia,
euglycemia
- Provide continuous or intermittent
EEG monitoring
Evaluate and treat rapidly reversible causes; - Provide lung-protective ventilation
involve expert consultation for continued management

Hs and Ts

Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypokalemia/hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade, cardiac
Toxins
Thrombosis, pulmonary
Thrombosis, coronary

• Fig. 98.2 Adult post–cardiac arrest care algorithm. CT, Computed tomography; ECG, electrocardio-
gram; EEG, electroencephalogram; ET, endotracheal tube; PaCO2, partial pressure of carbon dioxide;
ROSC, return of spontaneous circulation; SpO2, oxygen saturation; STEMI, non–ST-elevation myocardial
infarction; TTM, targeted temperature management.

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 516.e1

Bibliography Nolan JP, Ornato JP, Marr MJA, et al: Resuscitation highlights in 2021,
Resuscitation 172:64-73, 2022.
Panchal A, Bartos JA, Cabañas JG, et al: Part 3. Adult Basic and Advanced
Anderson E, Bosack R: Anesthetic considerations for patients with car- Life Support, 2020 AHA guidelines for cardiopulmonary resuscitation
diovascular disease. In Bosack RC, Lieblich S (eds): Anesthesia Com- and emergency cardiovascular care, Circulation 142:S3166-S4648,
plications in the Dental Office, 2014, Wiley, pp 25-48. 2020.
Bayés de Luna A, Coumel P, Leclercq JF: Ambulatory sudden cardiac Patel P, Giannakopoulos HE: The cardiovascular system. In Mizukawa
death: mechanisms of production of fatal arrhythmia on the basis of M, McKenna S, Vega L (eds): Anesthesia Considerations for the OMS,
data from 157 cases, Am Heart J 117:151, 1989. 2017, Quintessence, pp 199-217.
Becker DE: Fundamentals of electrocardiography interpretation, Anesth Raitt MH, Dolack GL, Kudenchuk PJ, et al: Ventricular arrhythmias
Prog 53:53-64, 2006. detected after transvenous defibrillator implantation in patients with
Becker DE, Haas D: Recognition and management of complications a clinical history of only ventricular fibrillation. Implications for use
during moderate and deep sedation. Part 2. Cardiovascular consider- of implantable defibrillator, Circulation 91:1996, 1995.
ations, Anesth Prog 58:126-138, 2011. Treasure T: Beware of “black swans” and “perfect storms”: the principle
Becker DE: Preoperative medical evaluation. Part 1. General principles of plenitude and office-based anesthesia, J Oral Maxillofac Surg
and cardiovascular considerations, Anesth Prog 56:92-103, 2009. 72:1441-1443, 2014.
D’Eramo E, Bontempi WJ, Howard J: Anesthesia morbidity and mortal- Tsao CW, Aday AW, Almarzooq ZI, et al: Heart disease and stroke statis-
ity experience among Massachusetts oral and maxillofacial surgeons, J tics—2022 update: a report from the American Heart Association,
Oral Maxillofac Surg 66:2421-2453, 2008. Circulation 145:e153, 2022.
Dowdy R, Mansour S, Cottle J, et al: Cardiac arrest upon induction of Tseng ZH, Olgin JE, Vittinghoff E, et al: Prospective countywide surveil-
general anesthesia, Anesth Prog 68:38-44, 2021. lance and autopsy characterization of sudden cardiac death: POST
Dubner SJ, Pinski S, Palma S, et al: Ambulatory electrocardiographic SCD study, Circulation 137:2689, 2018.
findings in out-of-hospital cardiac arrest secondary to coronary artery UTD: Pathophysiology and Etiology of sudden cardiac arrest. Available
disease, Am J Cardiol 64:801, 1989. at: https://www.uptodate.com/contents/overview-of-sudden-cardiac-
Fleisher LA, Fleischmann KE, Auerbach AD, et al: 2014 ACC/AHA arrest-and-sudden-cardiac-death/abstract/4.
guideline on perioperative cardiovascular evaluation and management Weaver WD, Hill D, Fahrenbruch CE, et al: Use of the automatic exter-
of patients undergoing noncardiac surgery: a report of the American nal defibrillator in the management of out-of-hospital cardiac arrest,
College of Cardiology/American Heart Association Task Force on N Engl J Med 319:661, 1988.
practice guidelines, J Am Coll Cardiol 64:e77, 2014. Wood MA, Stambler BS, Damiano RJ, et al: Lessons learned from data
Kramer K: The ADSA Ten Minutes Saves a Life! App, Anesth Prog logging in a multicenter clinical trial using a late-generation implant-
66:117-118, 2019. able cardioverter-defibrillator. The Guardian ATP 4210 Multicenter
Kras J: Crisis resource management. In Bosack RC, Lieblich S (eds): An- Investigators Group, J Am Coll Cardiol 24:1692, 1994.
esthesia Complications in the Dental Office, 2014, Wiley, pp 173-176.
Kras J: Simulation in dental anesthesia. In Bosack RC, Lieblich S (eds):
Anesthesia Complications in the Dental Office, 2014, Wiley, pp 177-180.

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99
Acquired Immunodeficiency Syndrome
P O OYA N S A D R - ES H K E VA R I , M E H R A N M E H R A B I , a n d S H A H R O K H C . B AG H ER I

CC history of pneumonia can result in a decrease in baseline oxygen

saturation on room air.)
A 58-year-old male who is seropositive for the human immuno- Maxillofacial. There is no evidence of hair loss or patchy ul-
deficiency virus (HIV) is referred to your office. He complains, ceration on the scalp. (Scalp ulceration may be seen in patients
“I am having pain in my mouth, and I need my teeth out in order with disseminated fungal diseases, such as cryptococcal infection.
to get dentures.” These ulcerations may also present in the oral cavity or on the
peripheral extremities. A biopsy can be used to confirm the diag-
HPI nosis. This finding can be used as a sign to evaluate other organs
for fungal invasion.) Bilateral temporal wasting and prominent
The patient has been receiving routine dental care, but during a zygomatic arches are noted. Examination of the neck reveals a
recent yearly checkup, he was found to have multiple mobile teeth. soft dorsal hump. (Lipodystrophy may result either directly from
(Accelerated periodontal disease is seen with HIV infection.) This HIV or as a side effect of antiretroviral therapy, particularly pro-
sudden change in his oral health has coincided with a recent exac- tease inhibitors. Other physical signs to investigate are seborrheic
erbation of his HIV infection, as measured by an increase in his dermatitis [dandruff], vesicular rash with central umbilication in
viral load, a decrease in his CD4 cell count, and the onset of gastro- the forehead [molluscum contagiosum], and enlargement of the
intestinal and constitutional symptoms. He has had several previous parotid glands [differential diagnoses consist of lymphoepithelial
hospital admissions. Currently, he complains of a foul-smelling cyst, lipodystrophy, and lymphoma].)
mouth odor (halitosis), gingival pain, loosening teeth, gingival Intraoral. Oral hygiene is poor, and the breath is fetid. Gen-
bleeding, and exposed roots. The onset of pain has contributed to eralized inflammation of the maxillary and mandibular gingivae,
difficulty with hygiene and further accumulation of calculus. exposed buccal bone, and mobility of the teeth are noted. Gentle
palpation of the gingival tissue results in bleeding and pain. There
PMHX/PDHX/Medications/Allergies/SH/FH is no facial or intraoral fluctuance, and there is no obvious swell-
ing. (In addition to HIV gingivitis and HIV periodontitis, the
The patient tested positive for HIV 6 years ago. (HIV antigen- oral examination should concentrate on the presence of warts
antibody testing is the main diagnostic HIV test when a prior [human papillomavirus]; oral neoplastic growths, such as Kaposi
history is not available or if the viral load is low or undetectable. sarcoma [human herpesvirus 8]; hairy leukoplakia [Epstein-Barr
An initial HIV test usually will either be an antigen–antibody test virus]; candidiasis; and other fungal infections. Aphthous ulcers,
or an antibody test. In case of a positive initial HIV rapid test lymphoma, herpes, and cytomegalovirus ulcerations also may be
result, follow-up testing is necessary.) He believes he acquired the seen in patients with AIDS.)
virus through unprotected sexual contact. Otherwise, his medical Chest. The chest is clear on auscultation. (If the patient pres-
history is noncontributory. ents with crackles, a chest radiograph is indicated.)
Cardiovascular. Regular rate and rhythm, S1 and S2, and no
Examination gallops, rubs, or murmurs. (HIV may affect the heart, resulting in
dilated cardiomyopathy, but this is not common.)
General. The patient is a cooperative male with evidence of
muscle wasting (cachexia) who appears anxious. (Generalized Imaging
muscle wasting is seen with advancing acquired immunodefi-
ciency syndrome [AIDS].) A routine preoperative chest radiograph is not indicated unless
Vital Signs. Blood pressure is 121/79 mm Hg, heart rate is the patient’s history or clinical examination is suggestive of symp-
90 bpm, respirations are 14 per minute, and temperature 37.8°C. toms such as shortness of breath, a decrease in oxygen saturation
(With advanced AIDS, it is common to have a normal tempera- on room air, or a productive cough. However, a chest radiograph,
ture despite the presence of an acute infection; this is due to the along with arterial blood gas analysis, may be valuable.
failure or deficiency of available white blood cells [WBCs] to For the current patient, the panoramic radiograph demon-
mount an appropriate inflammatory response, which results strates areas of moderate and severe vertical interproximal bone
in fever.) His oxygen saturation is 92% on room air. (A recent loss consistent with severe to moderate periodontal disease.

517
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518 S E C TI O N X Medical Conditions

Labs Treatment
During the perioperative evaluation of a patient with HIV infec- With the advances in ART, patients with HIV now are expected to
tion, a complete blood count (CBC) is valuable but should be live a normal life span, without developing AIDS or transmitting
used with caution. An increase in the WBC count may not be the disease to their partners or infants. This is primarily dependent
seen in response to physiologic or inflammatory demands, as on a long-term adherence to ARTs to keep the viral load undetect-
would be seen in immune-competent individuals. The lympho- able. The HIV Medicine Association of the Infectious Diseases
cyte subset can be used to assess the susceptibility to opportu- Society of America has recently updated its published guidelines
nistic infections. The neutrophil count may be elevated with on the primary care of these patients. There are also other guide-
bacterial infections. The hemoglobin and hematocrit levels may lines available from similar organizations, including the European
be used to assess volume status. (Hemoglobin would be falsely AIDS Clinical Society. The recommendations put forward by these
elevated.) Hemoglobin and platelet levels may be depleted, and references and other similar publications have consistently empha-
patients may require packed red blood cell or platelet transfu- sized the necessity of providing patient-centered, stigma-free care
sions before major surgery. and overcoming barriers to care at the societal, health system,
In patients with HIV, HIV RNA test (viral load) should be clinic, and individual levels. Clinicians must pay especial attention
performed every 4 to 6 weeks after initiation of antiretroviral to the treatment needs of pediatric and geriatric patients and those
therapy (ART) until viral RNA level is less than 50 copies/mL of persons of childbearing potential, including care during precon-
and then every 3 to 4 months. If viral suppression and stable ception and pregnancy. Managing the comorbidities in these pa-
CD4 count are consistent for more than 2 years, viral load can tients is both challenging and crucial.
be measured every 6 months. The CD4 count is initially checked There used to be some controversy regarding the optimal time
every 3 to 6 months for 2 years after starting ART. This regimen to initiate treatment for patients who are seropositive for HIV. With
is also followed if the CD4 cell count is less than 300/mm3 or if few exceptions (e.g., coinfection with cryptococcal meningitis or
viremia develops. If the CD4 count is within 300 to 500/mm3 tuberculosis), current standard of care is to start the patients on
and viral suppression is maintained for 2 years, CD4 can be ART either on the day of diagnosis or as soon thereafter as possible.
measured annually. Despite popular belief, neither the CD4 Rapid ART initiation is endorsed by the Adult and Adolescent
count nor the viral load alters maxillofacial surgical intervention. Antiretroviral Guidelines Panel of the Department of Health and
Nonetheless, a patient with a rapidly declining lymphocyte count Human Services, as well as the International Antiviral Society–USA
or an increase in viral load should be reassessed before any surgi- Antiretroviral Panel and New York Department of Health AIDS
cal intervention. Additional tests may be helpful, depending on Institute. Evidence shows that rapid entry programs have excellent
the extent of the surgical procedures or the presence of concur- retention and effective viral suppression in long term. On the other
rent comorbidities associated with immune suppression. Arterial hand, it is also evident that a long wait time before ART initiation
blood gas analysis is helpful for assessing the pulmonary status of is a predictor of treatment failure. Regardless of ART initiation tim-
a patient with active pneumonia. A basic metabolic panel may be ing, it is important to obtain baseline laboratory tests, including
used to evaluate intravascular fluid status in dehydrated and viral load, CD4 cell count, resistance testing, and safety assess-
volume-depleted patients. A blood urea nitrogen–to–creatinine ments. CD8 cell count and the CD4/CD8 ratio are not necessary.
ratio greater than 20 is suggestive of volume depletion. The co- HIV diagnosis should be ascertained, preferably using rapid testing
agulation factors are rarely depleted in patients with HIV, but with a fourth-generation antigen-antibody test if results of HIV
HIV or other infections may predispose a patient to dissemi- screening are not available for review. In appropriate racial or ethnic
nated intravascular coagulation. Coagulation studies should be groups, glucose-6-phosphate dehydrogenase deficiency may be as-
obtained as needed. Evaluation of hepatic function is also impor- sessed before initiating oxidant drugs including dapsone, prima-
tant. Although HIV may affect liver function directly, of more quine, and sulfonamides. A pregnancy test is a must in any patient
concern is a concurrent infection with hepatitis B or C virus. of childbearing potential and may modify the choice of ART.
(Note that the route of transmission is similar for HIV and the Antiretroviral therapy medications include nucleoside reverse
hepatitis B and C viruses.) transcriptase inhibitors (NRTIs; Table 99.1), non–nucleoside re-
On our patient’s most recent hospital admission, his CD4 verse transcriptase inhibitors (NNRTIs; Table 99.2), protease in-
count was 108 cells/mL; therefore, he was diagnosed with AIDS. hibitors (PIs; Table 99.3), integrase inhibitors (INIs; bictegravir,
(An absolute CD4 count ,200 cells/mL is an AIDS-defining cabotegravir, dolutegravir, elvitegravir, and raltegravir), and entry
feature in adults; in pediatric patients, the CD4 cell percentage inhibitors (including fusion inhibitors [enfuvirtide] and C-C
is more accurate.) The patient’s internist indicated that the pa- motif chemokine receptor [CCR5] antagonists [Maraviroc]). INIs
tient's recent episode of pneumonia was caused by the recent consist of two main classes: integrase strand transfer inhibitors
decline in his CD4 count. His platelets and hemoglobin were (INSTIs) and protein–protein interaction inhibitors (PPIIs). A
within normal ranges. His absolute neutrophil count (ANC) was combination of these medications is commonly referred to as
2300 cells/mL. The normal range of ANC in a healthy person is highly active antiretroviral therapy (HAART).
between 2500 and 6000 cells/mL. The ANC is calculated by The preferred initial ART regimens should include:
multiplying the WBC count by the percent of blood neutrophils. • A combination of two NRTIs and one NNRTI
Neutropenia is an ANC below 1000 cells/mL. • A combination of two NRTIs and one PI (boosted)
• A combination of two NRTIs and one INI or
Assessment • A combination of one NRTI and one INI (Dolutegravirmouth
extraction–lamivudine is the only US Food and Drug
AIDS secondary to HIV infection, now complicated by acute necro- Administration–approved two-drug combination to treat pa-
tizing ulcerative periodontitis, requiring full-mouth extraction. tients with HIV.)

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 CHAPTER 99 Acquired Immunodeficiency Syndrome 519

TABLE The initial regimen may be modified based on the results of

99.1 Nucleoside Reverse Transcriptase Inhibitors resistance testing. The rationale behind the choice of these regi-
mens is that the resistance to second-generation INSTIs and
Nucleotide Reverse ritonavir-boosted PIs is uncommon.
Transcriptase Inhibitor Abbreviation Side Effects Human immunodeficiency virus drug resistance testing is used
Retrovir AZT Anemia, neutropenia to determine potential genetic mutations in the virus that may
make PIs, NNRTIs, and NRTIs ineffective. INSTI genotyping is
Videx DDI Pancreatitis, peripheral recommended only if there is suspicion for INSTI mutation
neuropathy
transmission. Resistance testing, including INSTIs, is also indi-
Hivid DDC Pancreatitis, peripheral cated for patients who are experiencing virologic failure (HIV
neuropathy RNA .200 copies/mL) and should be performed while the pa-
Zerit D4T Pancreatitis, peripheral
tient is on the failing ART regimen or within 4 weeks of its dis-
neuropathy continuation. If use of CCR5 antagonist is being considered, a
coreceptor tropism assay may be considered. Similarly, if the use
Epivir 3TC Also used for hepatitis B of abacavir is being considered, a Human Leukocyte Antigen
virus infection subtype B*5701 (HLA B*5701) should be tested. A positive HLA
Ziagen ABC Rash, death B*5701 haplotype result may indicate an elevated risk for hyper-
sensitivity reaction to abacavir. These patients should never be
treated with abacavir.
When a patient presents with a CD4 count below 200 cells/mL,
TABLE they are started on trimethoprim–sulfamethoxazole (Bactrim) for
99.2 Nonnucleoside Reverse Transcriptase Inhibitors Pneumocystis jirovecii (formerly called Pneumocystis carinii) prophy-
laxis. At a CD4 count below 100 cells/mL, the patient is increas-
Nonnucleoside Reverse ingly susceptible to toxoplasmosis infections. Because this is
Transcriptase Inhibitor Side Effects treated with the same medication, no additional prophylactic is
Nevirapine (Viramune) Hepatotoxicity, hepatic necrosis during the needed. When the CD4 count drops below 50 cells/mL, there is a
first 4 weeks high risk of Mycobacterium avium complex infection. This is em-
pirically treated with clarithromycin or azithromycin (macrolide
Delavirdine (Rescriptor) Rash, headache
antibiotics). Viral infections, such as herpes simplex virus, are
Efavirenz (Sustiva) Teratogenic; Stevens-Johnson rash, hallu- treated with famciclovir or acyclovir. (There is no prophylactic
cinations, nightmares treatment; patients are treated only in the face of infection.) Some
infections, such as Candida spp., may present at a CD4 count
below 500 cells/mL, but prophylactic treatment of fungal infec-
tions is not recommended. Our patient was taking trimethoprim–
TABLE sulfamethoxazole at the time of his presentation to us. His viral
99.3 Protease Inhibitors load was 533 copies/mL HIV1 RNA.
Viral load is measured using polymerase chain reaction test
Number of Pills which is a type of nucleic acid amplification tests to detect HIV
Protease Inhibitor Taken Daily Common Side Effects RNA. Thresholds for lower limits of detection range from 20 to
Indinavir (Crixivan) 6 Nephrolithiasis 50 copies/mL in most assays. A viral load persistently below the
level of quantification of the assay is called viral suppression. The
Ritonavir (Norvir) 12 Weakness, loss of appetite, threshold for prevention of HIV sexual transmission is below 200
nausea and vomiting
copies/mL.
Saquinavir (Invirase– 9 Gastrointestinal disturbances Immune suppression can be caused by defects in various as-
Fortovase) pects of the immune system. Concerns and cautions are not the
Nelfinavir (Viracept) 10 Gastrointestinal disturbances same when dealing with different defects of the immune system.
(most commonly diarrhea) For example, a patient who is neutropenic is more susceptible to
bacterial infection, whereas T-lymphocyte deficiency increases
Amprenavir 16 Severe rash susceptibility to fungal, viral, and parasitic infections. In oral
(Agenerase) surgical procedures, more complications are associated with neu-
Lopinavir–ritonavir 6 Hepatitis tropenia (sepsis, oral ulceration, periodontal disease) than with
(Kaletra) lymphopenia. For patients with neutropenia, preoperative antibi-
otics are used to prevent sepsis. Postoperative antibiotics may also
be used.
The initial treatment of patients with acute necrotizing ulcer-
Accordingly, the most commonly used initial regimens, pend- ative periodontitis consists of fluid resuscitation as needed, anal-
ing the results of drug resistance testing, are as follows: gesics, and antibiotic therapy. With generalized severe periodontal
• Dolutegravir 1 tenofovir 1 either emtricitabine or lamivudine disease, full-mouth extraction is both definitive and curative. Pa-
• Bictegravir 1 tenofovir alafenamide 1 emtricitabine or tients with HIV infection are treated aggressively to prevent any
• Ritonavir-boosted darunavir 1 tenofovir 1 either emtric- odontogenic sources of infection, which may cause severe compli-
itabine or lamivudine cations in a patient with a declining immune system.

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520 S E C TI O N X Medical Conditions

The current patient underwent outpatient full-mouth extrac- ADA and consistent with other resources, nearly all patients with
tion under intravenous sedation. He received 2 g of ampicillin HIV tolerate oral surgery well. However, assessment should be
perioperatively and chlorhexidine mouthwash postoperatively. done on an individual basis. For instance, the ADA discusses that
After surgical treatment, the alveolar ridges healed without com- clinician should be aware of potential coagulopathies and glyce-
plications. Of note, the surgeon had a needlestick accident during mic imbalances with antiretroviral medications. Thrombocytope-
the procedure. He initially lightly washed the needlestick exposed nia below 60,000 cells/mL may modify the treatment plan, and
area with soap and water. After consultation with the facility’s on- neutropenia to below 500 cells/mL may require antibiotic pro-
call physician, he started post-exposure prophylaxis (PEP). This is phylaxis. Routine antibiotic use is discouraged because of the
another important topic to discuss; its must-knows are covered potential predisposition of patients to adverse drug reactions, su-
later in this chapter. perinfections, and drug-resistant microorganisms. Regardless of
Our patient presented back to our office 3 years later asking what source you may use for your reference, these guidelines are
about the possibility of getting dental implants. He reported com- intended to supplement, rather than replace, the routine periop-
pliance with his medications. He also reported that his last CD4 erative assessments and risk stratifications.
count was 432 cells/mm3, and his last viral load was undetectable
6 months ago. We planned bilateral sinus augmentations for him Complications
in preparation of future implant placement the next week. We
ordered a CBC, viral load, and CD4 count before the procedure. Patients affected by HIV infection may present with thrombocy-
His CD4 count was 158 cells/mm3, and his viral load was 290 topenia. This can be caused by idiopathic thrombocytopenic
copies/mL. He disclosed that although taking his medications as purpura (ITP) or thrombotic thrombocytopenic purpura (TTP).
prescribed, he has not been to his follow-up appointments for 6 ITP is an autoimmune disorder resulting from antibodies to gly-
months because his “numbers were good,” and for a while, and he coprotein platelet 2b3a-receptors. This may present as an acute
“didn’t think regular blood work were necessary anymore.” It condition (mostly in children) or a chronic condition (mostly in
should be noted that the primary reason for treatment failure, adult females). Treatment consists of prednisone, intravenous im-
particularly with initial regimens, is not only a suboptimal medi- munoglobulin, splenectomy, azathioprine, or vincristine. TTP
cation adherence but also failure to attend follow-ups. This has led presents as a combination of five symptoms: renal failure, central
to the development of HIV quality-of-care performance metrics, nervous system abnormalities, fever, thrombocytopenia, and ane-
endorsed by the National Quality Forum and the Center for mia. The exact cause is not well understood. A similar syndrome,
Medicare and Medicaid Services. Evidence shows that when these hemolytic uremic syndrome, is caused by Escherichia coli
performance measures are met, there is a significant decrease in O157:H7. In the presence of neurologic symptoms, the diagnosis
mortality rate. We explained to our patient that at this point, he of TTP is made; however, when renal failure is the prominent
has AIDS again, and he should be taking prophylactic antibiotics. feature, it is usually due to hemolytic uremic syndrome. The treat-
With his permission, we contacted his physician’s office and ment for patients with TTP is plasmapheresis.
scheduled him for an appointment within the next day. Although There also are other causes of both ITP and TTP. ITP may be
the numbers were not a contraindication to his surgery, we de- caused by any viral infection, leukemia, lupus erythematosus, cir-
cided to postpone any elective procedure until his more impor- rhosis, antiphospholipid syndrome, and medications (quinine,
tant issues were addressed. He was switched to another medicine heparin). TTP can be caused by cancer, bone marrow transplanta-
and improved over the course of a couple of months. Eventually, tion, pregnancy, and medication (ticlopidine, clopidogrel, cyclo-
he had his implants placed, which were successfully restored, and sporine, mitomycin, tacrolimus/FK-506, interferon-a).
he has been using them for more than 1 year now. As discussed, the risk of postoperative infection in a patient
As previously discussed, there is no universal guideline to follow with HIV infection or AIDS who undergoes maxillofacial surgery
for preoperative assessment of patients with HIV. There are, how- used to be controversial at best. Although earlier studies showed
ever, state and organization guidelines that largely reiterate the same an increased risk of infection in those with HIV, they were mostly
standards and goals. For instance, the Clinical Guidelines Program conducted before the advent of HAART. More recent studies have
developed by the New York State Department of Health AIDS denied a positive HIV status per se an increased risk of infection,
Institute highlights that if virally suppressed, HIV does not increase especially in dentoalveolar surgeries. Despite the low quality of
surgical risk and is not a contraindication to surgery. Also, the risk evidence, a recent systematic review and meta-analysis demon-
of HIV transmission to health care workers is eliminated in virally strated that HIV infection does not affect short-term implant
suppressed patients. In patients who are not virally suppressed, the survival. However, there is still a need for prospective evaluation
risks of elective surgery should be assessed on an individual basis. for the risk of infection after various maxillofacial surgeries,
This guideline advises against interruptions in ART and opportu- namely trauma, orthognathic surgery, and so on.
nistic infection prophylaxis or treatment. Another relevant and important topic to discuss in this chapter
In general, doctors should not hold or delay surgery if it is is the management of the occupational exposure to HIV. The PEP
emergent before determination of the patient’s CD4 count or recommendations will help clinicians in urgent decision making
HIV viral load. The nature and timing of the emergency will de- in cases of exposure to HIV and hepatitis B and C. Every facility
termine this decision. has guidelines in place to deal with such scenarios. Therefore,
For elective surgery, the status of the HIV should be deter- consultation should be obtained from the occupational health or
mined including viral load, CD4 count, and the overall clinical employee health services department promptly. Transmission of
status. Consideration should be given to the nature and magni- bloodborne pathogens is only confirmed if the potential exposure
tude of the surgery along with consultation with the experienced includes (1) an infectious body fluid (saliva, vomitus, urine, feces,
HIV care provider. sweat, tears, and respiratory secretions, unless visibly bloody, do
Another example is the American Dental Association’s (ADA’s) not transmit HIV) and (2) a portal of entry (percutaneous, per-
recommendations on HIV patient management. According to the mucosal, or contact with compromised skin). No evaluation is

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 CHAPTER 99 Acquired Immunodeficiency Syndrome 521

required if both requirements are not met. PEP is generally not retrovirus belonging to the Lenti virus family, was discovered
warranted in cases of unknown HIV status of the patient, but the concurrently by French and American scientists. The virus can be
decision should be individualized. A shared decision-making pro- transmitted via exposure of body fluids through sexual contact,
cess based on accurate risk assessment, PEP expert recommenda- sharing of needles or paraphernalia, blood transfusions (horizon-
tions, and your preferences would be crucial. In brief, PEP is not tal transmission), or from mother to fetus (vertical transmission).
justified for exposures that pose a negligible risk for transmission. In the bloodstream, HIV targets the lymphocytes and macro-
If, unlike in our case, the HIV status of the source person is phages, which are the only cells with CD41 receptors. T cells
unknown and if the source person is likely to have HIV risk fac- with a CXCR4 chemokine coreceptor are called T tropic, and
tors, the following tests should be performed from the source macrophages with CCR5 are called M tropic. The virus is unable
person: (1) HIV Ag/Ab or HIV Ab (rapid HIV testing preferred to infect these cells in the absence of these coreceptors. Interaction
if accessible); (2) hepatitis C (HCV) Ab or HCV RNA (HCV of the CD4 receptor with the viral glycoprotein 120 changes its
viral load); and (3) HBsAg (HBV surface antigen) or a hepatitis stereochemistry, exposing glycoprotein 41, which binds to hepa-
panel, including HBsAg, HBsAb, and HBcAb. Rapid HIV tests rin sulfate in the membrane of the host cells, fusing the viral en-
are generally very sensitive and specific. A positive rapid HIV test velope with the cell membrane. After genetic material enters the
result should be preliminarily considered a true positive for initial cell, a complementary DNA or coda is made from the original
PEP decision making. On the other hand, a negative rapid test RNA by the enzyme reverse transcriptase. This complementary
result should be considered a true negative. It is not necessary to DNA joins the host DNA using the enzyme integrase, forcing the
investigate if a source person is in the window period for PEP cell to make necessary proteins to replicate the virus. Finally, the
decision making unless acute HIV (acute retroviral syndrome) is packaged virus leaves the host cell, using the cell membrane as a
suspected clinically. In PEP, time is of the essence: the first dose viral envelope and subsequently infecting other cells. CCR5 in-
should be given as soon as possible rather than within days. Unless hibitors, fusion inhibitors, INIs, NRTIs, and NNRTIs are respec-
available in an hour or two, do not wait for the source person’s test tively used to inhibit every step in this process.
results. Many consider the outer limit of 72 hours after exposure After inoculation, a patient typically seroconverts in approxi-
for PEP initiation based on animal studies; however, there are no mately 3 weeks, although the time can range from 9 days to as
human data to establish such a time frame. Consultation with a long as 6 months. Routine laboratory testing for HIV before this
PEP expert is recommended if PEP initiation is considered be- date results in a negative test result. The patient may be asymp-
yond 72 hours. Consistent with our scenario, PEP is typically tomatic or may develop flulike symptoms. The viral load rapidly
recommended in case of an exposure to an HIV-positive patient increases and then decreases during this period, and the CD4
unless the viral load is undetectable. (The few risks of PEP may be count rapidly decreases before returning to nearly its original
greater than its benefits.) Initiation of PEP should not be delayed level. During the following years, if the infection goes untreated,
if the source person’s viral load or PEP expert consultation is not there is a steady decrease in the CD4 cell count, along with an
immediately available. PEP is taken for 28 days unless the source increase in the viral load. In general, the viral load reflects the
person’s laboratory test results are negative. speed of progression of AIDS, whereas the CD4 cell count reflects
Three-drug regimens are generally the PEP of choice for all the current immune status and is used to evaluate susceptibility to
exposures unless there are concerns about drug availability, poten- opportunistic infections.
tial toxicity, and adherence difficulties. The triple therapy in- Human immunodeficiency virus research has also focused on
cludes: “finding a cure.” Although the advent of HAART was a break-
• Truvada 1 tablet by mouth once daily through in HIV management, almost 38 million people are living
• Co-formulated tenofovir DF (Viread) 300 mg 1 emtricitabine with HIV (PLHIV) worldwide today. PLHIV still must take a
(Emtriva) 200 mg lifetime of treatments and endure significant emotional and
• Raltegravir (Isentress) 400 mg by mouth twice daily or dolute- physical stress. A recent systematic review has shown that the risk
gravir (Tivicay) 50 mg by mouth once daily of suicidality among PLHIV is high within all six World Health
If the source person not available for testing or their test result Organization regions during the modern ART era. The ability of
is positive, the exposed person should be screened for HIV at 6 the virus to rest in a latent state by integrating into the DNA of
weeks and 3 months. host cells has created one of the biggest obstacles in the quest for
HIV cure. The cells in which HIV lies dormant are called the viral
Discussion reservoir. ART only attacks actively replicating virus and is inef-
fective on the dormant virus. Researchers have been trying to ac-
Immune deficiency may be an inherited, acquired, or iatrogenic tivate reservoir cells into replication to force the virus out of la-
disorder. Inherited defects may result from quantitative or qualita- tency. Effective latency reversal agents (LRAs), however, are yet to
tive defects of the cells or cellular pathways involved in immunity be identified. Histone deacetylase (HDAC) inhibitors, including
(neutrophil, macrophages, complement, lymphocytes). Immune valproic acid and Vorinostat, are a new class of LRAs that coun-
suppression is also seen with organ transplantation for prevention teract the inhibitory effect of HDAC on transcription and result
of host-versus-graft or graft-versus-host disease and in chemo- in increased reservoir cell activation. Activation of the nuclear
therapy. AIDS is seen with conditions such as diabetes, leukemia, factor-kB signaling pathway by an inhibitor of apoptosis protein
and AIDS. antagonist, another potential LRA, has resulted in the successful
AIDS was recognized in 1981 after multiple homosexual male induction of HIV RNA expression in the blood and tissues of
patients were diagnosed with Pneumocystis pneumonia and Kaposi ART-suppressed animal models. In 2022, a clinical trial in Den-
sarcoma (more recently found to be also associated with human mark (Gunst et al.) investigated the effect of early addition of a
herpesvirus 8). Before 1981, Pneumocystis pneumonia was com- monoclonal anti–HIV-1 antibody with a CD4-binding site to the
monly seen in patients with cancer, and Kaposi sarcoma was en- ART followed by initiation of a HDAC inhibitor, romidepsin, in
demic to Africa and the Mediterranean region. In 1984, HIV, a patients newly diagnosed with HIV-1. This regimen enhanced

t.me/Dr_Mouayyad_AlbtousH
522 S E C TI O N X Medical Conditions

elimination of viruses and enhanced HIV-1–specific CD81 im-

munity and was associated with sustained virologic control with-
out ART. Dai et al. (2022) have developed a genome-wide screen
to identify genes that merit investigation as LRA targets. Knock-
out of these genes have potentiated the effect of existing LRAs.
Broadly neutralizing anti–HIV-1 antibodies (bNAbs) have also
been studied for HIV eradication. Rosás-Umbert et al. (2022)
have shown that bNAb treatment at the time of ART initiation
maintains HIV-1–specific CD81 T cell responses that are associ-
ated with ART-free virologic control. Despite all the promising
efforts, there have been two confirmed cases of patients cured of
HIV so far: one is known as “Berlin patient,” who has been off
ART with undetectable viral count since 2006, and the other one
is known as “London patient,” who has been in complete remis-
sion since 2019. Both these patients had undergone bone marrow
transplants (BMTs) from donors with mutations in their CCR5
cell surface receptors, which made it impossible for some variants
of HIV to enter cells. BMTs, however, are expensive and risky,
and donors with such mutations are rare. There has also been a
search for HIV vaccine with some promising preliminary results
but far from widespread application.
An estimated 1.2 million people in the United States have • Fig. 99.1 Cryptococcal infection of the palate in a patient with acquired
HIV, including about 158,500 who are unaware of their infec- immunodeficiency syndrome.
tion. This population is increasing at the rate of 40,000 new infec-
tions each year. About 40% of new HIV infections are transmit-
ted by people who do not know they have the virus. Among oral often in patients receiving monotherapy than in patients receiving
and maxillofacial surgery patients, the prevalence of HIV is esti- no therapy. Furthermore, the use of HAART resulted in a statisti-
mated to be as high as 4.8% in certain demographic areas. Al- cally significant reduction in lesions compared with the use of
though HAART has resulted in a significant decrease in opportu- monotherapy.
nistic infections, such as those presenting with oral manifestations, The differential diagnosis of oral lesions seen with HIV may
it has not eradicated these complications. be divided into bacterial, viral, fungal, neoplastic, and idiopathic
Oral manifestation of HIV may aid in both the diagnosis and categories. Bacterial infections may present as acute necrotizing
prognosis of the disease. These lesions are seen in up to 30% to gingivitis or periodontitis. Viral infections, such oral papillomas,
80% of patients who have tested positive for HIV, and they may are caused by the human papillomavirus and are commonly seen.
be infectious (bacterial, viral, fungal, and parasitic), neoplastic, or Fungal infections, such as histoplasmosis and cryptococcosis
idiopathic. A study published by Diz Dios and colleagues found a (Fig. 99.1), can cause oral ulcerations. An example of intraoral
reduction in oral lesions from 74.2% to 28.5% after the use of neoplastic disease is Kaposi sarcoma, caused by human herpesvi-
HAART. However, in this study, there was a significant decrease in rus 8, which is most seen in homosexual males. Idiopathic xero-
patient follow-up because of death or relocation. A study by Agu- stomia is commonly seen, resulting in cervical caries.
irre and associates evaluated 72 patients with various oral diseases. The surgical management of patients with HIV infection or
A significant improvement was seen in the prevalence of pseudo- AIDS requires an understanding of the pathophysiology, medica-
membranous candidiasis (from 80% to 32%) with the use of tions, and associated disease processes.
HAART. Only a small change was seen in acute necrotizing peri-
odontitis. Tappuni and Flemming evaluated 284 patients infected ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
with HIV and concluded that oral lesions are seen significantly less complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 522.e1

Bibliography Panel on Antiretroviral Guidelines for adult and Adolescents: Guidelines

for the use of antiretroviral agents in HIV-1 infected adults and
adolescents, Department of Health and Human Services. Available at:
Aguirre JM, Echebrria MA, Ocina E: Reduction of HIV-associated oral http://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadoles-
lesion after highly active antiretroviral therapy, Oral Surg Oral Med centgl.pdf. Accessed August 26, 2012.
Oral Pathol Oral Radiol Endod 88:114-115, 1999. PEP Quick Guide for Occupational Exposures, The National Clinician
Carey JW, Dodson TB: Hospital course of HIV-positive patients with Consultation Center, Updated on June 18, 2021. Available at: https://
odontogenic infections, Oral Surg Oral Pathol Oral Med Oral Radiol nccc.ucsf.edu/clinical-resources/pep-resources/pep-quick-guide-for-
Endod 91:23-27, 2001. occupational-exposures/.
Centers for Disease Control and Prevention: HIV/AIDS surveillance re- Ray N, Doms RW: HIV-1 coreceptors and their inhibitors, Curr Top
port, vol 18, Atlanta, 2008, The CDC. Microbiol Immunol 303:97-120, 2006.
Dai W, Wu F, McMyn N, et al: Genome-wide CRISPR screens identify Rosás-Umbert M, Gunst JD, Pahus MH, et al: Administration of broadly
combinations of candidate latency reversing agents for targeting the neutralizing anti-HIV-1 antibodies at ART initiation maintains long-
latent HIV-1 reservoir, Sci Transl Med 14(667):eabh3351, 2022. term CD81 T cell immunity, Nat Commun 13:6473, 2022.
Depoala LG: Human immunodeficiency virus disease: natural history Schmidt B, Kearns G, Perrott D, et al: Infection following treatment of
and management, Oral Surg Oral Med Oral Pathol Oral Radiol Endod mandibular fractures in human immunodeficiency virus seropositive
90:266-270, 2000. patients, J Oral Maxillofac Surg 53:1134-1139, 1995.
Diz Dios P, Ocampo A, Miralles C, et al: Changing prevalence of human Shanti RB, Aziz SR: HIV-associated salivary gland disease, Oral Maxil-
immunodeficiency virus–associated oral lesion, Oral Surg Oral Med lofac Surg Clin North Am 21:339-343, 2009.
Oral Pathol Oral Radiol Endod 90:403-404, 2000. Sivakumar I, Arunachalam S, Choudhary S, et al: Does HIV infection
Dodson TB, Nguyen T, Kaban LB: Prevalence of HIV infection oral and affect the survival of dental implants? A systematic review and meta-
maxillofacial surgery patients, Oral Surg Oral Med Oral Pathol Oral analysis, J Prosthet Dent 125(6):862-869, 2021.
Radiol Endod 76:272-275, 1993. Sleasman JW, Goodenow MM: HIV-1 infection, J Allergy Clin Immunol
Dodson TB: HIV status and the risk of post-extraction complications, 111:S582-S592, 2003.
J Dent Res 76:1644-1652, 1997. Tappuni AR, Flemming JP: The effect of antiretroviral therapy on the
Gunst JD, Pahus MH, Rosás-Umbert M, et al: Early intervention with prevalence of oral manifestations in HIV-infected patients: a UK study,
3BNC117 and romidepsin at antiretroviral treatment initiation in Oral Surg Oral Med Oral Pathol Oral Radiol Endod 92:623-628, 2001.
people with HIV-1: a phase 1b/2a, randomized trial, Nat Med Thompson MA, Horberg MA, Agwu AL, et al: Primary care guidance for
28:2424-2435, 2022. persons with human immunodeficiency virus: 2020 update by the
Human Immunodeficiency Virus (HIV), ADA Website. Available at: HIV Medicine Association of the Infectious Diseases Society of
https://www.ada.org/resources/research/science-and-research-insti- America, Clin Infect Dis 73(11):e3572-e3605, 2021.
tute/oral-health-topics/hiv#. Tsai YT, Padmalatha S, Ku HC, et al: Suicidality among people living
Mehrabi M, Bagheri S, Leonard MK Jr, et al: Mucocutaneous manifesta- with HIV from 2010 to 2021: a systematic review and a meta-regres-
tion of cryptococcal infection: report of a case and review of the lit- sion, Psychosom Med 84(8):924-939, 2022.
erature, J Oral Maxillofac Surg 63:1543-1549, 2005. Willis JR, Berndsen ZT, Ma KM, et al: Human immunoglobulin reper-
Miller EJ Jr, Dodson TB: The risk of serious odontogenic infection in toire analysis guides design of vaccine priming immunogens targeting
HIV-positive patients: a pilot study, Oral Surg Oral Med Oral Pathol HIV V2-apex broadly neutralizing antibody precursors, Immunity
Oral Radiol Endod 86:406-409, 1998. 55(11):2149-2167, 2022.
Nixon CC, Mavigner M, Sampey GC, et al: Systemic HIV and SIV la- Yan L, Ellman T, McNairy M, et al: Perioperative care in adults With
tency reversal via non-canonical NF-k B signalling in vivo, Nature HIV [Internet], Baltimore, MD, 2021, Johns Hopkins University.
578:160-165, 2020. Available at: https://www.ncbi.nlm.nih.gov/books/NBK576018/.

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100
End-Stage Renal Disease
FR ED E R I C F. R A H B A R I -O SKO U I a n d S H A H R O K H C . B AG H ER I

CC • Chemistry: sodium, 145 mEq/L; potassium, 5.6 mEq/L; bi-

A 68-year-old (age is a risk factor) African American (highest risk carbonate, 22 mEq/L; blood urea nitrogen (BUN), 68 mg/dL;
factor) female with a history of end-stage renal disease (ESRD) pres- creatinine, 6.9 mg/dL; glucose, 167 mg/dL; calcium, 7 mg/dL;
ents with her third episode of acute pericoronitis in 18 months. phosphate, 5.2 mg/dL
• Coagulation studies: prothrombin time, 11 seconds; partial
thromboplastin time, 33 seconds; international normalized
HPI ratio, 1.0
The patient has an impacted lower third molar that causes inter- • Liver function tests: aspartate aminotransferase, 42 U/L; ala-
mittent pain and has given rise to moderate right-sided facial nine aminotransferase, 33 U/L; g-glutamyl transpeptidase, 43
swelling, fever, malaise, and anorexia. U/L; alkaline phosphate, 34 U/L
• Urinalysis: 31 proteinuria; no red blood cells, WBCs, or casts
The laboratory findings are characteristic of ESRD. The he-
PMHX/PDHX/Medications/Allergies/SH/FH moglobin and hematocrit are decreased secondary to the de-
The patient’s medical history is notable for poorly controlled dia- creased production of erythropoietin by the kidneys. The elevated
betes mellitus, hypertension, hypercholesterolemia (all risk fac- BUN and creatinine levels reflect severely reduced glomerular
tors), ESRD on hemodialysis on a Monday–Wednesday–Friday filtration rate (GFR), which is also responsible for the elevated
schedule, secondary hyperparathyroidism (renal osteodystrophy), serum potassium. Proteinuria is a result of increased glomerular
and anemia. Her dental history is significant for multiple extrac- permeability. The decreased calcium level should be corrected to
tions over the past 20 years. Medications include insulin, felodip- the serum albumin level (or by checking an ionized calcium
ine (a calcium channel blocker), metoprolol (a beta-blocker), and level); if confirmed, it could be a result of decreased gastrointes-
losartan (an angiotensin receptor blocker). tinal absorption of calcium secondary to decreased renal produc-
tion of active vitamin D. She has a 28-pack-year smoking history
Imaging (risk factor).

A panoramic radiograph reveals a mesioangular impacted right man- Examination

dibular third molar with a pericoronal radiolucency. Renal osteodys-
trophy (secondary hyperparathyroidism) is evident as seen by a General. The patient is a mildly obese female in mild distress
generalized “ground-glass” pattern of the bone, loss of lamina dura, secondary to pain.
and a maxillary unilocular radiolucency (osteitis fibrosa cystica). This Vital signs. Her blood pressure is 162/98 mm Hg, heart rate
is a result of decreased renal conversion of 25-hydroxycholecalciferol is 104 bpm, respirations are 18 breaths per minute, and tempera-
to 1,25-dihydroxycholecalciferol (active vitamin D). A decrease in ture is 38.8°C.
active vitamin D results in reduced gastrointestinal adsorption of Neurologic. She is alert and oriented to place, time, and person.
calcium with a corresponding increase in parathyroid hormone to Maxillofacial. There is fluctuant, tender, and erythematous
augment serum calcium levels by increasing bone resorption. right-sided facial swelling extending from the angle of the man-
dible to the right submandibular space. The floor of the mouth
Labs and the oropharyngeal airway are normal. The right mandibular
third molar (tooth #32) is noted to be impacted with swelling of
Laboratory tests are ordered based on the severity and acuity of symp- the surrounding operculum. Right submandibular lymphade-
toms related to ESRD in conjunction with the patient’s nephrologist nopathy is noted.
and internist. Baseline complete blood count, metabolic panels, liver Pulmonary. The chest is clear to auscultation bilaterally.
function tests, and coagulation studies are usually obtained. Cardiovascular. She has a regular rate and rhythm with no
The following laboratory study results were obtained for this murmurs, rubs, or gallops.
patient: Extremities. There is no swelling, edema, or muscle weakness.
• Complete blood count: white blood cells (WBCs), 14,000/mL; She has left upper arm arteriovenous fistula, which is patent with
hemoglobin, 9.2 g/dL; hematocrit, 29.2%; platelets, 265,000/mL a good thrill.

523
t.me/Dr_Mouayyad_AlbtousH
524 S E C TI O N X Medical Conditions

Assessment septic and hypovolemic, normal saline should be administered by

stepwise boluses of 500 cc at a time (to avoid volume overload).
End-stage renal disease complicating management of an odontogenic Fluid resuscitation caused dilutional reduction of the serum cre-
abscess. atinine to 6.1 mg/dL. The patient’s elevated temperature was
treated with acetaminophen after blood cultures were drawn. As
Treatment much as possible, nonsteroidal antiinflammatory drugs (NSAIDs)
should be avoided even in patients with ESRD who are nonoligu-
The management of a patient with ESRD is often complicated. ric. This is helpful in preserving their residual urine output that
Of particular concern are fluid status and electrolyte balance. Ide- has a mortality benefit in this population.
ally, correction of metabolic and fluid abnormalities should be Although the degree of hyperkalemia was only mild and the
made in conjunction with a nephrologist before any surgical in- cardiac tolerance of mild hyperkalemia is typically much better in
terventions. This may be preferably accomplished by performing ESRD patients, an electrocardiogram was performed to evaluate
a dialysis session (to achieve euvolemia and normal electrolytes) or for loss of P waves, widened QRS complex, and peaked T waves
occasionally by judicious hydration (in case of hypovolemia). (none of which were present). Kayexalate was given orally to lower
Knowing the patient’s current weight and comparing it with her the serum potassium level. The patient was started on intravenous
“dry weight” from the dialysis clinic (the ideal body weight in (IV) clindamycin. No dosing adjustment was needed because the
absence of edema, dyspnea, or poorly controlled hypertension) is clearance of this drug is largely hepatic. Preoperative pain control
very helpful to decide about volume status management. Careful was achieved primarily with a scheduled hydrocodone–acetamin-
electrolyte management (for hypo- or hyperkalemia) can be ophen combination with morphine for breakthrough pain.
reached by either performing dialysis or using exchange resins to Hydrocodone and morphine are metabolized hepatically via con-
lower potassium if dialysis is not immediately available. Dialysis is jugation, but their metabolites are renally excreted. The half-lives
typically performed either by hemodialysis (most commonly used therefore tend to increase in those with ESRD, and a reduction in
modality in the United States and directly applicable to this case) frequency of administration (every 8 hours) was needed to avoid
or peritoneal dialysis (less common in the United States but toxicity and excessive sedation.
widely used in other countries). The optimal control of blood Hyperglycemia was initially treated with sliding-scale insulin.
pressure can be challenging in patients with ESRD, ranging from On the second day after admission, incision and drainage of the
persistent hypertension, intradialytic hypotension, labile hyper- right submandibular abscess and removal of the right mandibular
tension, or persistent hypotension. Ultrafiltration (removal of third molar were performed under a general anesthetic. The post-
fluid during dialysis) and antihypertensive medications are rou- operative course was uneventful. The patient was placed on an
tinely used for hypertension, and midodrine is often used in pa- ESRD renal diet as soon as she was able to eat, and at that time,
tients with hypotension. her usual insulin regimen was begun.
Many medications, particularly antibiotics, need to be appropri-
ately dosed or avoided based on the level of kidney function and Complications
dialyzability of the drug. All patients with ESRD who are able to
take oral nutrition should have a renal diet low in sodium and po- This patient had already reached ESRD and was already on chronic
tassium but increased protein (as opposed to pre-ESRD patients, dialysis. In case of advanced chronic kidney disease (CKD) before
who need to be on moderate protein restriction). Patients receiving initiation of dialysis, the development of uremic symptoms (often
dialysis are best scheduled for surgery the day after dialysis (to op- when the GFR is ,10 or 15 mL/min) is associated with a variety
timize fluid and electrolyte balance and to avoid the consequences of symptoms. These symptoms are listed in Table 100.1.
of possible intradialytic hypotension on the days of dialysis). The
patient’s usual dialysis can be resumed the day after surgery. In case
of postoperative hyperkalemia or fluid overload, dialysis may be TABLE Symptoms of Uremic Syndrome Caused by
needed urgently after surgery. The use of exchange resins (polysty- 100.1 End-Stage Renal Disease
rene sulfonate) can lower the serum potassium level rapidly. How- System Symptoms
ever, and because their onset of action is slow, the newly approved
potassium-lowering agents such as patiromer (Veltassa) and sodium Central nervous system Irritability, insomnia, lethargy, seizures, coma
zirconium cyclosilicate (Lokelma) are not indicated in acute severe Musculoskeletal Weakness, gout, pseudogout, renal
hyperkalemia and are only useful for management of chronic mild osteodystrophy
to moderate hyperkalemia in patients with ESRD. Patients under-
Hematologic Anemia, uremic platelet dysfunction
going hemodialysis often are on low to moderate (considered isoco-
agulant) doses (500–5000 IU) of heparin during dialysis to prevent Pulmonary Pulmonary edema, uremic pneumonitis
filter clotting. If there is a particular concern about increased peri- Cerebrovascular Pericarditis, arrhythmias, cardiomyopathy,
and postoperative risks of bleeding, waiting a minimum of 6 hours atherosclerosis
after cessation of heparin or avoiding heparin for that preoperative
session is a reasonable management strategy. Patients with success- Gastrointestinal Nausea, vomiting, anorexia, gastrointestinal
ful renal transplants may be considered to have adequate renal bleeding, ageusia
function but commonly receive immunosuppressive drugs, includ- Acid–base volume Hyperkalemia, acidosis, volume overload
ing corticosteroids, placing them at increased risk for infections and
Endocrine Hyperparathyroidism, hyperlipidemia,
adrenal insufficiency (requiring stress doses of hydrocortisone) in
delayed insulin clearance
the perioperative period.
The initial management of this febrile and anorexic patient Dermatologic Pruritus, skin discoloration (yellow)
included fluid resuscitation. In patients with ESRD who are

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 100 End-Stage Renal Disease 525

Uremic syndrome is caused by the combined effects of the ac- occur temporarily after removal of a regular urethral Foley cathe-
cumulation of various metabolites (not just urea). The initiation ter in an otherwise healthy individual. A postrenal cause of acute
of dialysis should be decided based on a combination of factors, renal failure that is distal to the ureteral orifices can be diagnosed
including serum creatinine (estimated GFR), uremic symptoms, with measurement of the postvoid residual. This is measured by
volume overload, hyperkalemia, presence of uremic pericarditis, having the patient void naturally and then either placing a tem-
and severe refractory acidosis. This should be considered generally porary catheter in the bladder or checking the bladder volume by
when the GFR approaches 15 mL/min for patients with diabetes ultrasonography to record the volume of remaining urine. A vol-
and 10 mL/min for those without diabetes. ume of less than 50 mL is considered normal.
In patients with CKD (not yet on dialysis), the development Another common consideration in ESRD is the judicious ad-
of acute renal failure should be closely monitored (by checking justment of medications to renal function and dialysis clearance of
serum creatinine levels). This situation is primarily relevant to the medications. Most drugs are metabolized in the liver and ulti-
inpatient procedures in which preoperative blood work is per- mately excreted by the kidneys. Many of those metabolites are
formed and may not apply to most outpatient cases. Causes of themselves metabolically active to some degree. The net result is an
acute renal failure can be divided into prerenal, renal, and postre- increase in the half-life of many drugs. In the presence of ESRD,
nal categories. The most likely cause of prerenal failure is hypovo- the clearance pathway of the medications and, more important,
lemia secondary to blood loss or dehydration. Laboratory indices their dialyzability, have to be considered for appropriate dosing.
that suggest a prerenal source includes a BUN-to-creatinine ratio However, the information about dialyzability of prescription drugs
of greater than 20 and a fractional excretion of sodium of less than can be scarce in many cases. It is possible to develop drug toxicity
1%. Furthermore, the rapid improvement in serum creatinine from failing to adjust either the dose or, more important, the fre-
with fluid resuscitation is highly suggestive of prerenal physiology. quency of drug administration. Although many drugs are relatively
Renal causes of acute renal failure include acute tubular necrosis, nontoxic, failure to renally dose a drug can result in significant
acute interstitial nephritis, and acute glomerulonephritis. Acute morbidity and mortality. Table 100.2 represents the metabolic
tubular necrosis may occur secondary to either hypoperfusion or characteristics and dialyzability of the most commonly used drugs
toxic agents such as myoglobinuria (rhabdomyolysis), contrast in the field of dentistry and maxillofacial surgery.
agents, drugs (aminoglycosides, amphotericin), crystals (acyclovir, The most commonly used IV fluids are normal saline (NS),
sulfonamides), or uric acid (tumor lysis syndrome). The hallmark ½ NS, dextrose 5% in water (D5W), Plasmalyte, bicarbonate,
laboratory feature of acute tubular necrosis is the presence of and lactated Ringer’s solution (LRS). Two considerations should
muddy brown casts within the urine sediment. Acute interstitial be used for judicious choice of IV fluids in patients with ESRD:
nephritis may occur with many drugs and is a potential concern the pH and the electrolyte composition. NS, ½ NS and D5W
in all patients with CKD. Drugs that can cause acute interstitial are significantly acidic (pH of 5–6) and if used extensively may
nephritis include cephalosporins, b-lactams, penicillins, Bactrim cause expansion acidosis. Plasmalyte is pH neutral, and LRS has
(sulfamethoxazole–trimethoprim), diuretics, NSAIDs, and (most a pH of 7.0. Bicarbonate containing solution (D5W with 150
recently) proton pump inhibitors. The presence of eosinophils mEq of bicarbonate/L) is clearly alkaline (pH 8). In a eu-
within the urine is suggestive of acute interstitial nephritis. The volemic patient with ESRD or advanced CKD, one should
last potential cause of acute renal failure is postrenal obstruction. avoid excessive sodium and potassium loading. Table 100.3
This is usually secondary to urethral obstruction prostatic hyper- summarizes the composition of the most commonly used
trophy, neurogenic bladder, or obstructive renal calculi. It can also IV fluids.

TABLE Metabolic Clearance and Dialyzability of the Most Commonly Used Drugs in Dentistry and Maxillofacial
100.2 Surgery

Drug Name Metabolism/Elimination Conventional Hemodialysis High-Permeability Hemodialysis Peritoneal Dialysis

Amoxicillin Mostly renal Yes Low No
Ampicillin Mostly renal Yes Low No
Clindamycin Hepatic No Not determined No
Clavulanic acid Mostly renal Yes Low Yes
Lidocaine Hepatic renal No Not determined Unlikely
Articaine Plasma carboxyesterase/renal Not determined Not determined Not determined
Bupivacaine Hepatic/renal Unlikely Unlikely Unlikely
Midazolam Hepatic renal No Unlikely Unlikely
Fentanyl Hepatic renal Unlikely No Not determined
Ketamine Hepatic/renal No Not determined Unlikely
Propofol Hepatic/renal Unlikely Unlikely Unlikely
Oxycodone Hepatic/renal Not determined Yes Not determined

t.me/Dr_Mouayyad_AlbtousH
526 S E C TI O N X Medical Conditions

TABLE
100.3 Composition of the Most Commonly Used Intravenous Fluids

Osmolality Na Cl K Ca Mg Lactate Dextrose

IV Fluid type pH (mOsm/L) (mEq/L) (mEq/L) (mEq/L) (mEq/L) (mEq/L) (g/L) (g/L)
5% Dextrose in water (D5W) 4.3 278 - - - - - - 50
D5W1 50 cc of sodium bicarbonate 8 2278 50 - - - - - 50
0.9% NaCl (Normal saline) 5.5 308 154 154 - - - - -
0.45% NaCl. (1/2 Normal saline) 5.6 154 77 77 - - - - -
3% NaCl (3% hypertonic saline) 5.2 1026 513 513 - - - - -
Plasmalyte 7.4 298 140 98 5 - 3 - -
Lactated Ringer’s solution (LRS) 6.5 275 130 109 4 3 - 28 -

Discussion peaked T waves, loss of P waves); moderate IV hydration; kayexa-

late; and in severe cases, dextrose and insulin in patients with CKD
There are many causes of ESRD. Diabetes nephropathy and hyper- and ideally renal replacement therapy (dialysis) in patients with
tensive nephrosclerosis are the two most common causes. Many ESRD. In patients with CKD, hypokalemia is typically a result of
patients with metabolic syndrome have both conditions, leading to excessive loop diuretic or poor oral intake and requires oral or par-
an epidemic of CKD in the United States. General management enteral replacement. Furthermore, perioperative care may be com-
of a patient with CKD before onset of ESRD includes a low-pro- plicated by impaired drug excretion, corticosteroids or immuno-
tein diet ( 0.8 g/kg of ideal body weight/day), sodium restriction suppressive drugs, hypertension, anemia, and arrhythmias related
(,2 g/day), potassium restriction (typically ,2 g/day), fluid intake to hyperkalemia. Bleeding may also complicate ESRD as a result of
adjustment based on volume status, and correction of hyperkalemia uremia. Bleeding time is typically elevated because of platelet dys-
and hypokalemia. After patients progress to ESRD and are on di- function and von Willebrand factor abnormalities. Uremia is best
alysis, they need to increase their protein intake to around 1.2 to controlled through dialysis, and von Willebrand factor levels may
1.5 g/kg ideal body weight per day. Patients on peritoneal dialysis be increased with 1-deamino-8-d-arginine vasopressin, cryoprecipi-
may need additional protein and potassium supplementations be- tate, or fresh-frozen plasma.
cause this modality leads to higher leakage of these two components
through the peritoneal membrane. The assessment and manage- ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
ment of hyperkalemia requires an electrocardiogram (wide QRS, complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 526.e1

Bibliography Klag MJ, Whelton PK, Randall BL, et al: Blood pressure and end stage
renal disease in men, N Engl J Med 334(1):13-18, 1995.
US Food and Drug Administration: Lokelma. Available at: https://www.
Bailie and Mason’s 2022 Dialysis of drugs. Available at: https://renalphar-
drugs.com/pro/lokelma.html.
macyconsultants.com.
US Food and Drug Administration: Veltassa. Available at: https://www.
Barrierre SL, Jacobs RA: Clinical use of antimicrobials. In Katzung B
drugs.com/pro/veltassa.html.
(ed): Basic and Clinical Pharmacology, ed 6, Norwalk, CT, 1995,
Ziccardi VB, Saini J, Demas PN, et al: Management of the oral and
Appleton and Lange, pp 760-761.
maxillofacial surgery patient with end stage renal disease, J Oral Max-
Grant J: Nephrology. In Ferri F (ed): The Care of the Medical Patient,
illofacial Surg 50(11):1207-1212, 1992.
ed 5, Philadelphia, 2001, Elsevier, pp 574-616.

t.me/Dr_Mouayyad_AlbtousH
101
Liver Disease
M E H R A N M E H R A B I , G A R Y F. B O U LO U X , a n d S U N G C HO

CC enlarged parotid glands (caused by metabolic and nutritional de-

rangements associated with chronic alcoholism), decreased sensa-
A 54-year-old White male presents to the emergency department, tion to light touch and direction of left V3, and left mandibular
complaining, “I was hit in the face, and my teeth do not meet angle swelling and ecchymosis.
right. It has not stopped bleeding.” Chest and pulmonary. Bilateral crackles in the lung bases
(fluid in the alveolar spaces), bilateral gynecomastia (enlarged
HPI breasts secondary to increased levels of estrogen), and hair loss
over the chest.
The patient was punched in the face the day before admission Cardiovascular. Regular rate and rhythm, with no murmurs,
while intoxicated with alcohol. He denies loss of consciousness gallops (S3 or S4), or rubs.
but reports the progressive development of left facial swelling, Abdominal. The abdomen is nontender and distended, with
pain, difficulty eating (secondary to malocclusion), and numbness shifting dullness (caused by ascites) and splenomegaly (caused by
of his left lower lip. In addition, he describes persistent ooze from portal hypertension secondary to liver cirrhosis). (It is very un-
inside his mouth where he was hit (secondary to coagulopathy). likely to palpate a nodule of liver on clinical examination.) Percus-
He was subsequently diagnosed with a left mandibular angle sion on the right upper quadrant indicates hepatomegaly, and
fracture. caput medusa (tortuous periumbilical veins secondary to portal
hypertension) is also noted.
PMHX/PDHX/Medications/Allergies/SH/FH Extremity. Bilateral lower extremity 11 pitting edema (sec-
ondary to hypoalbuminemia), Dupuytren contracture in the right
The patient was diagnosed with alcoholic cirrhosis of the liver and index and middle fingers (flexion deformity of the fingers second-
associated portal hypertension 2 years ago. He has had several ary to flexor tendon fibrosis), and palmar erythema.
hospital admissions over the past year for worsening ascites (fluid Skin. Multiple small petechiae, spider angiomas, and testicular
in the abdomen) and one for upper gastrointestinal (GI) bleeding atrophy (all secondary to decreased hepatic metabolism of estro-
(secondary to esophageal varices). He has had no regular dental gen) are present.
care. His current medications include furosemide (a loop di-
uretic), spironolactone (a potassium-sparing diuretic), proprano- Labs
lol (a nonselective beta-blocker), and omeprazole (a proton pump
inhibitor [PPI]). He drinks 2 quarts of wine every other day. The laboratory test in the workup of patients with liver disease can
(Drinking more than four standard drinks per day [each standard be complex and crucial to the evaluation of the extent of liver
drink is 5 fl oz of wine, 1.5 fl oz of hard liquor, or 12 fl oz of beer] injury and the degree of dysfunction with associated systemic
would increase the risk of liver insult.) involvement. A complete metabolic panel includes hepatic trans-
aminases. Elevated hepatic enzymes reflect hepatocellular dys-
Examination function. In the current patient, both aspartate aminotransferase
(AST) and alanine aminotransferase (ALT) levels are elevated.
General. Generalized muscle wasting (secondary to poor nutri- (The AST-to-ALT ratio usually is .2:1 with alcoholic hepatic
tion and protein catabolism) and lethargy (secondary to hepatic damage.) However, as the liver progress from hepatitis to cirrho-
encephalopathy). sis, these values return to normal. The functionality of liver is
Vital signs. Blood pressure is 155/92 mm Hg (elevated blood better evaluated by coagulation and albumin production. Or-
pressure), heart rate is 72 bpm, respirations are 22 breaths per dered separately, elevated alkaline phosphatase (ALP) and g-glu-
minute (tachypnea), and temperature is 36.2°C. tamyl transpeptidase (GGT) levels are also seen (reflecting biliary
Neurologic. The patient is alert and orientated 33 (person, system abnormalities). Elevated blood urea nitrogen (BUN) and
place, and time) but intermittently confused, with asterixis (flap- creatinine levels can be seen, especially if there is associated hepa-
ping of the hands with the arms and palms fully extended, a sign torenal syndrome. Hypokalemia and hypomagnesemia are also
of hepatic encephalopathy). common with malnutrition and need to be corrected.
Maxillofacial. Scleral icterus (because of hyperbilirubinemia), A complete blood count generally shows a macrocytic anemia
fetor hepaticus (caused by elevated serum ammonia level), (mean corpuscular volume .100/mm3) (secondary to vitamin B12

527
t.me/Dr_Mouayyad_AlbtousH
528 S E C TI O N X Medical Conditions

and folate deficiency) with thrombocytopenia (secondary to hy- the removal of 4 L of fluid (with care taken to prevent hypotension)
persplenism, increased sequestration, and decreased hepatic pro- brought an immediate reduction in the work of breathing and the
duction of thrombopoietin). An elevated prothrombin time (PT), respiratory rate. The patient was started on furosemide and spirono-
partial thromboplastin time (PTT), and international normalized lactone to reduce the severity and frequency of recurring ascites. The
ratio (INR) are secondary to decreased synthesis of coagulation hepatic encephalopathy was treated with administration of lactulose
factors. The PT is often elevated first because of the shorter half- (to decrease ammonia production by enteric bacteria). The coagu-
life of the vitamin K–dependent factor VII that is part of the ex- lopathy was treated with 6 units of fresh-frozen plasma (to overcome
trinsic pathway measured best by the PT (even small decreases in deficiencies of multiple coagulation factors) and 4 units of platelets
factor VII result in increased PT) or the INR. High blood am- (to increase the platelet numbers to .100,000 cells/mL). Subse-
monia levels reflect the inability of the liver to convert ammonia quently, the patient underwent open reduction with internal fixation
to urea for excretion by the kidneys. Hypoalbuminemia is reflec- of the fracture without complications.
tive of decreased albumin production in the liver. Finally, uncon-
jugated hyperbilirubinemia (causing scleral icterus) is seen be- Complications
cause of decreased bilirubin conjugation by the liver.
For the current patient, the following laboratory test results Complications for patients with liver disease are inherently de-
were obtained: pendent on the degree of functional impairment of the liver and
•y: CSohdeim
umist,r 133 mEq/L (increased water retention concomitant preoperative systemic conditions.
caused by low renal perfusion would result in relative hypona- Patients tend to be protein depleted, fluid overloaded, vitamin
tremia); potassium, 3.1 mEq/L; BUN, 48 mg/dL; creatinine, deficient, and coagulopathic, with electrolyte abnormalities, and
1.6 mg/dL; glucose, 172 mg/dL; magnesium, 1.0 mg/dL; bili- often have an impaired ability to metabolize medications.
rubin, 1.3 mg/dL; ammonia, 67 mmol/L; albumin, 2.2 mg/dL Adjunctive enteral feeding (nasogastric or orogastric tube) may
• Complete blood count: white blood cells, 4500/mL; hemoglo- be necessary in the perioperative period to meet caloric needs,
bin, 9.5 g/dL; hematocrit, 30.1%; platelets, 62,000/mL especially in the setting of oral and maxillofacial surgery, when
• Coagulation studies: PT, 17 seconds; PTT, 43 seconds; INR, 1.5 chewing may be difficult (e.g., intermaxillary fixation, swelling,
•er Lfuivnction tests: AST, 141 U/L; ALT, 84 U/L; GTT, pain). Lack of oral intake can result in dehydration; abdominal
45 U/L; ALP, 51 U/L pain; and low glycogen storage, which shifts metabolism to the fat
and lips. This results in a decrease in insulin and increase in coun-
Imaging terregulatory hormones such as cortisol, glucagon, and epineph-
rine. The increase in lipid metabolism results in increased ketone
A panoramic radiograph revealed a fracture of the left mandibular production, which is the underlying pathophysiology for alco-
angle. holic ketoacidosis. Parenteral nutrition may also be considered
For evaluation and diagnosis of liver cirrhosis, a computed but only in the setting of compromised GI function. (If the gut
tomography–guided liver biopsy can be done as needed to dem- works, use it.) Caloric requirements should be calculated with
onstrate destruction of normal hepatic architecture with fibrotic consideration to reducing short-chain fatty acids and mercaptans
changes, confirming the diagnosis of liver cirrhosis. acid content to prevent exacerbation of any encephalopathy. The
latter is thought to relate to the blood ammonia level (however, a
Assessment clear correlation between the grade of encephalopathy and am-
monia does not exist), which can be further reduced with the use
Mandibular fracture complicated by hepatic dysfunction secondary to of lactulose (encephalopathy is graded from 0 [minimal] to 4
alcoholic cirrhosis. [coma]). Malnutrition and impaired protein synthesis impair
wound healing, which can present as increased wound breakdown
Treatment and delayed healing.
Coagulopathy may be the result of decreased platelets from
Preoperative preparation of patients with severe liver disease is of splenic sequestration. (Hypersplenism occurs secondary to portal
paramount importance to prevent perioperative complications. hypertension and nitric oxide–induced splenic vasodilation, both
Preoperative management includes administration of 100 mg of secondary to liver cirrhosis and thrombopoietin reduction synthe-
thiamine (to prevent Wernicke encephalopathy, characterized by sized by the liver.) Platelet transfusion is the only treatment for
ophthalmoplegia, ataxia, and memory impairment), a nutritious thrombocytopenia. Spontaneous bleeding is seen with platelet
diet, and multivitamins with folic acid and vitamin B12 supple- counts less than 30,000/mL; for most minor procedures, a count
mentation. (Excess alcohol consumption is often associated with greater than 50,000/mL is appropriate. Ideally, the patient should
nutritional deficiencies.) Any coagulopathy needs to be addressed be transfused to a platelet count greater than 100,000/mL for
preoperatively (see the Complications section). major surgeries and procedures.
In the current patient, hypokalemia and hypomagnesemia were Coagulopathy may also be the result of decreased hepatic syn-
corrected with potassium chloride and magnesium sulfate infusions. thesis of clotting proteins, as is often the case with end-stage liver
Librium, a benzodiazepine, was given as a taper over 4 days to pre- disease, or it may be the result of decreased absorption of fat-solu-
vent life-threatening alcohol withdrawal (delirium tremens). Because ble vitamins (vitamins A, D, E, and K) from the GI tract. The
of the risk of aspiration (increased in patients with alcoholism), the latter is more common with cholestatic liver disease. (Decreased
patient was also continued on a PPI (decreases gastroesophageal re- bile salts reduce the absorption of fat and fat-soluble vitamins.) In
flux and the degree of chemical pneumonitis if aspiration occurs). this situation, vitamin K can be administered, with an appropriate
Because of the patient’s obvious respiratory distress as a result of the increase in the synthesis of vitamin K–dependent coagulation fac-
ascites, paracentesis (removal of peritoneal fluid) was performed (pleu- tors (factors II, VII, IX, and X). The endpoint of management is a
ral effusion, ascites, and an elevated diaphragm lead to atelectasis); substantial improvement in or normalization of the PT or INR.

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 101 Liver Disease 529

When decreased hepatic synthesis of coagulation proteins is the immunosuppressed to prevent graft rejection. This may result in
result of intrinsic liver disease (as in the current patient), transfu- an increase in both opportunistic and perioperative infections.
sion with fresh-frozen plasma is the treatment of choice. Care must The MELD score replaced the Child-Pugh classification, which
be taken to avoid worsening of the total-body fluid overload, is measured by albumin, hepatic encephalopathy, INR, and total
which is typical of ascites and may precipitate pulmonary edema. bilirubin. MELD-Na (sodium level) is used now as the predictor
Liver failure may also be associated with hepatopulmonary of death for liver transplant.
syndrome (triad of vasodilation, increase in alveolar-arterial gradi-
ent, and chronic liver disease), hepatorenal syndrome (decreased Discussion
renal perfusion, elevated renin and aldosterone, and exacerbated
reduction in capillary perfusion, with electrolyte disturbances, Liver disease can be the result of many insults. It is now considered
improved with administration of terlipressin or noradrenaline), the fifth most common cause of death after coronary disease, cere-
upper GI bleeding, and subacute bacterial peritonitis. There is a brovascular accident, chest disease, and cancer. The most common
hyperdynamic circulatory system with systemic vasodilation. This causes are alcohol consumption and viral hepatitis. The disease
is caused by increase in nitric oxide and downregulation of the progress from fatty liver to alcoholic hepatitis to chronic hepatitis
sympathetic nervous system. This results in an increase in cardiac to cirrhosis. Hepatitis C is more common than hepatitis B, with
output and eventual cirrhotic cardiomyopathy. Most drugs are an estimated 4 million cases in the United States. As many as 90%
metabolized by the liver and as such may need to be dosed ap- of these cases are chronic. As the population increases in prevalence
propriately or avoided altogether. Drugs that are renally excreted of obesity, hepatic steatosis (nonalcoholic fatty liver disease) and
are preferable to those that require hepatic metabolism. liver scarring is on the rise. Finally, biliary obstructive disease such
End-stage liver disease (ESLD) can be treated with liver trans- as cholangiocarcinoma or pancreatic cancer can result in hepatic
plantation, although most patients die of liver disease or are not failure. Viral hepatitis also poses a risk for transmission to the sur-
eligible for transplantation. In 2002, the Mayo Clinic began to geon and operating room staff from needlestick injury. Particular
stratify ESLD liver transplant recipients with an objective calcu- care should be taken to reduce this risk. The causes of liver dys-
lator to determine the severity of liver dysfunction. The Model function are many, but the consequences are often similar. Cir-
for End-Stage Liver Disease (MELD) score can be used to predict rhosis is the final common pathway of chronic inflammation and
morbidity and mortality in patients needing nonliver surgery. is irreversible. Alcoholic cirrhosis may coexist with alcoholic hepa-
The MELD score is readily calculated using the patient’s INR, titis. Liver dysfunction is associated with malnutrition, protein
bilirubin, and creatinine. The formula is available at the website catabolism, poor wound healing, coagulopathy, portal hyperten-
http://www.mayoclinic.org/meld/mayomodel5.html. Elective sion, splenomegaly, ascites, portosystemic venous shunts (esopha-
nonliver surgery is acceptable in a patient with a MELD score geal, periumbilical, retroperitoneal, and hemorrhoidal shunts),
below 10; a score between 10 and 15 necessitates careful assess- encephalopathy, and impaired drug metabolism and clearance. A
ment of risks and benefit; and a score above 16 effectively elimi- proper history and physical examination, in addition to appropri-
nates elective procedures. Our patient, despite having a MELD ate laboratory tests, are critical in the perioperative period for the
score of 16, was a candidate for open reduction and internal surgeon. All these factors combine to make management of pa-
fixation of his fractured mandible because it is not elective sur- tients with liver disease a challenging and difficult task.
gery. However, elevated MELD scores are associated with in-
creased perioperative morbidity and mortality. Successful liver ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
transplant recipients have functionally normal livers but are complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 529.e1

Bibliography Muir AJ: Surgical clearance for the patient with chronic liver disease, Clin
Liver Dis 16(2):421-433, 2012.
O’Leary JG, Yachimski PS, Friedman LS: Surgery in the patient with
Gasteiger L, Eschertzhuber S, Tiefenthaler W: Perioperative management liver disease, Clin Liver Dis 13(2):211-231, 2009.
of liver disease—review on pathophysiology of liver disease and liver Rinella ME: Nonalcoholic fatty liver disease a systemic review, JAMA
failure, Eur Surg 50:81-86, 2018. 313(22):2263-2273, 2015.
Howard RD, Bokhari SRA: Alcoholic ketoacidosis. [Updated 2022 May Williams R: Global challenges in liver disease, Hepatology 44(3):521-526,
8]. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2006.
2022.
Kamath PS, Wiesner RH, Malinchoc M, et al: A model to predict survival
in patients with end-stage liver disease, Hepatology 33(2):464-470, 2001.

t.me/Dr_Mouayyad_AlbtousH
102
SARS-CoV-2 and Oral and Maxillofacial
Surgery Considerations
SEI E D O M I D KE Y HA N , J IN A YAVA R I FA R , a n d PA R I S A YO U S E FI

fluticasone furoate and mometasone furoate use, can cause dam-

CC age to the chemoreceptors of the olfactory bulb.) Other known
drugs that can cause olfaction disorder are:
A 27-year-old White female presents after 2 weeks of minimally • Antibiotics: amoxicillin, azithromycin, and ciprofloxacin
invasive rhinoplasty using piezoelectric surgery with dorsal preser- •looB d pressure medications: amlodipine and enalapril
vation for postoperative follow-up. She complains about the de- t•atiSn drugs (cholesterol-lowering drugs): atorvastatin, lovas -
velopment of an olfactory disorder (dysosmia). tatin, and pravastatin
•oidThmyerdication: levothyroxine
HPI No history of allergy is reported.
The patient reports no history of prior olfactory dysfunction. Dur- Examination
ing her postoperative recovery, she received some visitors. She ap-
pears healthy and mentions that during the past week, her sense of General. The patient is a healthy, asymptomatic, well-dressed fe-
smell has been compromised after returning to a regular diet a few male. She wore a mask outdoors and took safety precautions to
days after surgery. She tried various strong perfumes to test whether prevent COVID-19 during the 2020 pandemic infection. She
this condition is only limited to certain odors. However, she has experiences partial to severe anosmia. Two weeks later, symptoms
partial to complete loss of olfaction. In her reports, she also mentions of dysgeusia also started to appear.
that dysosmia caused her to lose her appetite. She lost a little weight Maxillofacial. The patient does not have lymphadenopathy.
as a result of her reluctance to eat. The patient believes this condition Her facial skin is without any lesions or active dermatologic infec-
is associated with changes after her minimally invasive rhinoplasty tions or pathology. Her oral mucous membranes are moist. There
surgery using a piezoelectric procedure with dorsal preservation. are no signs of upper respiratory infection (postnasal drip, mucous
discharge, or erythema).
PMHX/PDHX/Medications/Allergies/SH/FH Intraoral. No abnormalities or lesions are noted. Oral hygiene
is good.
A minimally invasive rhinoplasty using piezoelectric surgery with Nasal. The external nasal bones are stable. The nasal mucosa is
dorsal preservation technique was performed on the patient 2 weeks nonerythematous with normal moisture and an absence of
earlier without a history of nasal obstruction and respiratory prob- irregular lesions.
lems before and immediately after surgery. Her COVID-19 reverse Pulmonary. The patient does not exhibit shortness of breath.
transcription polymerase chain reaction (RT-PCR) test result was
negative 48 hours before surgery. Head trauma, nerve pathway Imaging
disease, or nasal congestion from an upper respiratory infection are
not present in her medical history. (Severe head traumas or nerve The patient had no nasal obstruction before surgery.
pathway diseases, such as central nervous system infections or tu- Two weeks after minimally invasive rhinoplasty using piezo-
mors, can often affect neurotransmission, leading to altered sensory electric surgery with dorsal preservation, a chest x-ray examina-
perception as anosmia.) COVID-19 vaccines have not been admin- tion revealed no lung involvement. (A multifocal and bilateral
istered to the patient. The following medications were prescribed ground glass opacity is usually present in the lower lobes of the
after rhinoplasty, which are not known to interfere with smell: lungs along with consolidations that have a peripheral or basal
•exaD metazom 0.5-mg tablets q8h (#20) predominance in patients with COVID-19.)
• Cefalexin 500-mg tablets q6h (#20)
•henPylephrine 0.5% spray q8h for 3 day/(#1) Labs
•etraTcycline 3% ointment q8h (#20)
There is no history of smoking, cocaine, or other drug or Forty-eight hours before rhinoplasty, the patient’s RT-PCR test
medication use. (Chronic cocaine and intranasal steroids, such as result for COVID-19 was negative. Two weeks after the patient’s

530
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 102 SARS-CoV-2 and Oral and Maxillofacial Surgery Considerations 531

Before After Before After

A B
Before After Before After

C D
• Fig. 102.1. Before and After photo series of a 27-year-old patient who had minimally invasive rhinoplasty
using piezoelectric surgery with dorsal preservation. A, Frontal view. B, Side view. C, Three quarter view.
D, Base view. (From Keyhan SO: minimally invasive rhinoplasty using piezoelectric surgery using preservation
technique, 2020, Isfahan)

complaint, a repeated RT-PCR test was performed because of the The RT-PCR test was repeated 2 weeks after the postoperative
suspicion that the patient might have been infected with CO- visit because other symptoms of COVID-19, especially dysgeusia,
VID-19. (No routine laboratory tests are indicated for rhinoplasty had emerged. Positive results were obtained from the repeated
in an otherwise healthy patient. However, for patients with a his- PCR test. The patient’s positive PCR test result indicated the pres-
tory of clotting disorders or liver and kidney pathology, complete ence of COVID-19 infection. A chest radiograph revealed no
blood count with differential, prothrombin time [PT], partial abnormalities.
thromboplastin time, international normalized ratio [INR], so- A gradual improvement in sense of olfaction was noticed 2
dium, potassium, blood urea nitrogen and creatinine, alanine months after surgery. The patient completely recovered her sense
aminotransferase [ALT], aspartate aminotransferase [AST], and of smell after 6 months.
alkaline phosphatase are recommended for screening.)
Treatment
Assessment
It is possible for most people who test positive for COVID-19
It is usually 5 to 10 days after the onset of the COVID-19 symp- with mild to moderate illnesses to recover at home. Supportive
toms that the radiographic findings reach their peak severity. treatment can be provided with over-the-counter medications,
There were no abnormalities on the computed tomography scan such as acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) to
of the nose and chest radiography after surgery. alleviate symptoms.

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532 S E C TI O N X Medical Conditions

• Fig. 102.2. Nasal CT scan series before surgery showing no history of nasal obstruction. (From Keyhan
SO: minimally invasive rhinoplasty using piezoelectric surgery using preservation technique, 2020, Isfahan)

The US Food and Drug Administration (FDA) has approved soon as possible to determine whether the patient is eligible for
several treatments for COVID-19 infections that have the po- treatment.
tential to develop severe symptoms and result in hospitalization Treatment must be received immediately after diagnosis and
or death. In the case of an effective diagnosis, the health care development of symptoms. People who are more prone to get very
provider should prescribe the medication immediately. Even sick include unvaccinated individuals; older adults (adults older
mild symptoms should be reported to health care providers as than 50 years old [the risk proportionally increases with age]); and

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 102 SARS-CoV-2 and Oral and Maxillofacial Surgery Considerations 533

patients with certain medical conditions such as chronic lung • Monoclonal antibodies facilitate recognition and effective
disease, heart disease, and immunocompromised status. Vaccina- response to viruses by the immune system.
tion considerably decreases the severity, need for hospitalization, Several medications are available for COVID-19 at home or in
and chance of death from the disease. Yet individuals at high risk an outpatient setting depending on condition and severity of the
(especially those ages 65 years and older and immunocompro- illness. They include Table 102.1.
mised adults) can still benefit from treatment. Depending on the patient’s condition and hospitalization, the
health care provider might administer other types of treatment. A
Classification of Treatments combination of medications may be required to manage CO-
VID-19, suppress hyperactive or uncontrollable immunity, or al-
The FDA has approved several antiviral drugs as well as monoclo- leviate complications associated with COVID-19.
nal antibodies to treat mild to moderate cases of COVID-19, es-
pecially in those who are susceptible to becoming very ill.
• Antiviral treatments inhibit the certain part of viral replica-
Vaccines
tion in the body, reducing the risk of severe illness and death A wide range of COVID-19 vaccines are available in different re-
caused by viruses. gions, and they have proven to prevent serious illnesses, hospitaliza-
tions, and even deaths, especially for people with boosted vaccines.
According to the Centers for Disease Control and Prevention
(CDC), every qualified individual is recommended to receive
TABLE COVID-19 vaccines for self and public safety. These include:
102.1 COVID-19 Treatments and Medications • FDA-authorized vaccines for adults older than 18 years old
• FDA-authorized vaccines for children and teens ages 6 months
Medication Age Time Route to 17 years.
Nirmatrelvir Adults and chil- Start within 5 Oral
with ritona- dren ages 12 days of onset
vir (Paxlovid) years and older of symptoms
Preventive Medicines
(antiviral) A medicine given to adults and children ages 12 years and older
Remdesivir Adults and Start within 7 IV infusions for called tixagevimab and cilgavimab (Evusheld) has received an
(Veklury) children days of onset 3 consecu- Emergency Use Authorization (EUA) from the FDA. Evusheld is
(antiviral) of symptoms tive days a combination of two monoclonal antibodies that are given
together to help prevent infection with the COVID-19 virus.
Molnupiravir Adults Start within 5 Oral
(Lagevrio) days of onset
Health care providers administer Evusheld as two individual con-
(antiviral) of symptoms secutive intramuscular injections in a clinical setting. This medi-
cation is recommended in patients with moderate to severely
Bebtelovimab Adults and chil- Start within 7 Single IV suppressed immunity or severe allergies to COVID-19 vaccines.
(monoclonal dren ages 12 days of onset injection Individuals should be evaluated by their health care providers to
antibody) years and older of symptoms
determine their eligibility.
IV, Intravenous. For patients who do not require hospitalization or oxygen
Source: Centers for Disease Control and Prevention. https://www.cdc.gov/ supplementation via ventilation, it is strongly advised to prevent
coronavirus/2019-ncov/your-health/treatments-for-severe-illness.html administering any kind of systemic glucocorticoids such as
dexamethasone.

TABLE
102.2 COVID-19 Vaccines and Boosters

Manufac-
turer Type Primary series Booster
Pfizer- mRNA Two doses 3–8 Third dose: preferably with Pfizer-BioNTech or Moderna at least 2 months after the final dose
BioNTech weeks apart
Moderna mRNA Two doses 4–8 Third dose: preferably with Pfizer-BioNTech or Moderna at least 2 months after the final dose
weeks apart
Novavax Protein subunit Two doses 3–8 Third dose: preferably with Pfizer-BioNTech or Moderna at least 2 months after the final dose
weeks apart
Johnson & Viral vector One dose First booster (second dose): preferably with Pfizer-BioNTech or Moderna at least 2 months after J&J/
Johnson’s Janssen COVID-19 vaccine
Janssen Second booster (third dose): preferably with Pfizer-BioNTech or Moderna at least 2 months after the
first booster (only for adults older than 50 years of age)

Source: Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html#: :text5CDC%20recommends%20the%20

2023%E2%80%932024,serious%20illness%20from%20COVID%2D19.

t.me/Dr_Mouayyad_AlbtousH
534 S E C TI O N X Medical Conditions

TABLE
102.3 COVID-19 Vaccines and Boosters for Children

Manufacturer 6 Months–4 Years 5–11 Years 12–17 Years

Pfizer- Primary series: two doses Primary series: two doses 3–8 Primary series: two doses 3–8 weeks apart
BioNTech 3–8 weeks apart weeks apart Booster: preferably with Pfizer-BioNTech or Moderna at least
Booster: at least 8 weeks Booster: at least 5 months after 2 months after the final dose
after the final dose the final dose
Moderna Primary series only: two Primary series only: two doses, Primary series: two doses 4–8 weeks apart
doses 4–8 weeks apart 4–8 weeks apart Booster: Preferably with Pfizer-BioNTech or Moderna at least 2 months
after the final dose
Novavax Not authorized Not authorized Primary series: two doses 3–8 weeks apart
Booster: can only be with Pfizer-BioNTech at least 2 months after the
final dose

Source: Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html#: :text5CDC%20recommends%20the%20

2023%E2%80%932024,serious%20illness%20from%20COVID%2D19.

Nonhospitalized patients with mild to moderate COVID-19 • Blood clots and blood vessel (vascular) issues, including a blood
respond to antiviral and monoclonal antibody treatment with a clot that travels to the lungs from deep veins in the legs and
good prognosis. However, ritonavir-augmented nirmatrelvir (Pax- blocks blood flow to the lungs (pulmonary embolism)
lovid) and remdesivir (Veklury) should be selected as the first line
of treatment options for patients with mild to moderate CO- Neurologic Symptoms
VID-19 symptoms. As an alternative option, bebtelovimab and
molnupiravir should be considered only when the first line of • Difficulty thinking or concentrating (sometimes referred to as
treatment cannot be clinically achieved. “brain fog”)
• Headache
Complications • Sleep problems
• Dizziness when standing up (lightheadedness)
Post-COVID syndrome may occur in some patients. Several • Pins-and-needles feelings
other names are used to describe post-COVID conditions (PCC), • Change in smell or taste
including long COVID, long-haul COVID, postacute CO- • Depression or anxiety
VID-19, postacute sequelae of SARS-CoV-2 infection, long-term
effects of COVID, and chronic COVID. Temporary multiorgan Digestive Symptoms
effects or autoimmune disorders after severe COVID-19 are prob-
able. Organ systems, including the heart, the lungs, the kidneys, • Diarrhea
the skin, and the brain, can be affected during multiorgan effects. • Stomach pain
Because of these effects, COVID-19 survivors may have a greater
chance of developing newly diagnosed medical conditions such as Other Symptoms
diabetes, heart problems, or neurologic disorders. The typical
post-COVID condition is usually identified at least 4 weeks after • Joint or muscle pain
the patient recovers from COVID-19 infection. The symptoms • Olfactory disorder (anosmia)
gradually improve over time. After COVID-19 illness, rare indi- • Loss of taste (dysgeusia)
viduals have post-COVID conditions for months or even years, • Rash
resulting in chronic disability. Common post-COVID condition • Changes in menstrual cycles
symptoms are listed next.
Drug Side Effects
General Symptoms Paxlovid
• Tiredness or fatigue According to FDA guidelines, patients should let their health care
• Symptoms that get worse after physical or mental effort (also providers know if they are taking a hormonal contraceptive or
known as “postexertional malaise”) have kidney problems. Because Paxlovid interferes with the effi-
• Fever cacy of contraceptive medications, females who are at high risk of
pregnancy are recommended to have an extra reliable method to
Respiratory and Heart Symptoms contraception or impede sexual intercourse during Paxlovid treat-
ment. Health care providers may prescribe lowers dose for pa-
• Difficulty breathing or shortness of breath tients with renal disease.
• Cough There is a long list of medications that Paxlovid should be
• Chest pain avoided in oral and maxillofacial surgery settings, including carbam-
• Fast-beating or pounding heart (also known as heart palpitations) azepine, dihydroergotamine, lovastatin, midazolam (oral), naloxegol,

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 102 SARS-CoV-2 and Oral and Maxillofacial Surgery Considerations 535

phenobarbital, phenytoin, primidone, propafenone, quinidine, ri- Vaccine Side Effects

fampin, and sildenafil (Revatio) for pulmonary arterial hypertension.
Possible side effects of Paxlovid are: A severe reaction is uncommon after COVID-19 vaccination,
• Allergy. An allergic reaction can rise after just one dose. Pa- which is both safe and effective. The following are potential com-
tients should immediately stop the intake of Paxlovid if any plications of vaccines:
symptoms of allergic reaction start, including hives; trouble • Severe allergic reactions. It is quite uncommon to experience
swallowing or breathing; swelling of the mouth, lips, or face; anaphylaxis after receiving COVID-19 vaccination, with ap-
throat tightness or asthma; hoarseness; or skin rash. proximately 5 cases occurring per 1 million doses.
• Liver disease. The health care provider should stop the pre- • A rare but serious thrombosis with thrombocytopenia syn-
scription of Paxlovid right away if any of the following signs of drome (TTS) has been reported after the J&J/Janssen
liver failure appear: loss of appetite, yellowing of the skin and COVID-19 vaccine was administered to approximately 4 people
sclera of eyes (jaundice), dark-colored urine, pale-colored in 1 million doses. In TTS, blood clots form in large vessels, and
stools, itchy skin, or abdominal pain. platelets are low.
• Resistance to human immunodeficiency virus (HIV) medi- • It is extremely rare for people to develop Guillain-Barré syn-
cines. The use of Paxlovid may reduce the effectiveness of some drome (GBS) after receiving the J&J/Janssen COVID-19
HIV medicines in patients with untreated HIV infection. vaccine. Males older than 50 years of age are most often af-
The following side effects may also occur: altered sense of taste fected by GBS. According to Vaccine Safety Datalink recent
(Dysgeusia), diarrhea, high blood pressure, muscle aches, nausea, data analysis, GBS rates within the first 21 days after vaccina-
and feeling generally unwell. tion with J&J/Janssen COVID-19 were 21 times higher than
those after vaccination with Pfizer-BioNTech or Moderna
Remdesivir (Veklury) (mRNA COVID-19). After J&J/Janssen COVID-19 vaccina-
There are risks associated with remdesivir (Veklury), such as gas- tion, the rate of GBS was 11 times higher after 42 days. As a
trointestinal symptoms (e.g., nausea), elevated transaminase lev- result of two mRNA COVID-19 vaccines, Pfizer-BioNTech
els, a rise in the INR or PT, and hypersensitivity reactions. and Moderna, no increased risk of GBS was found.
According to the FDA, patients should undergo an estimated • Myocarditis and pericarditis are rare complications associated
glomerular filtration rate, liver function, and PT test before start- with mRNA and protein COVID-19 vaccination, most com-
ing remdesivir. These tests should be repeated and closely moni- monly observed in males aged 12 to 39 years. However, pa-
tored as clinically indicated during treatment. tients with myocarditis and pericarditis caused by COVID-19
vaccine respond well to treatment and recover quickly. Most
Lagevrio cases have been reported after receiving Pfizer-BioNTech,
During the COVID-19 pandemic, Lagevrio was granted an EUA Moderna (mRNA vaccines), or Novavax (protein vaccine).
by the FDA. While receiving Lagevrio and for 4 days after the last Maintaining longer intervals between the first and second
dose of Lagevrio, patients should use an extra form of contracep- doses may significantly reduce this rare risk.
tion frequently. • It is common for axillary (armpit) lymphadenopathy caused
Lagevrio is not authorized: by COVID-19 vaccine to persist for at least 6 weeks after vac-
• In children young than 18 years old cination. Those who receive two doses of mRNA vaccines are
• As a preventive method for COVID-19 infection most likely to develop swollen lymph nodes, especially on the
• In hospitalized patients side where the vaccine was administered. This is because of the
• For consumption longer than 5 consecutive days strong immune response elicited by the vaccine, which is tem-
The common side effects of Lagevrio are allergy, diarrhea, nau- porary. It is important to consider whether lymphadenopathy
sea, and dizziness. is vaccine related and how long has passed since vaccination. It
is recommended that recipients of the mRNA vaccine undergo
Bebtelovimab follow-up examinations at least 12 weeks after vaccination.
During the COVID-19 pandemic in 2019, bebtelovimab was • The most common side effects after vaccination are mild and
approved under EUA by the FDA for emergency use in the ab- usually last for less than 7 days. They can alter the recipient’s
sence of contraindications because little information was available ability to do daily activities. Systemic symptoms are fever,
at the time. The adverse effects are: chills, loss of appetite, fatigue, weakness, and headache. They
• Hypersensitivity, anaphylaxis, infusion-related reactions, rash, are usually more common after the second dose.
and pruritus. For primary and booster vaccinations, Pfizer-BioNTech or
• Increase in clinical severity of symptoms after SARS-CoV-2 Moderna COVID-19 vaccines are highly recommended over
monoclonal antibody administration is reported; may follow J&J/Janssen COVID-19 vaccines. A possible causal link exists
signs of fever, hypoxia or respiratory distress, arrhythmia (e.g., between J&J/Janssen COVID-19 vaccine and serious adverse
atrial fibrillation, sinus tachycardia, bradycardia), fatigue, and TTS. The incidence is about 3.83 cases per 1 million Janssen
altered mental state; and may require inpatient hospitalization. doses and has resulted in death.
• Limitations of advantage for potential risks for severe and hos-
pitalized patients with COVID-19 who require high-flow oxy- Discussion
gen or mechanical ventilation.
Bebtelovimab is not approved for the following patients: Patients with COVID-19 infection should postpone elective proce-
• Hospitalized because of COVID-19 dures until they have recovered and met the criteria for termination
• On oxygen-dependent therapy or respiratory support because of isolation and precautions against COVID-19 transmission is
of COVID-19 or having chronic underlying non-COVID-19 mitigated. It is recommended that patients should only undergo
comorbidity nonurgent surgeries if both anesthesiologists and surgeons agree on

t.me/Dr_Mouayyad_AlbtousH
536 S E C TI O N X Medical Conditions

the timing and manner of the procedure. Testing respiratory secre- COVID-19 and the time it takes for surgery, the following wait
tions with RT-PCR confirms SARS-CoV-2 infection in both asymp- times are suggested:
tomatic and symptomatic patients. In terms of symptom severity, •ourFweeks for an asymptomatic patient or recovery from only
symptomatic patients can further be divided into two groups: mild, nonrespiratory symptoms
•ild M to moderate symptoms (usually without viral pneumonia •ix w S eeks for a symptomatic patient (e.g., cough, dyspnea)
or oxygen saturation of ,94%) who did not require hospitalization
•eveSre or critical illness (e.g., pneumonia, hypoxemic respira - •ighE t to 10 weeks for a symptomatic patient who has diabetes,
tory failure, septic shock) is immunocompromised, or is hospitalized
Patients with mild to moderate COVID-19, may show re- •welTve weeks for a patient who was admitted to an intensive
peated positive RT-PCR test results for long periods of time after care unit because of COVID-19 infection
the first symptoms appear. Therefore, according to CDC recom- However, surgeons should not consider these timelines deci-
mendations, physicians should adopt time- and symptom-based sive; comprehensive preoperative risk evaluation should be tai-
strategies to determine whether patients with COVID-19 are lored to each patient and individualized, taking into account
infectious or not. surgical intensity, underlying illnesses, and the potential benefits
The CDC recommends halting isolation and other transmis- and risks of delaying surgery further. Special consult should be
sion-based precautions for patients with mild to moderate symp- given regarding the cardiopulmonary systems for who recovered
toms of COVID-19 infection at the following times: from COVID-19 and especially those with PCC.
t .leaAst 10 days have passed since symptoms first appeared.
1 Because continuing positive PCR test results are common after
t .leA
2 ast 24 hours have passed since the last fever without the recovery, the CDC strongly discourages repeating PCR testing in
use of fever-reducing medications. asymptomatic patients. If symptoms persist within 90 days, a con-
3ym
. pStoms (e.g., cough, shortness of breath) have improved. sultation with a doctor specializing in infectious diseases is recom-
In the presence of clinical suspicion of infection, all the nec- mended. After the 90-day recovery period, a nasopharyngeal PCR
essary precautions may be effective, as well as repeat RT-PCR test should be performed not less than 72 hours before surgery.
testing. Although dermal fillers and Botox swelling in patients who
Because COVID-19 is capable of indirectly affecting all major had COVID-19 are extremely rare, it is a potential factor. The
organ systems, surgeons should evaluate and optimize the pa- FDA’s clinical COVID vaccine trial first identified swelling
tient’s general medical condition before surgery. Thus, it is impor- among dermal filler patients. Only 3 of 15,184 participants ex-
tant to consider the risk of postoperative complications when perienced this side effect after receiving dermal filler, and it was
scheduling surgery after a diagnosis of COVID-19. either resolved by itself or by antihistamines, steroids, or both in
The Anesthesia Patient Safety Foundation and American all 3 cases. Neither the CDC nor the FDA has issued official
Society of Anesthesiologists recommend that surgery be de- guidelines regarding how long patients should wait before receiv-
layed by at least 7 weeks after SARS-CoV-2 infection and that ing facial fillers after receiving the COVID-19 vaccine, but it
patients experiencing continuing symptoms after 7 weeks may is strongly suggested that patients avoid cosmetic surgery for
benefit from a delay of further treatment. Hospitalization and 2 weeks after receiving their final dose, including dermal filler
severe COVID-19 disease are more likely to occur in patients injections and Botox. Most people’s immune systems stabilize
with diabetes. within 2 weeks before and after the vaccine is administered.
When elective surgery is decided to be performed after recov-
ery, it depends both on the severity and symptoms of ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
COVID-19. Taking into account the date of diagnosis of complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 536.e1

Bibliography Fact sheet for healthcare providers: emergency use authorization for Pax-
lovid [Internet], [cited 2022 Oct 2]. Available at: https://www.fda.
gov/media/155050/download.
American Board of Facial Cosmetic Surgery: Here’s what you need to Fact sheet for healthcare providers: emergency use authorization for La-
know about dermal fillers and the COVID-19 vaccine [Internet], gevrio (Molnupiravir) capsules [Internet], [cited 2022 Oct 2]. Avail-
2021 [cited 2022 Oct 2], American Board of Facial Cosmetic Surgery. able at: https://www.fda.gov/media/155054/download.
Available at: https://www.ambrdfcs.org/blog/dermal-filler-swelling- Fallahi HR, Keyhan SO, Adham G, et al: Novel techniques in rhino-
covid-19-vaccine/. plasty. In Keyhan SO, Fattahi T, Bagheri SC et al., (eds): Integrated
American Society of Anesthesiologists: ASA and APSF joint statement on procedures in facial cosmetic surgery [Internet], Cham, 2021 [cited
elective surgery and anesthesia for patients after COVID-19 infection 2022 Oct 2], Springer International Publishing, pp 249-270. Avail-
[Internet], 2023 [cited 2022 Oct 2], American Society of Anesthesiolo- able at: https://link.springer.com/10.1007/978-3-030-46993-1_20.
gists. Available at: https://www.asahq.org/about-asa/newsroom/news- Fallahi HR, Keyhan SO, Fattahi T, et al: Comparison of pizeosurgery and
releases/2023/06/asa-and-apsf-joint-statement-on-elective-surgery-pro- conventional osteotomy post rhinoplasty morbidities: a double-blind
cedures-and-anesthesia-for-patients-after-covid-19-infection. randomized controlled trial, J Oral Maxillofac Surg 77(5):1050-1055,
American Society of Anesthesiologists: ASA and APSF joint statement on 2019. Available at: https://linkinghub.elsevier.com/retrieve/pii/
elective surgery/procedures and anesthesia for patients after S0278239119300060.
COVID-19 infection [Internet], 2023 [cited 2022 Oct 2], American Ha SM, Chu AJ, Lee J, et al: US evaluation of axillary lymphadenopathy
Society of Anesthesiologists. Available at: https://www.asahq.org/ following COVID-19 vaccination: a prospective longitudinal study,
about-asa/newsroom/news-releases/2022/02/asa-and-apsf-joint-state- Radiology 305(1):46-53, 2022. Available at: http://pubs.rsna.org/
ment-on-elective-surgery-procedures-and-anesthesia-for-patients-af- doi/10.1148/radiol.220543.
ter-covid-19-infection. Keyhan SO, Bohluli B, Nazari S, et al: Preservation dorsal hump surgery,
American Society of Anesthesiologists: COVID-19 and elective surgery Oral Maxillofac Surg Clin N Am 33(1):51-59, 2021. Available at:
[Internet], [cited 2023 Oct 2], American Society of Anesthesiologists. https://linkinghub.elsevier.com/retrieve/pii/S1042369920300911.
Available at: https://www.asahq.org/in-the-spotlight/coronavirus-co- Keyhan SO, Fallahi HR, Cheshmi B: Dysosmia and dysgeusia due to the
vid-19-information/elective-surgery. 2019 novel coronavirus; a hypothesis that needs further investigation,
CCF: Swollen lymph nodes (lymphadenopathy/adenopathy): symptoms Maxillofac Plast Reconstr Surg 42(1):9, 2020. Available at: https://
& causes [Internet], 2022 [cited 2022 Oct 2], Cleveland Clinic. Avail- jkamprs.springeropen.com/articles/10.1186/s40902-020-00254-7.
able at: https://my.clevelandclinic.org/health/diseases/15219-swollen- Keyhan SO, Poorian B, Fallahi HR: Piezoelectric technology in rhino-
lymph-nodes. plasty, Oral Maxillofac Surg Clin N Am 33(1):23-30, 2021. Available
CDC: COVID-19 Treatments and medications [Internet], 2022 [cited at: https://linkinghub.elsevier.com/retrieve/pii/S1042369920300790.
2022 Oct 2], Centers for Disease Control and Prevention. Available Keyhan SO: Q/A Discussion commentary on rhinoplasty. In Keyhan
at: https://www.cdc.gov/coronavirus/2019-ncov/your-health/treat- SO, Fattahi T, Bagheri SC et al., (eds): Integrated procedures in facial
ments-for-severe-illness.html. cosmetic surgery [Internet], Cham, 2021, Springer International Pub-
CDC: Long COVID or post-COVID conditions [Internet], 2022 [cited lishing, pp 353-364. Available at: https://link.springer.com/10.1007/
2022 Oct 2], Centers for Disease Control and Prevention. Available 978-3-030-46993-1_27.
at: https://www.cdc.gov/coronavirus/2019-ncov/long-term-effects/ Mayo Clinic Staff: COVID-19: long-term effects [Internet], Mayo Clin
index.html. 2022. Available at: https://www.mayoclinic.org/diseases-conditions/
CDC: Selected adverse events reported after COVID-19 vaccination coronavirus/in-depth/coronavirus-long-term-effects/art-20490351.
[Internet], 2022 [cited 2022 Oct 2], Centers for Disease Control and NIH: Coronavirus disease 2019 (COVID-19) treatment guidelines [In-
Prevention. Available at: https://www.cdc.gov/coronavirus/2019- ternet], 2022 [cited 2022 Oct 2], National Institutes of Health. Avail-
ncov/vaccines/safety/adverse-events.html. able at: https://www.covid19treatmentguidelines.nih.gov/.
CDC: Stay up to date with COVID-19 vaccines including boosters [In- Rademacher WMH, Aziz Y, Hielema A, et al: Oral adverse effects of
ternet], 2022 [cited 2022 Oct 2], Centers for Disease Control and drugs: taste disorders, Oral Dis 26(1):213-223, 2020. Available at:
Prevention. Available at: https://www.cdc.gov/coronavirus/2019- https://onlinelibrary.wiley.com/doi/10.1111/odi.13199.
ncov/vaccines/stay-up-to-date.html. Remdesivir (Veklury) [Internet], [cited 2022 Oct 2]. Available at: https://
Chao S: What medications can affect your taste or smell? [Internet]. Avail- www.accessdata.fda.gov/dr ugsatfda_docs/label/2020/214787
able at: https://www.drugs.com/medical-answers/medications-affect- Orig1s000lbl.pdf.
taste-smell-3566579. Rousan LA, Elobeid E, Karrar M, et al: Chest x-ray findings and tempo-
Clinical considerations: myocarditis after mRNA COVID-19 vaccines ral lung changes in patients with COVID-19 pneumonia, BMC Pulm
[Internet], [cited 2022 Dec 1], CDC. Available at: https://www.cdc. Med 20(1):245, 2020. Available at: https://bmcpulmmed.biomedcen-
gov/vaccines/covid-19/clinical-considerations/myocarditis.html. tral.com/articles/10.1186/s12890-020-01286-5.
Clinical Review (remdesivir) [Internet], [cited 2022 Oct 2]. Available at: Schiffman SS: Influence of medications on taste or smell, World J Otolar-
https://www.fda.gov/media/144367/download. yngol Head Neck Surg 4(1):84-91, 2018.
Cosmetic Surgeons of Michigan: Can I get Botox or fillers after my CO- Smell (olfactory) disorders—anosmia, phantosmia & others [Internet],
VID vaccine? [Internet], 2021 [cited 2022 Oct 2], Cosmetic Surgeons [cited 2022 Dec 1], NIDCD. Available at: https://www.nidcd.nih.
of Michigan, PC. Available at: https://www.cosmeticsurgeonsofmich- gov/health/smell-disorders.
igan.net/blog/can-i-get-botox-or-fillers-after-covid-vaccine/.

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103
Von Willebrand’s Disease
DANIELL E M. CUNNI NGHAM , SH A H R O K H C . B AG H ERI , a nd K A M BI Z MOHAMMA DZ A DE H

CC vWD unless there is a suspicion of internal hemorrhage, especially

in the setting of trauma.
A 16-year-old White female is referred to your office for evalua-
tion of an asymptomatic radiopaque mass of the maxilla consis- Labs
tent with a complex odontoma.
The initial laboratory studies to evaluate for vWD should include
HPI routine coagulation studies (complete blood count [CBC] with
platelets, prothrombin time [PT], partial thromboplastin time
The lesion was identified on routine radiographic examination for [PTT], international normalized ratio [INR], bleeding time).
an unerupted primary premolar. There was no history of pain, These are good general screening tests that can be ordered at the
fever, swelling, or drainage from the area. discretion of the physician. The CBC is generally normal, except
in vWD type 2B, in which the platelet count may be decreased.
PMHX/PDHX/Medications/Allergies/SH/FH Patients may also have microcytic anemia because of iron defi-
ciency, especially females with menorrhagia. Bleeding time is a
The patient’s parents denied any significant past medical history. good screening test, although it is not sensitive or specific. Nor-
However, on further questioning, a history of prolonged bleeding, mal results do not rule out vWD. PT and INR are normal. How-
including heavy menstruation and several episodes of epistaxis ever, the PTT, in addition to measuring factor VIII activity, may
without the need for hospitalization, were identified (positive his- also measure concurrent deficiencies with other clotting factors.
tory of abnormal bleeding). This was first noted after the loss of This may be prolonged in vWD type 2N, severe disease type 1
her mandibular primary incisors. Careful questioning also re- deficiency, and type 3.
vealed a history of “easy” bruising on her extremities. The parents However, even if screening test results are normal, if vWD is
recall previous episodes of prolonged bleeding with other family suspected, more specific hemostatic assays should still be performed.
members. (Von Willebrand’s disease [vWD] is an autosomal There are other laboratory tests used to screen for and diagnose
dominant disorder.) The remaining history was negative. vWD:
• Plasma von Willebrand factor (vWF) levels (vWF:RCo, ris-
Examination tocetin cofactor activity assay, used to measure platelet aggre-
gation). Plasma vWF levels may vary from day to day. They are
General. The patient is a well-developed and well-nourished co- influenced by stress, pregnancy, hormone replacement therapy,
operative female in no apparent distress whose height and weight and blood type (individuals with type O have decreased levels);
are above the 50th percentile. a single level within the reference range does not exclude the
Maxillofacial. There is no notable facial swelling. During in- disease.
tranasal examination with a nasal speculum, slight epistaxis was • Plasma vWF antigen. The total plasma concentration of vWF
noted. Intraoral examination reveals bilateral buccal mucosa ec- protein, depending on the assay, could be the total of vWF
chymosis (skin discoloration caused by the escape of blood into binding sites or the total vWF protein present in the plasma.
the tissues from ruptured blood vessels). It does not reflect molecular structure; therefore, this value
Chest, abdomen, and extremities. Multiple petechiae (pin- could be normal in patients with abnormal multimers.
point-size hemorrhages of small capillaries, often seen with quan- • Factor VIII activity. This is a measure of the cofactor function
titative and qualitative platelet dysfunction) are seen on the upper of the clotting factor (factor VIII) in plasma.
and lower extremities, abdomen, and chest. • The ristocetin (an antibiotic) cofactor activity assay is the
gold standard for diagnosis of vWD; however, it is difficult to
Imaging obtain an accurate level. The levels of vWF rise during preg-
nancy and periods of stress and with hormone replacement
A panoramic radiograph reveals a well-defined radiopacity of the therapy; therefore, patient anxiety may acutely elevate the
right anterior maxilla with multiple teethlike structures and an vWF level despite a relative deficiency. A positive screening test
associated impacted first premolar (consistent with a compound result or a high index of suspicion based on the clinical history
odontoma). No routine imaging studies are necessary to evaluate may indicate further testing is necessary.

537
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538 S E C TI O N X Medical Conditions

When abnormalities are detected in the above listed testing, a useful for bleeding from the mucous membranes. This class of
number of specialized coagulation studies may be performed to drugs may be given orally or intravenously. With oral administra-
determine the subtype of vWD. A vWF multimer and ristocetin- tion, the drug must be given three or four times over a 24-hour
induced platelet aggregation can also be used to confirm the diag- period (because of the medication’s short half-life) for 3 to 7 days.
nosis in addition to the subtype. There are also collagen binding Topical agents such as Gelfoam (absorbable sponge made from
assays that can indicate a loss of high molecular weight (HMW) gelatin) or Surgicel (oxidized regenerated cellulose) soaked in
multimer and binding of factor VIII by vWF, which is not used to topical thrombin can also be used for local hemostasis, in addition
identify type 2N but is still used. A newer test is the vWF:GP1BA to collagen products (plugs, Helistat) among others.
that determines how well vWF binds to this platelet receptor. An In several studies, estrogen was found to increase the levels of
additional test that now has years of usage is the platelet function vWF in females taking oral contraceptives and hormone replace-
test, which is dependent on vWF and platelet function. This is ment therapy. However, no long-term studies have looked at the
used as a screening test for vWD because of its high specificity and risk-to-benefit ratio for hormone replacement therapy in vWD,
sensitivity and has proven to be highly reliable. but it is definitely helpful during menorrhagia.
Treatment is determined by clinical findings and the extent of
Assessment hemorrhage. There are no good laboratory tests that correspond
with the severity of the disease. vWF is not a reliable marker of
Compound odontoma of the maxilla requiring removal, complicated severity because this value can be artificially elevated in certain
by vWD. physiologic states, such as stress or pregnancy; therefore, a past
history of bleeding is an important clue to the severity of the
Treatment disease and to determination of optimal therapy.
Patients with the type 3 subtype require continuous surveil-
There are five modalities of treatment for patients with vWD: lance, including possibly physical therapists, to follow up for joint
1. Desmopressin (1-desamino-8-D-arginine-vasopressin [DDAVP]) effusions affecting joint mobility. They may also receive prophy-
2. vWF replacement therapy (using cryoprecipitate) lactic infusions of vWF–factor VIII concentrate to prevent mus-
3. Antifibrinolytic agents culoskeletal bleeding and joint damage.
4. Topical agents (thrombin or fibrin sealants) The current patient was referred to a hematologist for preop-
5. Estrogen therapy in females with no contraindications erative consultation and evaluation. Subsequently, the patient had
Desmopressin is a synthetic analog of antidiuretic hormone normal ristocetin activity and platelet levels. The hematologist
without vasopressor activity. It acts by increasing vWF and factor recommended premedication with 150 mg of DDAVP and four
VIII levels by indirectly stimulating the release of vWF from endo- doses of Amicar postoperatively for 24 hours. The patient was
thelial cells. DDAVP may be administered intravenously, intramus- subsequently sedated in the office, and the odontoma was
cularly, or intranasally. If given intravenously or intramuscularly for removed. Surgicel was placed in the defect and sutured with re-
acute bleeding, the dose is 0.3 mg/kg (maximum, 20 mg). Increases sorbable sutures. Hemostasis was observed in the office before
in vWF and factor VIII levels are seen within 30 to 60 minutes, discharge. At 1-week follow-up, the patient denied any complica-
with a duration of approximately 6 to 12 hours. Intranasal admin- tions and was healing appropriately.
istration has gained popularity with patients who have less serious
bleeding and for premedication before minor surgical procedures. Complications
The usual dose is 150 mg for children weighing less than 50 kg and
300 mg for larger children and adults. A test dose should be admin- The most obvious complication of vWD is persistent hemorrhage.
istered to observe the effects on vWF. DDAVP should not be ad- If hemorrhage is persistent after extractions, Surgicel, topical
ministered to patients with type 2B vWD because it may worsen thrombin, collagen, direct pressure, and DDAVP may be used
the disease (see the Discussion section). It also does not seem to be unless contraindicated. In the setting of acute bleeding, cryopre-
as efficacious in patients with severe bleeding disorders and type 3 cipitate is the treatment of choice. Cryoprecipitate can be used to
disease, probably secondary to the lack of stored vWF. treat patients with all types of vWD. (Cryoprecipitate contains
Replacement therapy with vWF appears to be the gold stan- factors VIII and XIII, vWF, fibrinogen, and fibronectin. It can be
dard for treatment. However, for cryoprecipitate (which contains stored at 218°C for up to 1 year.)
factor VIII) to contain viable vWF, it cannot be pasteurized, only Each treatment regimen has various side effects. DDAVP may
screened. If possible, this should be avoided because there is an cause vasodilation, headache, hypotension, or hypertension (which
increased risk of viral transmission. Most factor VIII concentrates is usually mild). More serious complications of DDAVP include
do not contain sufficient high-molecular-weight vWF; however, tachyphylaxis (rapid development of immunity to a drug) and
the drugs Humate-P (human antihemophilic factor–vWF com- significant hyponatremia and seizures secondary to water reten-
plex) and Alphanate (antihemolytic factor) do contain sufficient tion. Therefore, DDAVP is usually limited to once-daily dosing,
amounts. These drugs may be used with cryoprecipitate in pa- along with water restriction and careful monitoring of serum so-
tients with type 2B or type 3 vWD because these patients cannot dium levels. It is also contraindicated in patients with arterial vas-
be treated with DDAVP. In 2015, the US Food and Drug Admin- cular disease and if older than age 70 years or younger than 2 years.
istration approved recombinant vWF Vonvendi. For significant Replacement with cryoprecipitate carries an increased risk of
bleeding, the goal of replacement therapy is to maintain the activ- transmission of bloodborne pathogens secondary to the inability to
ity of factor VIII and vWF between 50% and 100% for 3 to 10 adequately pasteurize the extract. Fortunately, as a result of the
days. Clotting factor concentrates may also be used containing improved sensitivity of blood testing, the risk of transmission is low.
both vWF and factor VIII (recombinant and plasma derived). Prolonged use of antifibrinolytic therapy carries a risk of
Fibrinolytic therapy with tranexamic acid (Amicar) can also be thrombosis. Hypercoagulable patients need to be carefully evalu-
used. This prevents the lysis of blood clots and can be especially ated. Topical agents are generally safe but are costly and can only

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 103 Von Willebrand’s Disease 539

be used as a local measure. Certain preparations of topical throm-

bin may contain bovine factor V; broad exposure could precipi- Gingival bleeding
tate the formation of antibodies to this factor that cross-react with (28.9%–34.2%)
human factor V, aggravating hemorrhage. Hemorrhage after
dental extraction Epistaxis
Discussion (7.9%–34.2%) (26.3%–52.6%)
Von Willebrand’s disease is the most common inherited bleeding
disorder; however, recent guidelines have made the cutoff of diag- Postoperative
nosis lower than what was previously (vWF of 30 IU/dL). This bleeding
has decreased the number of patients diagnosed with vWD and (39.5%–47.4%)
created a subcategory as “having a risk for bleeding,” in which
patients have a vWF level between 30 and 50 IU/dL. Most pa-
tients do not seek medical attention and are only diagnosed on Gastrointestinal
the basis of unexplained heavy bleeding (e.g., during menstrua- bleeding
tion) or easy bruising. Bleeding history may become more appar- (2.6%–7.9%)
ent with age. This disorder is characterized by a mutation in vWF Menorrhagia
itself or in the amount of vWF produced. This factor is responsi- (74%–93%)
ble for primary hemostasis by aiding platelet aggregation and ad- Hematuria
herence to the endothelial lining and by serving as a carrier pro- (5.3%)
tein for factor VIII. Factor VIII has a significantly shortened Ecchymosis and
half-life when it is not bound to vWF; this is the reason factor Postpartum
hematomas
VIII levels are evaluated through laboratory tests. bleeding
(44.7%–50%)
There are three subtypes of inherited vWD. Types 1 and 2 are (13%–55%)
typically autosomal dominant, but type 1 may also be inherited
in a recessive manner as well as one of the subtypes of type 2 (2A).
The number of cases caused by a de novo vWF variant is un-
known. Type 1 is a quantitative deficiency in vWF itself. Symp- Joint bleeding
toms range from mild to moderately severe (Fig. 103.1). It is (7.9%)
possible that the deficiency may be from abnormally fast clearance
of the protein or inadequate production.
Type 2 is a qualitative abnormality of vWF ( 60% of vWD
cases). Type 2 is subdivided into four subtypes: 2A, 2B, 2M, and • Fig. 103.1 Clinical bleeding symptoms by type and frequency in patients
2N. The classification is based on where the mutation occurs on with type 1 von Willebrand disease. (From Armstrong E, Konkle BA: von
the vWF itself. Willebrand disease. In Young NS, Gerson SL, High KA (eds): Cl inical
Type 2A (usually dominant but may also be recessive) is a Hematol ogy, St. Louis, 2006, Mosby.)
qualitative defect in which the quantity levels are normal but the
ability of the factor to bind to platelets is diminished. This type of
vWF also does not coalesce well with other vWF, resulting in di-
minished large multimers, which in turn results in decreased remains normal (as does the quantity of available vWF), but fac-
platelet adhesiveness. Therefore, vWF antigen assay results are tor VIII levels are greatly reduced. Because this subtype is reces-
normal, but cofactor assays and large multimers are reduced or sive, a second mutated allele must also be inherited for symptoms
absent. to develop. It can be difficult to distinguish this subtype from
Type 2B, a dominant inheritance pattern ( 5%), contains the factor VIII deficiency (hemophilia) because in both conditions,
defect on the platelet binding site itself, which actually increases the patients have low levels of factor VIII. Type 2N vWD should
binding of platelets to vWF. This takes platelets out of circulation, be considered when a patient presents with a family history of
causing thrombocytopenia. It is imperative to determine whether autosomal penetrance (seen in both males and females, not gen-
the patient has this subtype, especially if treatment is to be insti- der-linked, Mendelian genetics) rather than X-linked.
tuted, because treatment with DDAVP may actually exacerbate Type 3 is rare ( 1 in 1 million people) and is characterized by
the condition. DDAVP causes an increase in the release of vWF, complete absence or very low levels of vWF; this results from dif-
subsequently causing increased binding of platelets to vWF and ferent genetic defects, including nonsense, missense, and frame-
removing more platelets from circulation, worsening the throm- shift mutations. These patients have severe bleeding and at first
bocytopenia. may be diagnosed as having factor VIII deficiency before vWF
Type 2M is characterized by a qualitative defect and can form testing is obtained. The inheritance pattern is recessive.
appropriate multimers; however, its ability to bind to platelets is Von Willebrand’s disease may also be acquired with various
diminished. Therefore, plasma antigen levels are normal and large disease states, usually autoimmune conditions such as systemic
multimers are present, but the cofactor assays are decreased. This lupus erythematosus. Other mechanisms include decreased syn-
mutation is autosomal dominant. thesis, proteolysis, binding to tumor cells, and increased clearance
Type 2N (N is for Normandy, where this type was first de- of vWF.
scribed) is a rare autosomal recessive disorder. The defect affects
the ability of vWF to bind to factor VIII, but the ability to bind ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
with factor VII remains normal. Therefore, platelet function complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 539.e1

Bibliography Mazurier C, Dieval J, Jorieux SK, et al: New von Willebrand factor (vWF)
defect in a patient with factor VIII deficiency but with normal levels
and multimeric patterns of both plasma and platelet vWF: character-
Aledort LM: Treatment of von Willebrand’s disease, Mayo Clin Proc ization of abnormal vwF/ FVIII interaction, Blood 75:20, 1990.
66:841, 1991. McKeown LP, Connaghan G, Wilson O, et al: 1-Desamino-8-arginine-
Batlle J, Torea J, Rendal E, et al: The problem of diagnosing von Wille- vasopressin corrects the hemostatic defects in type 2B von Wille-
brand’s disease, J Intern Med Suppl 740:121-128, 1997. brand’s disease, Am J Hematol 51:158, 1996.
Chang AC, Rick ME, Ross Pierce L, et al: Summary of a workshop on Moffat EH, Giddings JC, Bloom AL: The effect of desamino-D-arginine
potency and dosage of von Willebrand factor concentrates, Hemo- vasopressin (DDAVP) and naloxone infusions on factor VIII and possi-
philia 4(Suppl 3):1, 1998. ble endothelial cell (EC) related activities, Br J Haematol 57:651, 1984.
Federici AB, Berntorp E, Lee CA, et al: A standard trial infusion with Posan E, McBane RD, Grill DE, et al: Comparison of PFA-100 testing
desmopressin is always required before factor VIII/von Willebrand and bleeding time for detecting platelet hypofunction and von Will-
factor concentrates in severe type 1 and 2 von Willebrand disease: ebrand disease in clinical practice, Thromb Haemost 90:483, 2003.
results of a multicenter European study [abstract], Throm Haemost Ratnoff OD, Saito H: Bleeding in von Willebrand’s disease, N Engl J Med
(Suppl):795, 1999. 290:1089, 1974.
Franchini M, Mannucci PM: Von Willebrand factor (Vonvendi®): the Rodeghiero F, Castaman G, Dini E: Epidemiological investigation of the
first recombinant product licensed for the treatment of von Wille- prevalence of von Willebrand’s disease, Blood 69:454, 1987.
brand disease, Expert Rev Hematol 9:825-830, 2016. Schneppenheim R: The pathophysiology of von Willebrand disease:
Goodeve A, James P: von Willebrand disease. In Gene Reviews® [Inter- therapeutic implications, Thromb Res 128(Suppl 1):S3-S7, 2011.
net], 2017, pp 1-35. Shepherd LL, Hutchinson RJ, Worden EK, et al: Hyponatremia and
Lee CA, Brettler DB: Guidelines for the diagnosis and management of seizures after intravenous administration of desmopressin acetate for
von Willebrand disease, Haemophilia 3:1-25, 1997. surgical hemostasis, J Pediatr 114:470, 1989.
Lethagen S, Harris AS, Sjorin E, et al: Intranasal and intravenous admin- Sutor AH: DDAVP is not a panacea for children with bleeding disorders,
istration of desmopressin: effect on factor VIII/vWF, pharmacokinet- Br J Haematol 108:217, 2000.
ics and reproducibility, Thromb Haemost 58:1033, 1987. Wagner DD: Cell biology of von Willebrand factor, Annu Rev Cell Biol
Mannucci PM: Treatment of von Willebrand’s disease, N Engl J Med 6:217, 1990.
351:683, 2004.

t.me/Dr_Mouayyad_AlbtousH
104
Oral Anticoagulation Therapy in Oral
and Maxillofacial Surgery
S U Z A N N E B AR N E S , D M D, N A S H W I N L A U N G A N I , D M D, M D a n d A U S TI N WAY, D M D, M D

CC Intraoral. The patient has multiple missing teeth, periodon-

tally compromised remaining dentition, gross carious decay on
A 63-year-old male is referred to your office by a general dentist remaining dentition, multiple retained root tips, large bilateral
in your community for full-mouth extractions, alveoplasty, and mandibular tori, and prominent maxillary canine eminences.
mandibular tori removal before maxillary and mandibular com- Neurologic. Cranial nerves II to XII are grossly intact bilaterally.
plete denture fabrication. Integumentary. Well-healed abdominal surgery scars. Notable
contusions on the extremities secondary to anticoagulation therapy.
HPI
Labs
The patient has poor oral health, generalized decay, and general-
ized stage III periodontal disease. He also has moderately sized The patient’s complete blood count (CBC) results are as follows:
mandibular tori that will impede the seating of the future prosthe- • White blood cell count: 8500 white blood cells per microliter
sis and will require removal at the time of extractions. The patient • Hemoglobin: 15.4 g/dL
has had inconsistent dental care throughout the course of his life • Hematocrit: 45.2%
and has mainly sought dental care on an emergency basis only. He • Platelets: 225,000 platelets per microliter
has had multiple maxillary and mandibular teeth extracted in the Coagulation study results are:
past because of pain and local infection. The patient is unhappy • Prothrombin time (PT): 17 seconds
with his current smile and oral health and desires complete den- • Activated partial thromboplastin time (aPTT): 75 seconds
ture fabrication. • Partial thromboplastin time: 135 seconds
Spectrometry and high-pressure liquid chromatography is the
PMHX/PDHX/Medications/Allergies/SH/FH standard approach for assessment of direct-acting oral anticoagu-
lant (DOAC) plasma concentration, but this is often impractical in
The patient’s past medical history is significant for nonvalvular the general laboratory setting in regard to cost and time. As such,
atrial fibrillation, type II diabetes mellitus, hyperlipidemia, and clinicians are often advised to evaluate the PT, aPTT, and thrombin
hypertension. He also has a history of deep vein thrombosis time (TT) preoperatively. PT is a basic test of coagulation that is
(DVT) in the right lower extremity at age 52 years. The patient’s responsive to factors II, V, VII, and X and fibrinogen. aPTT is a
surgical history is remarkable for an appendectomy at age 25 years basic test of coagulation that is responsive to all coagulation factors
and an abdominal hernia repair at age 34 years. His current except factors VII and XIII. The TT is a basic test of coagulation
medications include Eliquis (apixaban, a factor Xa inhibitor), that is responsive to fibrinogen and to the inhibitors of fibrin for-
metformin (a biguanide), atorvastatin (an HMG-CoA reductase mation. PT, aPTT, and TT can all be prolonged by any DOAC.
inhibitor), and hydrochlorothiazide (a diuretic). He reports no DOACs directly affect thrombin and factor Xa and consequently
known drug allergies. He has a 40-pack-year history of smoking impact the ability of fibrinogen to convert to fibrin and form a clot.
and does not report any alcohol or recreational drug use. It should be noted, however, that all three aforementioned studies
may be prolonged secondary to defects of coagulation other than
Examination the DOAC taken by the patient. Although not routinely used in the
clinical perioperative setting, other specific tests used to assess
General. The patient is an obese male in no acute distress and is plasma DOAC concentrations include dilute thrombin time, anti–
awake, alert, and oriented to person, place, and time. factor IIa assay, Ecarin tests, and anti–factor Xa assay.
Vital signs. Blood pressure is 134/88, pulse is 78 bpm, respira-
tions are 14 breaths per minute, and temperature is 36.7°C. Imaging
HEENT. Normocephalic, atraumatic. Extraocular movements
are intact. Gross visual acuity is intact. Gross hearing is intact. Panorex imaging demonstrates multiple teeth with periapical ra-
Nose is midline. Throat and oropharynx are clear and hemostatic. diolucencies suggestive of gross carious decay, multiple retained

540
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 CHAPTER 104 Oral Anticoagulation Therapy in Oral and Maxillofacial Surgery 541

root tips, and generalized horizontal bone loss in maxillary and blood concentration trough. As such, in our patient, we would
mandibular arches. recommend they continue to take their normal medications
ahead of their surgery. Based on their medication schedule, the
Assessment patient would be scheduled to have surgery 4 hours after his
morning DOAC dose. The teeth will be atraumatically extracted
63-year-old-male with a past medical history significant for nonval- with associated alveoplasty with special attention to minimize the
vular atrial fibrillation, type II diabetes mellitus, hyperlipidemia, extent of the mucoperiosteal flap. Sites will be packed with
hypertension, and a history of DVT who requires full-mouth extrac- Gelfoam saturated in thrombin and primarily closed with
tions and preprosthetic surgery. His atrial fibrillation is managed 3-0 chromic gut sutures in a running locking fashion to further
with a DOAC, Eliquis (apixaban, a factor Xa inhibitor). promote hemostasis. The patient would continue to follow up
until his staged treatment was completed in a safe manner that
Treatment ultimately reduced the risks of perioperative hemorrhage.

Given the patient’s history of nonvalvular atrial fibrillation and Complications

prior DVT, a discussion with the patient’s primary care provider
and cardiologist is warranted in regard to the perioperative man- Intraoperative and postoperative hemorrhage are risks for any
agement of Eliquis. We must determine whether the risks of hold- patient undergoing an oral and maxillofacial procedure; however,
ing the DOAC preoperatively outweigh the benefits of decreased patients on anticoagulative therapy should be identified before
intraoperative hemorrhage and postoperative bleeding. Based on surgery, and special care and attention should be taken in an at-
the risk stratification, two scenarios should be discussed: (1) the tempt to reduce and control bleeding. Whether treating a patient
patient’s physician provides clearance to hold the DOAC preop- in the office setting under local anesthesia with or without intra-
eratively or (2) the risks of thromboembolism or recurrent DVT venous sedation or in the operating room under general anesthe-
are too high to hold the DOAC perioperatively. sia, preoperative identification of patients who are at increased
Per the American Heart Association (AHA), the length of time risk for perioperative bleeding should prompt the surgeon and
to stop DOAC use varies based on the bleeding risk of the proce- staff to have materials and instruments ready and available to aid
dure. For minor bleeding risk procedures, the patient can stop 12 in hemostasis and hemorrhage control. Reasons for perioperative
to 24 hours before the procedure and restart 6 hours after inter- bleeding can broadly be divided into two categories: bleeding
vention. The time to stop the DOAC increases up to 96 hours from local factors or bleeding secondary to systemic factors. Local
before the procedure for low bleeding risk procedures. Generally, factors include bleeding that occurs as a result of performing the
dental procedures, cutaneous procedures (i.e., skin biopsy), and procedure itself and include hemorrhage secondary to soft tissue
other procedures less than 1 hour in length are considered low- and bone manipulation, inflammation, or the presence of infec-
risk bleeding procedures. Procedures with high bleeding risk in- tion at the operative site. Bleeding from systemic factors is attrib-
clude otorhinolaryngologic surgery, invasive procedures at deep uted to the use of anticoagulant medications or presence of sys-
lesions, and other procedures longer than 1 hour in length. The temic coagulopathy.
determination of bleeding risk must also take into account the Generally, patients who do not have systemic coagulopathy
patient’s medical comorbidities. As such, risk stratification can be and who experience increased levels of intraoperative bleeding can
best determined with the patient’s physician to guide timing of be adequately treated with local hemostatic measures. This list of
perioperative DOAC discontinuation. In our vignette, if the pa- patients usually includes those taking anticoagulant medications.
tient is to hold their normal DOAC dose for 72 hours preopera- There are myriad products available that aid in providing hemo-
tively, then the aforementioned dentoalveolar treatment should be stasis in oral and maxillofacial procedures; however, the first-line
completed in one appointment as long as the patient can tolerate treatment to control local hemorrhage is direct pressure with
the length of the procedure and there are manageable expected gauze. If direct pressure is inadequate or the surgeon would like
levels of intraoperative bleeding. For our patient, treatment was to use additional materials to ensure postoperative hemostasis,
completed under general anesthesia. The remaining dentition was many products exist, including, but not limited to, electrocautery,
extracted in an atraumatic fashion with conservative mucoperios- local anesthetic with a vasoconstrictor, absorbable gelatin sponge
teal flaps. Local hemostatic measures were used to aid in hemostasis, (Gelfoam), bone wax, oxidized cellulose (Surgicel), and silver ni-
with the authors’ preference being placement of Gelfoam saturated trate. Gauze can also be impregnated with thrombin or tranexamic
with thrombin directly in the extraction sockets. The surgical sites acid, and firm pressure can be applied directly to the site of hem-
were then primarily closed using 3-0 chromic gut suture in a run- orrhage. After local hemostasis is achieved and indicated materials
ning locking fashion to aid with hemostasis. Per AHA guidelines, have been used for hemorrhage control, closure of the operative
we can then recommend the patient to restart their DOAC 6 hours site with appropriate sutures also aids in continued hemostasis
after surgery. after surgery.
In the equally likely situation that the risk stratification deems Unfortunately, for patients with systemic coagulopathies, local
it unacceptable to hold the patient’s DOAC, a discussion is held measures can aid in hemostasis but are generally not sufficient
with the patient to explain the reasoning for staging the procedure alone to control perioperative bleeding. These patients require a
as to minimize intraoperative and postoperative hemorrhage. thorough work-up, including pertinent laboratory tests (CBC,
Based on current American Dental Association recommendations PT or INR, PTT), and a discussion with the patient’s hematolo-
cited from the European Heart Rhythm Association, it is not gist preoperatively. Because of the significant risk of perioperative
necessary to hold a DOAC for extraction of up to three teeth. A bleeding in these patients, they are most commonly treated in the
limited number of studies have recommended performing dento- operating room under general anesthesia and frequently require
alveolar surgery at least 4 hours after the patient’s last DOAC dose postoperative admission for observation. Depending on the cause
in an attempt to complete the procedure during the DOAC’s of the coagulopathy, these patients often require perioperative

t.me/Dr_Mouayyad_AlbtousH
542 S E C TI O N X Medical Conditions

treatment with certain factors, medications, or platelets. Patients Surgeons should recognize that DOACs are categorized into
with hemophilia A or B are deficient in factor VIII and IX, respec- two main classes based on their mechanism: direct thrombin in-
tively, and generally require preoperative treatment with appropri- hibitors and factor Xa inhibitors (Table 104.1). Consequently,
ate recombinant factor replacement before oral and maxillofacial being aware of the specific DOAC can prove useful in the event
surgery procedures. Postoperative use of systemic tranexamic acid that a patient requires a reversal agent for life-threatening bleed-
or topical use in the form of a mouthwash can aid in reduction of ing. Moreover, it is noteworthy that each DOAC has variations in
postoperative bleeding. Patients with von Willebrand’s disease half-life, which can theoretically impact perioperative bleeding
usually require pretreatment with desmopressin (DDAVP), factor risks based on when the patient took their last dose. For example,
VIII, tranexamic acid, or a combination of these options. Patients in patients whose DOACs cannot be stopped preoperatively, the
with platelet disorders, such as Glanzmann’s thrombasthenia, surgeon should attempt to complete treatment at least 4 hours
Bernard Soulier disease, and idiopathic thrombocytopenic pur- from the last dose to provide treatment during the drug concen-
pura, should be medically optimized before surgery and may re- tration trough.
quire platelet transfusions and steroids. Each patient and their Although DOACs are becoming much more popular and
specific circumstances should be evaluated on an individual basis, have replaced warfarin in many patients, warfarin remains a
but it is generally optimal for platelet counts to be greater than commonly prescribed medication for patients with history of
100,000 cells/mm3 before surgery. As previously mentioned, pa- DVT, pulmonary embolus, peripheral vascular disease, atrial fi-
tients with systemic coagulopathies frequently require postopera- brillation, or prosthetic heart valves and must be discussed.
tive admission for observation to ensure continued hemostasis Warfarin elicits its effects on coagulation by targeting factors II,
after completion of the surgical procedure. Postoperative admis- VII, IX, and X, as well as proteins C and S of the coagulation
sion planning and preoperative optimization with appropriate cascade. These factors are vitamin K dependent and are pro-
medications are coordinated in conjunction with the patient’s duced by the liver. Physicians should monitor the therapeutic
hematology team. window for warfarin by evaluating the PT. The PT evaluates the
Although rare in oral and maxillofacial surgery, a mention of extrinsic pathway of the coagulation cascade and is commonly
the possibility of life-threatening bleeding and appropriate treat- reported after it has been adjusted to the INR. An INR value of
ment must be discussed. For patients taking warfarin, two main 1.0 is considered normal. Before oral and maxillofacial proce-
options exist for reversal, vitamin K and fresh-frozen plasma dures, the surgeon should evaluate the patient’s INR and
(FFP). Although vitamin K is an option, the time required to consider the invasiveness of the planned procedure when deter-
achieve reversal with this medication limits its use in the setting mining how to manage patients on warfarin. Just as with all
of life-threatening hemorrhage when emergent reversal is needed. anticoagulant medications, the surgeon must weigh the risk-to-
Vitamin K has been shown to require 10 to 12 hours for full re- benefit profile of holding the medication versus having the pa-
versal to occur. As a result, the choice for patients on warfarin tient continue the medication during the procedure. Although
experiencing life-threatening hemorrhage and in need of emer- no specific guidelines exist, most routine extractions can be
gent reversal is FFP. Patients taking unfractionated heparin completed with the patient continuing warfarin as long as the
(UFH) and in need of emergent reversal because of hemorrhage preoperative INR falls between 2.0 and 3.0. However, if the
should be given protamine sulfate. Until recently, no specific re- INR rises above 3.0, great variability exists among surgeons
versal agents were available for the direct factor Xa inhibitors concerning proceeding forward with extractions. As previously
(apixaban, rivaroxaban). The Food and Drug Administration mentioned, the invasiveness and extent of the procedure should
(FDA) approved andexanet alfa in May of 2018 for reversal of always be considered, in addition to preoperative INR, when
apixaban and rivaroxaban in patients experiencing life-threaten- determining whether to have a patient hold warfarin before
ing hemorrhage or uncontrolled bleeding. The medication is surgery. Major surgical procedures may necessitate the holding
given intravenously and is a recombinant human coagulation of warfarin before surgery. In these instances especially, a de-
factor Xa. For those who are taking the direct thrombin inhibitor tailed discussion with the patient’s prescribing physician preop-
dabigatran, reversal is achieved with the monoclonal antibody eratively is of utmost importance. A number of options exist for
idarucizumab. This drug binds dabigatran reversibly with high holding warfarin before surgery. Warfarin can be held 4 days
affinity and is useful for life-threatening hemorrhage. Because of before surgery and then resumed after the surgery. Warfarin can
their recent approval and expense, however, these reversal agents also be held 4 days before the procedure and bridged with either
are not yet widely available in hospitals across the United States. a LMWH, such as enoxaparin, or UFH. Importantly, the bridg-
ing anticoagulant must still be held at least 6 hours before the
Discussion planned procedure and then can be subsequently restarted
6 hours after the surgery is completed. Regardless of the method
Direct oral anticoagulants have grown increasingly popular since used, it should be specifically tailored and individualized for the
they were first approved by the FDA in 2010. They are arguably specific patient and their needs after thorough discussion with
considered superior to anticoagulation with vitamin K antago- their prescribing physician.
nists (i.e., warfarin) or low-molecular-weight heparins (LMWHs) Whether the decision is made to continue or hold warfarin
in reducing the risks of thromboembolic complications with before surgery, it is crucial that local measures to control hemor-
similar or reduced bleeding risks. Moreover, the DOACs require rhage still be used. As previously discussed, in the event life-
fewer monitoring requirements, offer more immediate drug onset threatening bleeding is encountered in the perioperative period,
and offset, and have fewer drug and food interactions. As a result FFP must be given emergently because of its far superior onset of
of these preferable qualities, the AHA notes that DOAC prescrip- action compared with vitamin K.
tions have exceeded those for warfarin, with apixaban most com-
monly prescribed for patients with nonvalvular atrial fibrillation ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
(as our patient in the vignette). complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 104 Oral Anticoagulation Therapy in Oral and Maxillofacial Surgery 543

TABLE
104.1 Summary of More Recent Anticoagulation Medications

DOAC Generic Name Mechanism of Reversal Agent for Life-

(Brand Name) Action FDA-Approved Indications Threatening Bleeding
Dabigatran (Pradaxa) Direct thrombin 1. Stroke prevention in NVAF Idarucizumab (humanized
inhibitor 2. Treatment of DVT and PE fragment of a monoclonal anti-
3. Prevention of recurrent DVT and PE body, which binds dabigatran
4. Prevention of thromboembolism after total hip replacement reversibly with high affinity)
Rivaroxaban (Xarelto) Direct factor Xa 1. Stroke prevention in NVAF Andexanet alfa (recombinant
inhibitor 2. Treatment of DVT and PE human coagulation factor Xa)
3. Prevention of recurrent DVT and PE or
4. Prevention of thromboembolism after total hip and knee replacement Four-factor prothrombin complex
5. Prevention of thromboembolism in acutely ill inpatients concentrate such as Kcentra,
6. Prevention of major cardiovascular events in patients with chronic Beriplex P/N, or Octaplex
CAD and PAD
Apixaban (Eliquis) Direct factor Xa 1. Stroke prevention in NVAF Andexanet alfa (recombinant
inhibitor 2. Treatment of DVT and PE human coagulation factor Xa)
3. Prevention of recurrent DVT and PE or
4. Prevention of thromboembolism after total hip and knee replace- Four-factor prothrombin complex
ment concentrate such as Kcentra,
Beriplex P/N, or Octaplex
Edoxaban Direct factor Xa 1. Prevention and treatment of cancer-associated DVT Andexanet alfa (recombinant
(Lixiana, Savaysa) inhibitor 2. Prevention of thromboembolism after total hip and knee human coagulation factor Xa)
replacement OR
3. Prevention of thromboembolism after PCI with PAC Four-factor prothrombin complex
concentrate such as Kcentra,
Beriplex P/N, or Octaplex

CAD, Coronary artery disease; DOAC, direct-acting oral anticoagulant; DVT, deep vein thrombosis; FDA, Food and Drug Administration; NVAF, nonvalvular atrial fibrillation; PAD, peripheral artery
disease; PCI, percutaneous coronary intervention; PE, pulmonary embolism.

t.me/Dr_Mouayyad_AlbtousH
 543.e1

Bibliography 3858/FDA-Approves-First-and-Only-Antidote-for-Factor-Xa. Retrieved

December 15, 2022.
Heo Y: Andexanet alfa: first global approval, Drugs 78(10):1049-1055,
Agrawal A, Kerndt C, Manna B: Apixaban. In StatPearls, 2022, StatPearls 2018. Available at: https://doi.org/10.1007/s40265-018-0940-4. Kanjee
Publishing. Available at: https://www.ncbi.nlm.nih.gov/books/ Z, McCann ML, Freed JA: Availability of specific direct oral an-
NBK507910/. Retrieved December 15, 2022. ticoagulant reversal agents in US hospitals, JAMA Netw Open
Chen A, Stecker E, A Warden B: Direct oral anticoagulant use: a practical 4(5):e2110079, 2021. Available at: https://doi.org/10.1001/jamanet-
guide to common clinical challenges, J Am Heart Assoc 9(13):e017559, workopen.2021.10079.
2020. Available at: https://doi.org/10.1161/jaha.120.017559. Kumbargere Nagraj S, Prashanti E, Aggarwal H, et al: Interventions for
Cocero N, Basso M, Grosso S, et al: Direct oral anticoagulants and treating post-extraction bleeding, Cochrane Database Syst Rev 3(3):
medical comorbidities in patients needing dental extractions: manage- CD011930, 2018. Available at: https://doi.org/10.1002/14651858.
ment of the risk of bleeding, J Oral Maxillofac Surg 77(3):463-470, cd011930.pub3.
2019. Available at: https://doi.org/10.1016/j.joms.2018.09.024. Oral anticoagulant and antiplatelet medications and dental procedures,
Curto A, Albaladejo A: Implications of apixaban for dental treatments, 2022, September 28, American Dental Association. Available at:
J Clin Exp Dent 8(5):e611-e614, 2016. Available at: https://doi. https://www.ada.org/resources/research/science-and-research-insti-
org/10.4317/jced.53004. tute/oral-health-topics/oral-anticoagulant-and-antiplatelet-medica-
Direct oral anticoagulant reversal agents for life-threatening bleeding (im- tions-and-dental-procedures. Retrieved December 15, 2022.
minent risk of death from bleeding), UpToDate. Available at: https:// Tripodi A, Ageno W, Ciaccio M, et al: Position Paper on laboratory testing
www.uptodate.com/contents/image?imageKey5HEME%2F112299. for patients on direct oral anticoagulants. A Consensus Document from
Retrieved December 15, 2022. the SISET, FCSA, SIBioC and SIPMeL, Blood Transfus 16(5):462-470,
FDA approves first and only antidote for factor xa inhibitors reversal, 2018. Available at: https://doi.org/10.2450/2017.0124-17.
(2021, December 30), American Society of Hematology Clinical
News. Available at: https://ashpublications.org/ashclinicalnews/news/

t.me/Dr_Mouayyad_AlbtousH
106
Acute Asthmatic Attack
J OYC E X U , J OYC E T. LE E, S H A H R O K H C . B AG H ER I , a n d A L I R. R A H I M I

CC Maximum
inspiration
A 17-year-old male with a history of asthma is referred to your of-
fice for evaluation of symptomatic partially impacted third molars. 4

Lung volume (L)

Asthma is seen in about 3% to 5% of the population and can 3 FEV1/FVC 50%
FEV1
occur in any age group; however, it is particularly common in chil- 2 FVC
1
this age group.
0
1 2 3 4 5 6
HPI A Seconds

The patient is a high school student with a history of pain and Maximum
inspiration
recurrent episodes of pericoronitis of the mandibular third mo-
Lung volume (L)

treatment. 3 FEV1/FVC 80%

FEV1 FVC
2
PMHX/PDHX/Medications/Allergies/SH/FH 1

The patient has a history of asthma, diagnosed at age 8 years. He 1 2 3 4 5 6

states that his asthmatic episodes are usually exacerbated by exer- Seconds
B
cise and seasonal allergies. (Other common triggers of asthma
exacerbation include cold weather; irritant exposures such as to- • Fig. 106.1 Forced vital capacity (FVC) in a patient with an airway ob-
bacco smoke; recent upper respiratory infection; and certain struction (A) and in an individual with an unobstructed airway (B). FEV1,
medications, including nonsteroidal antiinflammatory drugs.) He Forced expiratory volume in 1 second.
has had two previous visits to the local emergency department
(ED) secondary to acute episodes that did not readily respond to
his albuterol (b2 agonist) inhaler; he required intravenous (IV) there frequently is a strong family history of asthma or other al-
methylprednisolone (a systemic corticosteroid), nebulized alb- lergies. Genetic factors may play a role in the pathogenesis of
uterol, and ipratropium (an anticholinergic bronchodilator). The asthma. However, it is important to mention that not all patients
episodes resolved without the need for endotracheal intubation. with asthma have allergies and that the association between
(ED visits and endotracheal intubation both correlate with the asthma and allergies is not entirely clear.)
severity of the asthma.) The patient does not have a history of
status asthmaticus (asthmatic episode poorly responsive to stan- Examination
dard therapeutic measures). His last asthma attack was approxi-
mately 1 month ago. (The frequency of attacks is an indicator of General. The patient is a well-developed, well-nourished male in
the control of this patient’s asthma.) no apparent distress.
His current medications include an albuterol metered-dose in- Vital signs. Stable with normotensive blood pressure.
haler (MDI), used as needed, and montelukast (a leukotriene recep- Oral and maxillofacial. Partially erupted, impacted third
tor antagonist) 10 mg/day. He routinely monitors his status with a molars are noted. The tongue is normal in size. The patient has a
peak flow meter. (Patients use this device to monitor changes in the class I skeletal and dental relationship. The maximal interincisal
forced expiratory volume in 1 second [FEV1]; Fig. 106.1.) opening is 45 mm. The uvula and soft and hard palates are easily
The patient states that he smokes occasionally. (Cigarette visualized; bilateral tonsils are within normal limits in size and
smoke is an airway irritant that may precipitate bronchospasm.) recessed within the tonsillar crypts (Mallampati class I). The thy-
He also has a history of allergic rhinitis (hay fever) and eczema. romental distance is greater than four finger widths. (Evaluation
There is a positive history of asthma in several of his family mem- of the airway is important, especially in patients who may require
bers. (In patients with an allergic component to their asthma, advanced airway interventions.)

548
t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 106 Acute Asthmatic Attack 549

Cardiovascular. Regular rate and rhythm with no murmurs, Upon removal of the last third molar, the patient became dia-
gallops (S3 or S4), or rubs. (Patients with asthma can have other phoretic, agitated, tachycardic (140 bpm), and tachypneic, with
comorbidities, such as chronic obstructive pulmonary disease, shallow breaths (25 per minute). (Tracheal tugging, use of accessory
which may produce “splitting” of the second heart sound with an muscles of respiration, and intercostal retractions are other signs of
accentuated pulmonic component.) severe asthmatic exacerbation.) The surgical sites were packed, the
Chest. Bilaterally clear on auscultation. (The major symptoms oropharynx was suctioned, and the tongue was retracted as the
during an acute asthmatic attack are cough, dyspnea, expiratory airway was repositioned and supported. The patient’s condition
wheezing, and chest tightness. Wheezing is not pathognomonic for continued to deteriorate, with a progressive decline in oxygen satu-
asthma and reflects airflow obstruction through a narrow airway). ration as measured by the pulse oximeter. Inspiratory suprasternal
retractions revealed the obstructive nature of the patient’s condi-
Labs tion. The diagnosis of an acute asthmatic attack was made. Two
puffs of albuterol were given, in addition to two puffs of ipratro-
No labs are indicated in the routine care of a patient with well- pium bromide, while the vital signs were monitored closely. Supple-
controlled asthma. However, patients whose asthma is poorly mental 100% oxygen was delivered via a full face mask. Minutes
controlled are often referred for pulmonary function testing. The later, the patient began to show worsening signs of respiratory dis-
most objective and relevant tests for measuring the degree of air- tress, with a further decrease in the pulse oximeter reading to below
way obstruction in patients with asthma are the FEV1 and the 85%. Emergency medical services (EMS) was activated. Mean-
peak expiratory flow. In patients with well-controlled asthma, the while, 0.5 mg of a 1:1000 solution of epinephrine was injected
FEV1 should be 80% of the forced vital capacity (FVC). (Com- subcutaneously. An attempt to mask ventilate with 100% O2
parison of obstructive with restrictive pulmonary diseases reveals revealed airway resistance and chest tightness. Positive-pressure
that the vital capacity and FEV1 are decreased in both; however, ventilation using the bag-mask technique was unsuccessful despite
in obstructive diseases, both the functional residual capacity airway repositioning. A 10-mg dose of IV succinylcholine was
[FRC] and the residual volume [RV] are increased, whereas in given, and the patient’s anesthesia was deepened with 50 mg of IV
restrictive lung diseases, both the FRC and RV are decreased.) ketamine. (Ketamine is a dissociative agent with potent bronchodi-
latory effects. Causes of bronchospasm often are attributed to light
Imaging anesthesia; therefore, ketamine is a valuable drug to consider.) The
patient’s airway soon became easier to ventilate with the bag-mask
In the current patient, the panoramic radiograph is significant for technique with 100% oxygen at a flow rate of 12 L/min. (Consid-
partial bony impacted third molars. eration should be given to administration of diphenhydramine
Chest radiographs are not indicated in asymptomatic patients 50 mg IV in cases of suspected allergic response; 20 mg of
with a history of asthma and are not particularly helpful except for dexamethasone IV can also be used to reduce the inflammatory
ruling out other diseases. During acute asthmatic exacerbations, response.) The patient responded to these measures, showing a
the chest radiograph may reveal hyperinflation of the lung fields gradual rise in the pulse oximeter reading, diminished chest wall
(flattened diaphragm) and decreased vascular markings. rigidity, and improved air exchange and compliance. His vital signs
normalized, except for a persistent tachycardia (a residual side effect
Assessment of repeated doses of sympathomimetics is tachycardia). Upon ar-
rival of EMS, the patient was transported to the hospital for further
American Society of Anesthesiologists (ASA) class II patient with four im- observation of his acute asthmatic event.
pacted third molars, planned for extraction under IV sedation anesthesia.
The ASA classification ASA II is defined as a patient with a Complications
mild systemic disease that is well-controlled and poses no limita-
tions for daily activities. Complications arising in patients with asthma range from mild
wheezing and dyspnea to severe bronchospasm, hypoxia, and death.
Treatment A positive respiratory history (upper respiratory infection in the
previous 2 weeks, nocturnal dry cough, wheezing during exercise,
After reviewing the risks, benefits, and alternatives, the patient and wheezing more than three times in the past 12 months) was
elected to have his third molars removed under IV general anes- associated with an increased risk of bronchospasm, perioperative
thesia the next day. The patient was instructed to record his peak cough, desaturation, or airway obstruction. Bronchospasm is a life-
flow the morning of the surgery and to bring his albuterol MDI threatening emergency that must be treated as soon as it is recog-
with spacer to the office. (Spacers are devices used to increase the nized. In the office setting, it is important to alert EMS as soon as
effectiveness of medication delivery.) possible because the patient’s condition may deteriorate rapidly. The
The day of surgery, the patient’s lungs were clear on auscultation incidence of bronchospasm is low in patients with well-controlled
bilaterally. (Because of the episodic nature of asthma, pulmonary asthma who are undergoing outpatient IV general anesthesia.
auscultation should be conducted routinely before surgery.) After Bronchospasm is the acute manifestation of asthma. It results in
the patient had been prepared for surgery, he self-administered increased airway resistance, which causes a decrease in the ratio of
three puffs of albuterol (90 mg per puff) using his spacer. IV general FEV1 to FVC (see Fig. 106.1). Signs and symptoms of bronchospasm
anesthesia was achieved with midazolam 5 mg, fentanyl 50 mg, and include dyspnea, stridor, wheezing, mucus secretion, and hypoxia.
propofol titrated to effect. (Propofol is the preferred general anes- Initial treatment should include 100% oxygen and an inhaled short-
thetic for patients with asthma because it has shown to attenuate acting b-2-selective adrenergic agonist (SABA). b2 agonists relax the
the bronchospastic response to intubation in both patients with and smooth muscle in bronchial walls and produce bronchodilation.
without asthma, whereas IV methohexital [Brevital] is more often The clinician should also look for causes of the asthma exacer-
associated with bronchoconstriction in response to endotracheal bation, such as undiagnosed latex allergies or medication allergies.
intubation during induction compared with propofol.) Urticaria, pruritus, and facial edema are findings consistent with

t.me/Dr_Mouayyad_AlbtousH
550 S E C TI O N X Medical Conditions

allergic reactions that may produce bronchospasm. If an allergic or aspirin-induced asthma. Although the mediators that produce
reaction is suspected, diphenhydramine and corticosteroids an acute asthmatic attack vary, the resulting physiologic responses
should be administered intravenously. Administration of epineph- are similar for all types of asthma. Because airway resistance is in-
rine may be indicated in patients experiencing bronchospasm re- versely related to the diameter of the bronchial lumen, pediatric
fractory to inhaled b2 agonists; the most common dose and route patients are predisposed to rapid decompensation during broncho-
of administration are 1 mg injected subcutaneously. spasm (Fig. 106.2).
Ipratropium, a short-acting muscarinic antagonist, in conjunc- Perioperative management of patients with asthma is primarily
tion with SABA used in the setting of acute asthma exacerbations based on risk stratification. Successful management of asthma
has proven to decrease the likelihood of hospital admission com- requires an active patient–physician partnership. Patients must un-
pared with SABA alone. In addition, systemic glucocorticoid derstand the pathophysiology of their disease and the need for medi-
therapy is essential for the resolution of asthma exacerbations that cation compliance, and they must be able to monitor the current
are refractory to intensive bronchodilator therapy because the status of the disease state. Many emergency visits by individuals with
persistent airflow obstruction is likely attributable to airway in- asthma are attributed to the patients’ lack of understanding about
flammation and intraluminal mucus plugging. Early administra- their disease. Elective surgery is contraindicated in patients with
tion is warranted in the case of asthma exacerbation. asthma whose disease is not well controlled. Patients should be asked
If bronchospasm persists and the patient is hypoxic, intubation about their medication regimens, their understanding of medication
is indicated. It is important to realize that intubation does not delivery, and the use of peak flow meters. Patients whose understand-
protect against or treat the bronchospasm. However, it facilitates ing and medication compliance are not optimal should be referred to
ventilation of the narrowed airways and allows effective delivery their primary care physicians for evaluation before elective surgery.
of nebulized medications. If mechanical ventilation is used after Intraoperative management of patients with asthma should
intubation, it is important to be mindful that asthma is an ob- emphasize adequate oxygenation, avoiding excessive airway stim-
structive airway disease and that overzealous high pressure or flow ulation by use of throat packs, and suctioning. A pretracheal
on inspiration can cause barotrauma, resulting in either a pneu- stethoscope is recommended for auscultation monitoring. In pa-
mothorax or tension pneumothorax. tients who are intubated, decreased tidal volumes and increased
end-tidal carbon dioxide levels may indicate bronchospasm. Dur-
Discussion ing extubation, minimal stimulation of the airway is advised.
“Deep” extubation may be prudent to avoid excessive excitement
Asthma is a common chronic respiratory condition that can pres- in the emerging patient, because extubation may generate enor-
ent with acute exacerbations. It affects both children and adults mous negative pressure, resulting in acute pulmonary edema.
and is highly variable in severity, response to treatment, and Administering a dose of IV lidocaine before extubation also de-
clinical presentation. Asthma is a form of obstructive airway dis- creases airway stimulation. Despite these precautions, some pa-
ease characterized by an acute and reversible increase in airway tients with asthma experience bronchospasm during the course of
resistance. Recent evidence suggests that asthma causes changes in surgery. Management of an acute asthmatic exacerbation should
the respiratory epithelium. The prevalences of asthma are 8.0% in consist of early detection and intervention. Bronchospasm is a
adults and 6.5% in the pediatric population. There is evidence potentially life-threatening emergency that must be treated. Treat-
that this is increasing in the United States, with higher prevalence ment should consist of assessment of vital signs, supplemental
in those from areas with the lowest annual household income oxygen, inhaled b2 agonists, a short-acting muscarinic antagonist,
compared with those from areas with higher household incomes. corticosteroids, and ventilatory support if indicated.
The various types of asthma are categorized according to the
underlying cause of the exacerbation. These types may include ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
atopic or IgE-mediated, exercise-induced, occupational, infectious, complete set of bibliography.

Normal Edema Resistanc Cross-section

1 mm area
( R
1
radius4

Infant 4 mm ↑ 16x ↓ 75%

Adult 8 mm ↑ 3x ↓ 44%

• Fig. 106.2 Airway resistance in an infant and in an adult patient.

t.me/Dr_Mouayyad_AlbtousH
 550.e1

Bibliography National Heart, Blood, and Lung Institute: Expert panel report 3 (EPR3):
guidelines for the diagnosis and management of asthma, 2007.
Newman KB, Milne S, Hamilton C, et al: A comparison of albuterol
Bone RC: Goals of asthma management: a step-care approach, Chest administered by metered-dose inhaler and spacer with albuterol by
109:1056, 1996. nebulizer in adults presenting to an urban emergency department
Centers for Disease Control and Prevention: Most recent national with acute asthma, Chest 121:1036, 2002.
asthma data, Centers for Disease, Control and Prevention, 2023. Ogle OE: Management of Medical Problems, Philadelphia, 1998, Saunders.
Currie GP: Recent developments in asthma management, Br Med J Owen CL: New directions in asthma management, Am J Nurs 3:99, 1999.
330:585, 2005. Pizov R, Brown RH, Weiss YS, et al: Wheezing during induction of
Eames WO, Rooke GA, Wu RS, et al: Comparison of the effects of general anesthesia in patients with and without asthma, Anesthesiology
etomidate, propofol and thiopental on respiratory resistance after 82(5):1111, 1995.
tracheal intubation, Anesthesiology 84(6):1307-1311, 1996. Rea HH, Cragg R, Jackson R, et al: A case-controlled study of deaths
Ezekiel MR: Handbook of Anesthesiology, Laguna Hills, Calif, 2004, CCS from asthma, Thorax 41:833, 1986.
Publishing. Rodrigo GJ, Rodrigo C, Hall JB: Acute asthma in adults: a review, Chest
Fanta CH, Rossing TH, McFadden ER Jr: Glucocorticoids in acute 125:1081, 2004.
asthma: a critical controlled trial, Am J Med 74:845, 1983. Rodrigo GJ, Rodrigo C: The role of anticholinergics in acute asthma
Hirshman CA, Bergman NA: Factors influencing intrapulmonary airway treatment: an evidence-based evaluation, Chest 121:1977, 2002.
caliber during anesthesia, Br J Anaesth 65(1):30-42, 1990. Von Ungern-Sternberg BS, Boda K, Chambers NA, et al: Risk assessment
Hurford WE: Clinical Anesthesia Procedures of the Massachusetts Gen- for respiratory complications in pediatric anesthesia: a prospective
eral Hospital, ed 5, Philadelphia, 1998, Lippincott-Raven. cohort study, Lancet 376(9743):773-783, 2010.
Kirkland SW, Vandenberghe C, Voaklander B, et al: Combined inhaled
beta-agonist and anticholinergic agents for emergency management in
adults with asthma, Cochrane Database Syst Rev 1(1):CD001284, 2017.

t.me/Dr_Mouayyad_AlbtousH
107
Stroke and Cerebrovascular Disease
BR AN KO N . H UI S A

Stroke is the second cause of death and is a leading cause of serious Vital signs. The patient’s blood pressure is 166/97 mm Hg,
long-term disability worldwide. Approximately 800,000 people in heart rate is irregular at 77 bpm, respiratory rate is 17 breaths per
the United States have a stroke each year, of which 88% are isch- minute, and temperature is 36.5°C.
emic and 12% are hemorrhagic. The most important risk factors Maxillofacial. Normocephalic. The skin is dry and intact. The
for stroke include older age, atrial fibrillation, hypertension, and pupils are equal, round, and reactive to light and accommodation.
prior stroke. Other important risk factors include dyslipidemia, There is no scleral icterus. Visual acuity is grossly intact. The ex-
diabetes, smoking, and chronic kidney disease. This chapter dis- ternal auditory canals are clear bilaterally, the tympanic mem-
cusses a common cerebrovascular accident case presentation of an branes are intact, and the nares are patent. The patient has a right
acute ischemic stroke and the current strategies to best handle central facial droop (the forehead and orbicularis are spared) and
perioperative risk on these patients. mild dysarthria (cranial nerves [CNs] VII and X). CNs II through
This chapter addresses the following: XII are grossly intact bilaterally. The neck is supple and without
• Ischemic stroke lymphadenopathy.
• Hemorrhagic stroke Intraoral. The mucosa is moist and pink. No ulcers, masses,
• Acute stroke or discolorations of the oral cavity are noted. There five absent
• Secondary stroke prevention teeth. Generalized severe periodontal disease is noted with root
• Antiplatelets exposure on several teeth.
• Oral anticoagulation Cardiovascular. Irregular rhythm. No extra sounds. Positive
• Perioperative stroke left carotid bruit. Peripheral pulses present.
Pulmonary. Normal inspiration expiration sounds. No
CC wheezes or rhonchi.
Abdominal. Soft and tender.
A 65-year-old male with periodontal disease and multiple vascular Neurologic: Awake, Alert, Oriented times two (AAOX2) normal
factors is who is scheduled for teeth extractions next month pres- attention, disoriented to time. Language: decrease on fluency with
ents to a hospital with a new onset of stroke symptoms. poor repetition, fair comprehension, and poor naming. Memory:
unable to assess verbal memory because of aphasia. Mood: adequate.
HPI Motor. There is right pronator drift of outstretched arms.
Muscle bulk and tone are normal.
The patient had a new sudden onset of slurred speech, right facial Strength. Strength is 4 of 5 on the right arm and leg and full
droop, and right-sided weakness. He was taken to the nearest otherwise. Reflexes: 21 and symmetric at the biceps, triceps, knees,
emergency department. He was evaluated within the first 3 hours and ankles. Plantar response is extensor on the right and flexor on
of the onset of his symptoms. the left. Sensory: decreased to light touch; pinprick on the right.
Position sense and vibration sense are intact in the fingers and toes.
PMHX/PDHX/Medications/Allergies/SH/FH Coordination. There is right dysmetria on finger-to-nose test.
There are no abnormal or extraneous movements.
The patient has a history of coronary arterial disease, diabetes mel- Gait. The gait is paretic and unsteady (Fig. 107.1).
litus type II, hypertension, and hyperlipidemia. He has two car-
diac stents placed 5 years earlier. He is currently taking losartan, Imaging
metoprolol, aspirin, metformin, and atorvastatin. He has no
known drug allergies. The patient has a 30-pack-year history of Initial head computed tomography (CT) scan did not show any
smoking; he quit smoking 5 years ago. He drinks socially and acute ischemia or any hemorrhage. CT angiography of his head
denies illicit drug use. showed an acute occlusion of the left distal middle cerebral artery.
Ischemic strokes are commonly caused by intracranial vessels
Examination occlusions, and hemorrhagic stroke are caused by either intracra-
nial or subarachnoid vessel rupture. Only head CT or brain mag-
General. The patient is a well-nourished, well-developed male in netic resonance imaging can discriminate between ischemic or
no apparent distress. hemorrhagic stroke.

551
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552 S E C TI O N X Medical Conditions

IDENTIFYING A STROKE delays. Medical evaluation of stroke requires management of risk

factors, stroke complications, and a comprehensive medical evalu-
Blurred vision Loss of balance
ation to determine the etiology of the stroke.
Transient ischemic attacks (TIAs) are cerebral ischemic events
that typically resolve within 1 hour of their onset. Although they
Speech deficit Facial droop do not require acute thrombolytic therapies or thrombectomy, an
(forehead spared) emergent or urgent evaluation is warranted to prevent any future
stroke event. Having a TIA carries a high risk of ischemic stroke
within 3 months of the event.
This patient with acute ischemic stroke received both intrave-
nous tissue plasminogen activator tPA and thrombectomy. He
was next admitted to the ICU. His symptoms almost fully re-
Upper or lower solved the next day with the exception of mild paraphasic errors
extremity
weakness and word-finding difficulties. He was started on Eliquis for sec-
ondary stroke prevention and was discharged to home on his
previous medications plus Eliquis. As per the following discus-
sion, the patient’s dental procedure should be postponed, and
anticoagulation should be continued.
Secondary stroke prevention treatments. Antithrombotic
therapy, including antiplatelet or anticoagulant agents, is recom-
mended for nearly all patients without contraindications. Dual
antiplatelet therapy is recommended only for the short term in
very specific patients, including those with minor strokes, high-
Refer to stroke center ASAP
risk TIAs, and severe symptomatic intracranial stenosis. Statins
• Fig. 107.1 Common clinical manifestations of stroke. should be started in all patients with ischemic stroke or TIA and
low-density lipoprotein greater than 70 mg/dL. Anticoagulation
with Coumadin or direct-acting oral anticoagulants (DOACs) is
recommended if the patient has atrial fibrillation and no signifi-
Labs cant contraindications. Internal carotid artery stenosis is an im-
portant and treatable cause of stroke. Patients with severe stenosis
The patient’s complete cell count was within normal limits. Co- or more than 70% ipsilateral to a nondisabling stroke or TIA
agulation panel was normal. Glucose was elevated at 255 mg/dL, should be evaluated for urgent carotid endarterectomy or carotid
and HbA1C was 8.5%; all other basic metabolic panel laboratory artery stenting early after the stroke. Use of stents is not recom-
values were within normal limits. The electrocardiogram showed mended intracranially. It is considered medically reasonable to
atrial fibrillation. percutaneously close a patent foramen ovale in stroke patients
between 18 and 60 years of age with embolic stroke of undeter-
Assessment mined source (ESUS) etiology and large shunts.

Acute ischemic stroke symptoms in the setting of new-onset atrial fi-

brillation, multiple vascular risk factors, and an acute left middle
Discussion
cerebral artery occlusion.
Stroke Types and Risk Factors
Treatment Recommendations for prevention strategies often depend on the
specific subtype of TIA or stroke. First steps to determine to the
Treatment of patients with ischemic stroke includes emergent use cause of stroke come from the evaluation of brain imaging, vascu-
of thrombolytic therapy, catheter-based thrombectomy guided by lar imaging, and cardiac evaluation. These are usually performed
cerebral angiography, and use of anticoagulants or antiplatelets. during the hospital stay. The cause of stroke typically is classified
Conversely, patients with hemorrhagic strokes may require emer- into large vessel, small vessel, cardiogenic, and cryptogenic. ESUS
gent neurosurgical intervention, tight blood pressure control, and is a stroke that appears to be a non–small vessel type on neuroim-
avoidance of anticoagulants and antiplatelets. aging but without an obvious source after a minimum standard
All patients with acute stroke should admitted to hospitals evaluation, which includes cerebrovascular imaging, echocardiog-
equipped with stroke units. Patients with subarachnoid hemor- raphy, extended rhythm monitoring, and key laboratory studies
rhages and large ischemic or hemorrhagic strokes usually require such as a lipid profile and HbA1c.
intensive care units (ICUs) proficient in neurocritical care. For any stroke subgroup, management of vascular risk factors
Thrombolytic therapy and thrombectomy for acute ischemic remains extremely important for secondary stroke prevention.
stroke are very effective therapies in reversing acute ischemic Management of risk factors includes but is not limited to diabe-
stroke symptoms, with number needed to treat of 1:7 and 1:3, tes control, smoking cessation, lowering lipids, and especially
respectively. However, the effectiveness of these treatments is time controlling hypertension. Lifestyle factors, including healthy diet
dependent. For instance, thrombolytic therapy for ischemic stroke and physical activity, are also important for preventing a second
can be only given within 4.5 hours of the onset of the symptoms. stroke. Low-salt and Mediterranean diets are recommended for
Hence, patients with acute stroke symptoms should get emergent stroke risk reduction. Intensive medical management produces
attention and be transported to the closest stroke center without better results.

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 CHAPTER 107 Stroke and Cerebrovascular Disease 553

Invasive Procedures and Acute Cerebrovascular extractions increase the risk of acute vascular events during the
Events first 8 weeks after treatment.
A better way to estimate the risk of stroke after dental surgical
There is a positive association between periodontitis and cerebro- procedures or more invasive maxillofacial surgeries comes from
vascular disease found in multiple epidemiologic studies. Inflam- the extrapolation of large observational studies that comprise
matory markers, bacteremia, and development of atherosclerosis multiple other noncardiovascular perioperative procedures.
have been postulated as potential mechanism for these epidemio-
logic findings. Effective treatment of periodontitis does improve
oral health and resolve systemic inflammation. However, there is
Perioperative Stroke
insufficient evidence to support or refute the potential benefit of Perioperative stroke is defined as any cerebrovascular event with
the treatment of periodontitis in preventing stroke. motor, sensory, or cognitive dysfunction lasting at least 24 hours,
Many oral surgical interventions aim to resolve acute and occurring intraoperatively or within 30 days after surgery. Accord-
chronic oral infections. However, in theory, dental procedures ing to retrospective epidemiological studies, the incidence of
could trigger an acute host response with local inflammation, mi- perioperative stroke in patients undergoing noncardiac, non-
crobial dissemination, and systemic inflammation. Then there is a neurologic surgery is between 0.1% and 1.0%. The most com-
presumptive small risk of stroke associated with certain oral surgi- mon perioperative stroke type is ischemic. Hemorrhagic stroke in
cal procedures. This risk is generally very low. People with certain the perioperative period is rare and may represent only up to 5%
medical conditions, such as heart disease or a history of stroke, of all reported perioperative stroke cases.
may be at increased risk for stroke during dental procedures. Fifty percent of strokes in the perioperative setting occur
Theoretically, manipulation of an inflamed oral cavity might within the first 24 hours, and up to 93% occur within the first 72 hours.
create exposure of inflammatory markers, transient bacteremia, Factors that contribute to stroke risk in these patients seem dis-
and transient thrombophilia, increasing the risk of cardiovascu- tinct from other types of surgery and appear to be temporally re-
lar events, including stroke (Fig. 107.2). However, current evi- lated to the intraoperative and immediate postoperative periods.
dence does not support that invasive dental procedures such as Putative mechanisms of perioperative noncardiac, nonneurologic

Invasive dental treatment

Bacteremia Local trauma

Increase in proinflammatory
Endotoxins or bacterial Immunoinflammatory cytokines and acute phase
surface molecules challenge proteins

Hypercoagulable Endothelial
state dysfunction

Coronary thrombosis or Atheroma formation or

microembolism erosion and rupture
Acute vascular events

• Fig. 107.2 Theoretical sequence of events after manipulation of an inflamed oral cavity creating expo-
sure of inflammatory markers, transient bacteremia, and transient thrombophilia, all increasing the risk of
cardiovascular events. (From Luthra S, Orlandi M, Leira Y, et al. Invasive dental treatment and acute
vascular events: a systematic review and meta-analysis, J Clin Periodontol 49(5):467-479, 2022.)

t.me/Dr_Mouayyad_AlbtousH
554 S E C TI O N X Medical Conditions

surgery stroke include hypotension, large-artery stenosis, anemia, of thrombosis include those with mechanical cardiac valves, those
thromboembolism, fat embolism, and enhanced coagulability in with atrial fibrillation and high CHA2DS2-VASc scores, and
the setting of systemic inflammation, endothelial dysfunction, those with recent stroke and recent cerebrovascular or cardiac
and recent stoppage of antithrombotic medications. stent deployment.
Numerous studies have consistently identified advancing age, Patient with mechanical valves who are taking Coumadin re-
renal disease, and prior TIA or stroke as the main risk factors for quire bridging with low-molecular-weight heparin or unfraction-
perioperative stroke. Other risk factors that have been identified ated heparin during the procedure.
as independent predictors include myocardial infarction within 6 For patient taking DOACs, it is recommended to give the last
months, atrial fibrillation, hypertension, chronic obstructive dose 2 days before the operation and resume treatment 24 hours
pulmonary disease, current smoking, female sex, and diabetes after surgery. However, DOACs have short half-lives and are usu-
mellitus. ally inactive after 24 hours. Therefore, it is reasonable to hold
Patients with symptomatic carotid stenosis with a grade of DOACs only for 24 hours in very low hemorrhage risk procedures.
stenosis of 70% or more are at considerable significant risk for For patients who had recent carotid or intracranial stenting in
stroke recurrence. In these patients, it is recommended to perform the previous 6 months, it is preferred to defer surgery or continue
carotid artery endarterectomy or stenting before any other DOACs.
planned elective surgery. If the patient’s bleeding risk is acceptable, DOACs should be
Patients with a history of stroke are at increased risk of periop- continued perioperatively; otherwise, P2Y12 inhibitor therapy
erative stroke, and the timing of surgery relative to the most re- (clopidogrel, prasugrel, and ticagrelor) should be discontinued for
cent event modulates this risk. American Stroke Association the minimum amount of time possible and aspirin monotherapy
(ASA) guidelines recommend waiting for elective surgery 6 to 9 continued. Complex cases should always be discussed with the
months from stroke or TIA. patient’s neurologist or cardiologist.
A more recent large observational study estimated that the risk
of noncardiovascular postoperative stroke and death leveled off Conclusions
when more than 90 days had elapsed between a previous stroke, but
the rate of stroke was still 50% higher than in patients without Stroke is a devastating neurologic disease. Patients who have had
previous stroke. The authors suggest that the recent scientific state- a recent TIA or stroke should complete an emergent stroke
ment by the ASA guidelines to delay elective nonneurologic, noncar- evaluation and receive timely acute treatments. Management of
diac surgery at 6 months after a recent stroke may be too conservative stroke risk factors and lifestyle modification is paramount for
and proposed a more practical target of 90 days of waiting. stroke prevention. Dental and maxillofacial procedures might in
theory increase the risk of stroke mainly via inflammation; how-
Discontinuation of Anticoagulants and ever, no current epidemiological evidence exists for this. The
most important perioperative risk of stroke is having a recent
Antiplatelets Before Surgery prior stroke or TIA. It is recommended to delay any elective oral
Anticoagulants and antiplatelets are mainstream treatments for procedure at least 90 days from stroke or TIA. Patients taking
secondary stroke prevention. Discontinuation of anticoagulations anticoagulants or antiplatelets present a challenge, and careful
or antiplatelets carries an increased risk of stroke recurrence. The assessment between thrombotic risk and hemorrhagic risk is
decision to hold therapy should depend on careful assessment of warranted.
thromboembolic risk versus the bleeding risk from the planned
procedure. In general, oral and maxillofacial surgical procedures ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
carry a mild to moderate risk of bleeding. Patients with high risk complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 554.e1

Bibliography Hart RG, Catanese L, Perera KS, et al: Embolic stroke of undetermined
source: a systematic review and clinical update, Stroke 48(4):867-872,
2017.
Adams HP Jr, Bendixen BH, Kappelle LJ, et al: Classification of subtype Kleindorfer DO, Towfighi A, Chaturvedi S, et al: 2021 Guideline for the
of acute ischemic stroke: definitions for use in a multicenter clinical prevention of stroke in patients with stroke and transient ischemic
trial: TOAST: Trial of Org 10172 in Acute Stroke Treatment, Stroke attack: a guideline from the American Heart Association/American
24:35-41, 1993. doi:10.1161/01.str.24.1.35. Stroke Association, Stroke 52(7):e364-e467, 2021.
Amarenco P: Transient ischemic attack, N Engl J Med 382(20):1933- Luthra S, Orlandi M, Leira Y, et al: Invasive dental treatment and acute
1941, 2020. vascular events: a systematic review and meta-analysis, J Clin Peri-
Benesch C, Glance LG, Derdeyn CP, et al: Perioperative neurological odontol 49(5):467-479, 2022.
evaluation and management to lower the risk of acute stroke in pa- Manfredini M, Poli PP, Creminelli L, et al: Comparative risk of bleeding
tients undergoing noncardiac, nonneurological surgery: a scientific of anticoagulant therapy with vitamin K antagonists (VKAs) and with
statement from the American Heart Association/American Stroke non-vitamin K antagonists in patients undergoing dental surgery,
Association, Circulation 143(19):e923-e946, 2021. J Clin Med 10(23):5526, 2021.
Brown DL, Levine DA, Albright K, et al: Benefits and risks of dual versus Powers WJ, Rabinstein AA, Ackerson T, et al: Guidelines for the early
single antiplatelet therapy for secondary stroke prevention: a system- management of patients with acute ischemic stroke: 2019 update to
atic review for the 2021 guideline for the prevention of stroke in pa- the 2018 guidelines for the early management of acute ischemic
tients with stroke and transient ischemic attack, Stroke 52(7):e468- stroke: a guideline for healthcare professionals from the American
e479, 2021. Heart Association/American Stroke Association, Stroke 50(12):e344-
Glance LG, Benesch CG, Holloway RG, et al: Association of time e418, 2019.
elapsed since ischemic stroke with risk of recurrent stroke in older Sanz M, Del Castillo AM, Jepsen S, et al: Periodontitis and cardiovascu-
patients undergoing elective nonneurologic, noncardiac surgery, lar diseases. consensus report, Glob Heart 15(1):1, 2020. doi:10.5334/
JAMA Surg 157(8):e222236, 2022. gh.400.
Goyal M, Menon BK, van Zwam WH, et al: Endovascular thrombec- Selim M: Perioperative stroke, N Engl J Med 356:706-713, 2007.
tomy after large-vessel ischaemic stroke: a meta-analysis of individual Virani SS, Alonso A, Benjamin EJ, et al: Heart disease and stroke statis-
patient data from five randomised trials, Lancet 387(10029):1723- tics–2020 update: a report from the American Heart Association,
1731, 2016. Circulation 141:e139-e596, 2020.
Hacke W, Kaste M, Bluhmki E, et al: Thrombolysis with alteplase 3 to
4.5 hours after acute ischemic stroke, N Engl J Med 359(13):1317-
1329, 2008.

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108
Diabetes Mellitus
P O OYA N S A D R - ES H K E VA R I , M E H R A N M E H R A B I , a n d S H A H R O K H C . B AG H ER I

CC PMHX/PDHX/Medications/Allergies/SH/FH
A 53-year-old male with a history of type 1 diabetes mellitus The patient was diagnosed with DM1 (an autoimmune destruc-
(DM1) presents to the emergency department (ED) complaining tion of pancreatic beta cells) in his 20s and has been taking insulin
of swelling of mouth and neck, making it difficult for him to since. (The two main types of diabetes are type 1 [DM1] and type
swallow. 2 [DM2]. DM1 used to be called juvenile-onset [usually develops
in children or young adults but can occur at any age] or insulin-
HPI dependent diabetes. [There is no insulin production in DM1,
hence the need for daily insulin injections or an insulin pump.]
The patient states he started having pain in his lower right jaw 1 DM2, on the other hand, used to be called adult-onset or non–
month ago when he had a tooth pulled, despite taking clindamy- insulin-dependent diabetes. In DM2, despite adequate production
cin. (Empiric clindamycin is not recommended because of resis- of insulin initially, the cells do not respond to insulin the way they
tance of oral streptococci, such as Streptococcus anginosus [milleri] should. The insulin receptor is a tetramer of two ligand-binding
group [20%–30%], and anaerobes, such as Prevotella spp. and alpha and two transmembrane beta subunits joined by disulfide
Porphyromonas spp. [31%–38%].) He presented to the same hos- bonds. These subunits are coded by a single gene, and mutation in
pital 2 weeks ago with right jaw pain and swelling and was diag- either the structural gene or some of the processing steps may lead
nosed as having a right dental abscess. The dentist on call saw the to insulin resistance. The insulin may bind the receptor normally,
patient and performed an incision and drainage bedside under but the signaling cascade may not be triggered. β-cell compensa-
local anesthesia and placed a drain for continued source control, tion results in hypersecretion of insulin, ultimately leading to
which was removed a couple days later as an outpatient. β-cell burn-out. DM2 is more likely to occur after 40 years of age,
The patient states he was given a prescription for amoxicillin in overweight patients, and in those with a family history of diabe-
and has been compliant with oral hygiene and chlorhexidine tes. Unfortunately, because of sedentary lifestyles and the fast-food
mouthwash. (Penicillin alone cannot fight the b-lactamase–pro- epidemic, DM2 has become more prevalent in younger people,
ducing oral anaerobes, and penicillin monotherapy is no longer including adolescents.) Our patient takes glargine (Lantus, a long-
recommended.) However, since the drain was removed, he has acting synthetic insulin that provides a steady concentration of
had increasing pain and swelling. (Source control through drain- insulin) once a day and preprandial lispro (Humalog, a rapidly
age is the most important therapeutic modality for pyogenic acting insulin) three times a day. He is currently being followed by
odontogenic infections, and premature removal of the drain is not his family practitioner. His medical history also includes hypothy-
advised.) Swelling has since progressed to the point that it is hard roidism (patients with DM1 are more likely to have a co-occurring
for him to open his mouth and swallow, causing significant dis- autoimmune disorder; 30% of the population with DM1 also have
comfort and poor oral intake. autoimmune hypothyroidism, and 10% of them have concurrent
Swelling has rapidly progressed during the past 24 hours, celiac disease), Parkinson’s disease, stage 3 chronic kidney disease
which is why he presented to the outside facility yesterday for (a common sequela of DM), hypertension, hyperlipidemia, and
evaluation. The workup was also notable for hyperglycemia (blood nephrotic syndrome. His other medications include amlodipine,
glucose . 1000 mg/dL), acute kidney injury (AKI) (creatinine, losartan, aspirin 81 mg, atorvastatin, bisoprolol, carbidopa–
1.99 mg/dL) and hyperkalemia (potassium, 7.5 mmol/L) (some of levodopa, levothyroxine, and ergocalciferol. He has had no prior
the key presentations of the hyperglycemic emergencies, namely surgeries but was hospitalized for hypoglycemia twice during the
diabetic ketoacidosis [DKA] in DM1, and hyperosmolar hypergly- previous year. (Previous episodes of hypoglycemia are a risk factor
cemic state [HHS] in type 2 diabetes [DM2]). The patient re- for future episodes.) He reports that his blood glucose was between
ceived intravenous (IV) normal saline (to replete volume and re- 80 and 160 mg/dL during the past year, as measured with his
verse AKI), 20 units of regular insulin (to treat hyperkalemia), home Accu-Chek device. (The ideal preprandial blood glucose level
and IV Unasyn (ampicillin–sulbactam) (the preferred antibiotic is 90–130 mg/dL.) However, he lost his device and stopped moni-
regimen in odontogenic infection in absence of penicillin allergy). toring his blood glucose a couple of months ago. He also has
Given the extent of the infection, the patient was transferred to missed several of his primary care and diabetes check appointments.
our hospital to be managed by the oral and maxillofacial surgery (Poorly controlled blood glucose decreases the ability to fight
service. infections.)

555
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556 S E C TI O N X Medical Conditions

There is no family history of diabetes mellitus. (DM1 has a findings and suspicion of sources of infection or pathology. Non-
strong association with HLA-DR3, DR4, and DQ alleles; how- odontogenic sources of infection, including parotitis and lymph-
ever, a family history is often lacking. A positive family history is adenitis, should be considered in all patients. Our patient had a
often seen with DM2.) maxillofacial computed tomography (CT) scan done, which
showed multi-space odontogenic abscesses involving the right
Examination parapharyngeal space but no airway deviation; right submasse-
teric, pterygomandibular, and infratemporal spaces (collectively
General. The patient is a thin, visibly uncomfortable male (unlike called the masticator space); right sublingual and submandibular,
patients with DM2, those with DM1 are frequently thin or ca- submental, and left sublingual and submandibular spaces (col-
chexic). His speech is muffled, but there is no breathing difficulty lectively known as Ludwig’s angina).
or drooling.
Vital signs. His vital signs are stable, and he is afebrile. His Assessment
oxygen saturation is 97% on room air.
Maxillofacial. The patient has right lower and midfacial A 53 year-old male with multispace odontogenic abscesses, including
edema and induration, submental edema and induration, and Ludwig’s angina, complicated by poorly controlled diabetes, impend-
left submandibular induration. There is tenderness to palpation ing DKA, and potential airway compromise.
in all these areas. He presents with restricted mouth opening to Hepatocytes, in the absence of insulin (DM1) and in response
1.5 cm. to the presence of glucagon, increase the process of gluconeogen-
Intraoral. Examination is limited because of trismus and pain, esis and glycogenolysis to make more glucose. The absence of in-
but from the limited examination, there appears to be purulence sulin also leads to increased lipolysis by hepatocytes. The free fatty
draining intraorally from the posterior right mandible. Oral hy- acids are then converted into acetyl CoA through a process called
giene is poor with multiple carious teeth. The floor of the mouth beta-oxidation. In energy-deficient states, such as starvation, ace-
is indurated and slightly elevated. tyl CoA is metabolized into ketone bodies through the process of
ketogenesis. The final products of this process are aceto-acetate
Labs and b-hydroxybutyrate, which can serve as energy sources in the
absence of insulin-mediated glucose delivery. Ketone bodies have
In the ED, his labs were notable for hyperkalemia to 6.1 mmol/L a low pKa and cause metabolic acidosis.
(lack of insulin means potassium cannot enter the cells and is Another major issue in a hyperglycemic state is hypovolemia.
maintained in the extracellular space), bicarbonate of 28 mmol/L Glucose freely filters in the glomerulus and fully reasorbs in the
(normal serum level is 22–29 mmol/L, the primary buffering proximal convoluted tubule. The overflow of glucose into the
mechanism for acidosis), anion gap of 14 mmol/L (.10 in mild bloodstream overwhelms the resorption capacity of the proximal
DKA, .12 in severe DKA, and usually within normal limits [8– convoluted tubules, and the remainder of the filtered glucose is
12 mmol/L] in HHS), creatinine 2.41 mg/dL (AKI secondary to passed into the urine. Increased urine glucose causes osmotic di-
hypovolemia), blood glucose of 728 mg/dL (HHS usually presents uresis and volume depletion. The renin–angiotensin–aldosterone
with much higher blood glucose values than DKA), white blood system tries to compensate for the loss of water and volume. Al-
cell (WBC) count of 21.1 3 109/L (indicating severe infection), dosterone pulls sodium back into the bloodstream, and water
and a platelet count of 100 3 109/L (thrombocytopenia). ECG follows. However, this is not enough to counteract the osmotic
did not reveal any changes associated with hyperkalemia. (The diuresis. Moreover, reabsorption of sodium comes at the price of
expected ECG changes in hyperkalemia include peaked T waves, potassium excretion into urine. As a result, the patient will be in
P wave flattening, PR prolongation, and widened QRS complex.) a state of total potassium deficit despite their hyperkalemic
Urinalysis showed a ketone level of 15 mmol/L (normally no ke- plasma.
tones are found in urine), 30 to 49 red blood cells (RBCs) per The presence of significant amounts of ketones in plasma and
high-power field (hpf ) (a normal result is #4), greater than urine and marked metabolic acidosis are the distinguishing fea-
300 mg of protein (normally, there is ,150 mg of protein in the tures of DKA. HHS, also known as hyperosmolar nonketotic state
urine per day), and a WBC count of 4 WBC/hpf (normal, 0–5). or HONK, is primarily seen in DM2 and presents with increased
To better assess the patient’s glucose control, we ordered a plasma osmolarity (.320 mOsm/kg; normal low is 280 mOsm/
glycosylated hemoglobin (HbA1c) level test. (HbA1c is an effective, kg, and normal high is 300 mOsm/kg) caused by profound dehy-
objective tool for assessing patient compliance and long-term dration and hemoconcentration.
hyperglycemic status. Prolonged elevation of serum blood glucose The American Diabetes Association categorizes the severity of
causes nonenzymatic, irreversible glycosylation of hemoglobin in DKA as follows:
RBCs. Because the life expectancy of RBCs is 120 days, the • Mild: blood pH of 7.25 to 7.30 (normal, 7.35–7.45) and se-
HbA1c gives an estimate of glycemic control during the past 90 to rum bicarbonate of 15 to 18 mmol/L (normal .20) in an alert
120 days. An HbA1c greater than 6% is consistent with diabetes, patient
and a value greater than 7% is indicative of poor glycemic control. • Moderate: blood pH of 7.00 to 7.25 and serum bicarbonate of
Therefore, the HbA1c directly correlates with poor glycemic con- 10 to 15 mmol/L with potential mild drowsiness
trol for the previous 3 to 4 months.) HbA1c was 9.1 in our pa- • Severe: blood pH less than 7.00 and serum bicarbonate less
tient, indicating poor diabetic control. than 10 mmol/L with possible stupor or coma
Our patient had an arterial blood pH of 7.4 and a normal
Imaging bicarbonate level, which rules out metabolic acidosis. (The defi-
ciency in insulin [either absolute deficiency or a relative defi-
For the surgical management of patients with diabetes mellitus, ciency caused by excess counterregulatory hormones] is more
the need for adjunctive imaging studies is dictated by the clinical severe in DKA compared with HHS. The small level of residual

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insulin secretion in DM2 is sufficient to minimize the develop- After 20 days in the hospital, which included going through
ment of ketoacidosis but does not control hyperglycemia.) The additional washout surgeries, overcoming pneumonia, and even-
elevated serum osmolality (348 mOsm/kg) indicates a diagnosis tually being downgraded to the hospital floor, our patient was
or component of HHS but may also be seen in DKA. Although discharged home with scheduled follow-ups with his primary care
acidosis and ketonemia may be present in HHS, they are not as and our clinic. When on the floor, his blood glucose was managed
pronounced as they are in DKA. It should be noted that DKA using sliding scale insulin (SSI) (a common short-term diabetic
and HHS may have overlapping features because DKA may also management tool for hospitalized patients), and he was dis-
present with hyperosmolarity. The acidosis in DKA causes charged with adjusted doses of his home diabetes medications.
distressing symptoms (e.g., nausea, dyspnea, abdominal pain), The term “sliding scale” refers to increasing the premeal insulin
driving the patient to seek care earlier. In addition, patients dose based on the preprandial blood glucose level. For example, if
with DKA are much younger on average and have higher glo- preprandial blood glucose is between 140 and 180 mg/dL, 4 units
merular filtration rate than those with HHS. As a result, patients of short-acting insulin is commonly administered; for a blood
with DKA excrete more glucose in urine, limiting the hypergly- glucose level between 181 and 220 mg/dL, this could increase to
cemia. Although mostly seen in patients with DM2, the working 6 units. The disadvantage of SSI is the necessity of strict adher-
diagnosis for our patient was HHS because of the initial blood ence to a regular meal schedule, physical activity, and a prescribed
glucose greater than 1000 mg/dL, the elevated serum osmolality, diet. Other inpatient glycemic control methods exist, each with
a normal bicarbonate level, and a normal to mildly elevated its own advantages and disadvantages. A “basal-bolus strategy”
anion gap. allows flexible insulin doses administered according to meal
preferences and physical activity; however, it demands well-trained
Treatment medical staff. A recent Cochrane systematic review concluded that
the basal-bolus strategy may result in better short-term glycemic
The patient was admitted to the medical intensive care unit control in noncritically hospitalized adults but could increase the
(MICU) for the management of his emergency (patients with risk for severe hypoglycemic episodes. Although the acute manage-
DKA or HHS should be admitted to the ICU) and close monitor- ment of our patient’s diabetic emergencies were successful, he now
ing of airway before urgently going to the operating room (OR) faces the challenge of continued management of his condition
for incision and drainage of multiple space abscesses. The MICU after discharge.
recommended improving the electrolyte derangements (potas- Proper management of diabetes consists of a group effort by
sium was still 6.2) before planned surgery unless surgery was health care providers concentrating on setting a goal, diet and
emergently necessary. The patient was monitored on telemetry in exercise modification, smoking session, medications, self-moni-
the meantime. This is a complex situation, and the risk vs. benefit toring of blood glucose level, monitoring for complications of
of a delay in definite surgical care should be discussed among the diabetes, and intermittent laboratory assessment and feedback.
surgeon, the anesthesiologist, and the intensivist on a case-based Although glycemic control is important, blood pressure and cho-
basis. An airway emergency or impending airway compromise lesterol monitoring should not be overlooked.
cannot wait and should be taken care of promptly. The patient In general, pharmacologic management of diabetes consists of
received 26 units of Lantus and 1 L of lactated Ringer solution oral hypoglycemic agents for DM2; insulin and insulin analogs for
while in the ED, and fluid boluses and insulin drip continued in types 1, 2, and 4 DM (discussed later); and insulin pumps for those
the MICU. The patient’s potassium was corrected to 4.4, and his with DM1. Oral hypoglycemic agents decrease plasma glucose by
blood glucose decreased to 113 mg/dL in 4 hours and was emer- various mechanisms. Sulfonylureas (glipizide, glyburide) and meg-
gently taken to the OR for incision and drainage. Box 108.1 litinides (repaglinide, nateglinide) stimulate the production of insu-
summarizes the strategies in the management of DKA. Treatment lin by the pancreas. Glucophage (metformin, biguanides) decreases
of HHS is based on the same concept and algorithm with some hepatic glucose production by inhibiting gluconeogenesis and gly-
modifications. For instance, it needs more free water and greater cogenolysis. a-Glycosidase inhibitors (acarbose), which are rarely
volume replacement (caution for heart failure in elderly with used because of the high incidence of flatulence and abdominal
preexisting cardiac issues). discomfort, prevent carbohydrate absorption from the intestinal
tract. Thiazolidinediones (TZDs) (pioglitazone [Actos] and rosigli-
tazone [Avandia]) stimulate target cells’ response to insulin. There
might be a higher risk of bladder cancer in patients taking piogli-
tazone and of myocardial infarction in patients taking rosiglitazone.
• BOX 108.1 Management of Diabetic
Glucagon-like peptide (GLP-1) agonists (exenatide, liraglutide)
Ketoacidosis
stimulate glucose-dependent insulin secretion, decrease glucagon
• IV fluids: start with high flow 0.9% NS; add dextrose 5% when glucose secretion, slow gastric motility, and induce early satiety. Dipeptidyl
,200 mg/dL peptidase-4 inhibitors (sitagliptin, saxagliptin, linagliptin) slow
• Insulin: start with a drip; switch to basal-bolus injections only when: degradation of GLP-1.
Glucose ,200 mg/dL Current insulin formulations in the United States are biosyn-
Anion gap ,12 mEq/L thetic, generated from human DNA since 1983. The traditional
Bicarbonate .15 mEq/L method of producing insulin by mashing pork or beef pancreas
Patient tolerating PO was introduced in the 1920s. In July 2005, the manufacturing
2-h overlap of the IV and injections
• Potassium: replete IV if K ,5.2 mEq/L and hold insulin for potassium ,3.3
company announced discontinuation of animal-based insulin
• Monitor electrolytes, vital signs, and mentation production. However, it continues to be available in other
countries.
IV, Intravenous; NS, normal saline; PO, oral. For patients with type DM2, those with an HbA1C of 6.5
to 7.5 should be on monotherapy; those whose HbA1c is 7.6 to

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558 S E C TI O N X Medical Conditions

TABLE There has been a steady increase in the use of continuous insu-
108.1 Some Commonly Available Insulin Preparations lin pump systems for patients with DM1. Despite the wide vari-
ety of available devices, all insulin pumps use similar underlying
Preparation Onset Peak Effect Duration of Action concepts. The goal is to modify the delivery of exogenous insulin
Lispro (Humalog) 5 min–0.25 h 0.5–1 h 2–4 h to best approximate the normal biologic function of the pancreas.
Given the widespread use of insulin pumps, familiarity with the
NovoLog 5 min–0.25 h 0.5–1 h 2–4 h basics of pump function and its perioperative management con-
Regular insulin 0.5 h 2–5 h 8–12 h siderations are essential. The oral surgeon and patient, especially
(Humulin R, if planning to do sedation, should come up with a plan for the
Novolin R) intraoperative management of the pump in the event of hypogly-
NPH (Humulin N, 1–2.5 h 8–14 h 16–24 h
cemia or hyperglycemia. It is best to obtain a signed consent to
Novolin N) adjust the pump settings as needed throughout the perioperative
period. Another important consideration is to defer any elective
Lente 1–2.5 h 8–12 h 16–24 h surgery to at least 24 hours after the catheter has been moved.
Protamine zinc 4–6 h 10–18 h .32 h Usually, catheters are moved to a new position every 3 days, and
(Ultralente) the oral surgeon should verify the last time the site was moved.
The goal is to avoid new onset cannula occlusion, erratic absorp-
Glargine (Lantus) 2–3 h 7–12 h 24–48 h tion, or pump malfunction during the procedure. Most patients
on insulin pumps receive supratherapeutic doses of insulin to
decrease their average blood glucose. Although this is advanta-
geous in the long term, it increases the risk of hypoglycemia intra-
9 should be on dual therapy; and those whose HbA1c is above 9 and operatively. Some pumps have an exercise mode that reduces the
who are symptomatic should be treated with insulin (asymptomatic infusion rate of insulin in preparation for physical exertion. It is
could be treated with triple therapy). The insulin preparation may often preferred to maintain the patient’s normal basal rate (over
be rapid acting (e.g., lispro, glulisine, aspart insulin), short acting reducing the basal rate to 80%) intraoperatively because the body
(regular insulin), intermediate acting (NPH), long acting (glargine, is in a relative state of insulin deficiency during surgery. If hyper-
insulin detemir), or ultra-long acting (degludec, FDA approved in glycemia is encountered intraoperatively, a bolus may be delivered
2015). Short-acting and rapid-acting insulin also may be prescribed based on the preoperative discussion with the patient. After seda-
for administration by the IV route. Table 108.1 provides a sum- tion, the caretaker or escort should be able to manage the insulin
mary of some currently available insulin preparations. pump because the patient is likely not to be able to do so reliably
The more common scenario involves an outpatient procedure on their own.
for a patient with diabetes in an oral surgery clinic. On the same
day of the admission of our patient with HHS, we had scheduled Complications
extractions of third molars under IV sedation for a 22-year-old
female with DM1. The operation was scheduled early in the The complications of diabetes can be divided into acute and
morning. This shortens the nothing-by-mouth period and helps chronic categories. Acute complications primarily include DKA,
with anxiety management. She was instructed to continue taking nonketotic hyperosmolar syndrome, and hypoglycemia. Chronic
glargine but to withhold lispro insulin in the morning. Generally, complications are predominantly related to the long-term effects of
oral hypoglycemic agents are stopped the day before surgery. hyperglycemia on the vasculature and can be divided into micro-
Short-acting insulin medications should be avoided on the morn- vascular retinopathy (nonproliferative [also known as preprolifera-
ing of surgery to prevent dangerous hypoglycemia. For short tive] and proliferative), nephropathy, neuropathy (peripheral distal
ambulatory procedures, such as extractions of third molars in this symmetric polyneuropathy, autonomic neuropathy, proximal
patient, long-acting insulin preparations (e.g., glargine) may be painful motor neuropathy, and cranial mononeuropathy), and
continued. On the morning of surgery, the patient appeared to be macrovascular disease (accelerated atherosclerosis, coronary artery
jittery and nervous. Her skin was slightly clammy, and her palms disease, myocardial infarction, and peripheral vascular disease).
were sweaty (sympathetic response to hypoglycemia). She was Although tight glycemic control has been shown to improve mi-
found to be tachycardic (heart rate, 120 bpm), and her blood crovascular disease (Diabetic Clinical Control Trial), its role in
pressure was 120/80 mm Hg. On placement of the IV catheter, macrovascular disease remains controversial. The United Kingdom
the patient became less responsive (neurologic effect of hypogly- Prospective Diabetes Study indicated no benefits, but a follow-up
cemia). An Accu-Chek reading confirmed a blood glucose level of study showed some improvement. There is no doubt that macro-
55 mg/dL (hypoglycemia). One ampule of 50% (25 g) dextrose vascular disease may be improved with control of lipid levels and
was administered through the IV line (standard management of blood pressure, smoking cessation, and aspirin therapy.
hypoglycemic episode). Within minutes, the patient became more The symptoms of hypoglycemia may be confused with those of
responsive, and her heart rate decreased to 80 bpm. Retrospec- cerebrovascular events, vasovagal syndrome, or a variety of disor-
tively, it was found that the patient had misunderstood the preop- ders considered in the differential diagnosis of a delirious patient
erative instructions, and although she had refrained from breakfast (hypoxia, infection, metabolic abnormalities, myocardial infarc-
in the morning, she had continued routine insulin injections just tion, and medication overdose and withdrawal). Hypoglycemia is
before arriving at the office. The surgery was completed without defined as a blood glucose level below 60 mg/dL. The symptoms
any perioperative complications. may be divided into those that are neurologic and those that
For major procedures requiring hospital admission, cessation are secondary to increased adrenergic (sympathetic) outflow. Neu-
of long-acting insulin 1 to 2 days before surgery and administra- rologic symptoms consist of visual disturbances, paresthesias,
tion of a short-acting insulin may be advocated. lethargy, irritability, delirium, confusion, seizures, and coma.

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 CHAPTER 108 Diabetes Mellitus 559

Adrenergic symptoms consist of nausea, anxiety, weakness, sweat- consequence of another disease (type 3, or secondary, diabetes,
ing, and tremors. In a previously undiagnosed patient, the differ- including a wide variety of diseases such as Cushing’s disease,
ential diagnosis should include primary or secondary hyperinsu- hemochromatosis, and cystic fibrosis), and (4) gestational diabetes
linemia (insulinoma). Other important considerations include (type 4). The distinction among classifications has been blurred
sepsis, malnutrition, and liver failure. The most common reason recently because the pediatric population with DM2 is increasing,
for hypoglycemia in a patient with diabetes is insulin mismanage- and patients with DM2 are being treated with exogenous insulin.
ment. Patients with renal failure are more prone to hypoglycemia A serum insulin or C-peptide level below 0.6 ng/mL suggests
because a small fraction of gluconeogenesis is conducted by the DM1, whereas a level above 1 ng/mL suggests DM2.
kidneys. Treatment of hypoglycemia in an awake patient consists Symptoms of diabetes, although unique, are variable in onset
of oral glucose administration (e.g., orange juice). If IV access is of presentation based on the type of diabetes. DM1 commonly
available, dextrose 10% or 50% in water is acceptable. In the presents with acute symptoms, whereas DM2 may go undiag-
unconscious patient with no IV access, 1 mg of glucagon intra- nosed for many years. Presenting symptoms of type 3 diabetes are
muscularly or subcutaneously can be administered. Diazoxide, variable, based on the primary disease. Females with type 4 diabe-
octreotide, and hydrocortisone are other alternatives. DKA and tes usually present at 24 to 28 weeks of gestation because of
nonketotic hyperosmolar coma are discussed elsewhere in this elevation of prolactin-related peptide. Regardless of the diabetic
book. It is important to rapidly treat any suspicion of hypoglyce- subtype, symptoms consist of polyuria, weight loss, increased ap-
mia because hyperglycemia in a misdiagnosed patient does not petite, fatigue, blurred vision, and thirst. Postprandial hyperglyce-
have any immediate emergent complications; however, untreated mia develops early, and the fasting blood glucose level eventually
undiagnosed hypoglycemia may be devastating. increases. The initial diagnosis is often made because of symptoms
It is commonly known that patients with diabetes are more sus- arising from oral or vaginal candidiasis and DKA.
ceptible to infections. It is thought that various steps in neutrophil For the routine workup of a patient with well-controlled dia-
function are altered, including leukocyte adherence, chemotaxis, and betes, no routine preoperative laboratory testing is necessary for
phagocytosis. Antioxidants that are involved in the bactericidal ac- minor oral surgical procedures except for a preoperative blood
tivity may also be altered. The defects in neutrophil function are at glucose level (especially important in a patient with poorly con-
least partially reversible by strict glycemic control (blood glucose trolled diabetes). Patients with hypoglycemia should be treated
between 80 and 110 mg/dL). However, it is hypothesized that the with oral or IV glucose (dextrose) or intramuscular glucagon as
pathophysiology of the immunologic defects in people with diabetes needed, and those with hyperglycemia may need to be treated
is not exclusively related to glycemic control. with an insulin preparation. Elective surgical procedures should
be delayed in the face of excessively abnormal blood glucose read-
Discussion ings. Patients with infectious processes that require surgical inter-
vention should be treated promptly because infections are fre-
Diabetes mellitus is a prevalent and destructive endocrine disorder quently the precipitating cause of the glycemic abnormality.
that may affect any organ in the body. More than 366 million For patients undergoing major surgery, a complete metabolic
people are affected worldwide. In the United States, approximately panel and blood count should also be obtained.
26 million people have diabetes, and 79 million have prediabetes, Patients with impaired fasting glucose are more prone to de-
according to the Centers for Disease Control and Prevention. Dia- velop DM2 than the general population. Other risk factors for
betes is the leading cause of blindness, nontraumatic leg amputa- developing DM2 include age older than 45 years, a family history
tion, and end-stage renal disease. It is also implicated as a risk of DM2, racial predisposition (Hispanic, Native American, Afri-
factor in cardiac, cerebral, and vascular disease processes. The most can American), hypertension and dyslipidemia, and a history of
common type, non–ketone-induced diabetes, is on the rise, cor- gestational diabetes or polycystic ovarian disease. DM1 is more
relating with the increased incidence of obesity in the United common in White and least common in Asian populations. Dia-
States. Mokdad and colleagues randomly selected a cohort of betes is diagnosed when the fasting blood glucose level exceeds
200,000 adult patients; they observed the prevalence of diabetes to 126 mg/dL; a random blood glucose level is greater than 200 mg/
be 7.9%, an increase from 7.3% in 2000. The prevalence of obesity, dL with polydipsia, polyuria (when serum blood glucose level
defined as a body mass index greater than 30 kg/m2, was 20.9%, an exceeds the threshold of 240 mg/dL), polyphagia, weight loss,
increase of 5.6% from the previous year. and hyperglycemic crisis; a 2-hour postprandial blood glucose
Insulin is an anabolic hormone produced by the beta cells of level greater than 200 mg/dL after consumption of an oral glu-
the pancreas. Its production is stimulated by elevated blood glu- cose load of 75 g; or when the HbA1C is 6.5% or higher. Patients
cose, causing the subsequent effects of glucose uptake by cells, with prediabetes have a 2-hour postprandial glucose tolerance of
promotion of triglyceride synthesis and storage, inhibition of ke- 140 to 200 mg/dL or a fasting blood glucose level of 100 to
togenesis, activation of various enzymes (e.g., glycogen synthase, 125 mg/dL. An individual has metabolic syndrome if they have
HMG-CoA reductase, lipid lipases), and inhibition of catabolic has three of the following conditions:
pathways, such as gluconeogenesis and ketogenesis (Fig. 108.1). • Elevated triglycerides
The counterregulatory hormones are cortisol, epinephrine, growth • Low high-density lipoprotein
hormone, and glycogen. The hyperglycemia seen in diabetes is not • Abdominal obesity
only caused by a lack of insulin but also by an imbalance between • Fasting glucose level of 100 mg/dL or higher
insulin and its counterregulatory hormones. • Hypertension
Diabetes is a disorder resulting from deficiency or defects in Diabetes is a costly disease, and until recently, only symptom-
insulin action. The pathophysiology is related to four main causes: atic treatment was available. A patient’s compliance with daily
(1) defects in production (DM1, juvenile-onset diabetes, ketoaci- injections and diabetic diets is frequently difficult to control, es-
dosis-prone diabetes), (2) defects at the site of action (DM2, pecially in an unmotivated patient. Traditionally, when diabetes
adult-onset diabetes, non–ketoacidosis-prone diabetes), (3) a was discussed, the term “treatment” was not advocated because

t.me/Dr_Mouayyad_AlbtousH
560 S E C TI O N X Medical Conditions

Brain

Carbohydrates

(Fat) lipids 6
Glucose uptake
into cells

5 Lipogenesis
Gut

Pancreas
1
Liver (glycogen) 7
Beta cells
Systemic circulation

1
Insulin

4 Glycogenesis Glomeruli
stimulated by insulin

3
Protein
synthesis

Kidney
Muscle (protein)

In the absence of insulin:

1. Blood glucose increases 5. Lipid breakdown (lipolysis)
2. Glucose spills out into the urine (osmotic diuresis, causing 6. The brain cells cannot uptake glucose and instead
dehydration) use ketones
3. Decreased protein synthesis (catabolism) 7. Increased ketones (ketogenesis) cause ketoacidosis
4. Increased gluconeogenesis and decreased glycogenesis,
further increasing plasma glucose

• Fig. 108.1 The actions of insulin.

the underlying disease was not altered with any of these medica- from exogenous insulin. Islet cell transplantation for DM1 shows
tions. In 2000, clinical trials on islet cell transplantation showed promise, providing an alternative with the potential for more de-
promising results. Multiple cadaveric islets were prepared and finitive treatment.
transplanted into the recipient’s liver. In the same year, Shapiro and
associates studied seven patients who had received islet cell trans- ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
plants; they found a success rate of 100%, with total independence complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 560.e1

Bibliography Rehman J, Mohammed K: Perioperative management of diabetic pa-

tients, Curr Surg 60:607-611, 2003.
Robertson PR: Islet transplantation as a treatment for diabetes: a work in
Colunga-Lozano L, Gonzalez Torres F, Delgado-Figueroa N, et al: Slid- progress, N Engl J Med 350:694-705, 2004.
ing scale insulin for non-critically ill hospitalised adults with diabetes Shapiro AMJ, Lakey JRT, Ryan EA, et al: Islet transplantation in seven
mellitus, Cochrane Database Syst Rev 11(11):CD011296, 2018. patients with type 1 diabetes mellitus using a glucocorticoid-free im-
doi:10.1002/14651858.CD011296.pub2. munosuppressive regimen, N Engl J Med 343:230-238, 2000.
Diabetes Control and Complications Trial Research Group: The effect of UK Prospective Diabetes Study (UKPDS) Group: Intensive blood-glu-
intensive treatment of diabetes on the development and progression cose control with sulphonylureas or insulin compared with conven-
of long-term complications in insulin-dependent diabetes mellitus, N tional treatment and risk of complications in patients with type 2
Engl J Med 329(14):977-986, 1993. diabetes (UKPDS 33), Lancet 352(9131):837-853, 1998.
International Diabetes Foundation: One adult in ten will have diabetes by US Department of Health and Human Services/Centers for Disease
2030. Available at: http://www.idf.org/media-events/press-releases/2011/ Control and Prevention: National diabetes fact sheet: national estimates
diabetes. Accessed February 27, 2013. and general information on diabetes and prediabetes in the United States,
Joshi N, Caputo GM, Weitekamp MR, et al: Infections in patients with 2011. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.
diabetes mellitus, N Engl J Med 341:1906-1912, 1999. pdf. Accessed February 27, 2013.
Marks JB: Perioperative management of diabetes, Am Fam Physician 67: Yen PM, Young AS: Review of modern insulin pumps and the periopera-
93-100, 2003. tive management of the type 1 diabetic patient for ambulatory dental
Mayfield J: Diagnosis and classification of diabetes mellitus: new criteria, surgery, Anesth Prog 68(3):180-187, 2021. doi:10.2344/anpr-68-03-16.
Am Fam Physician 58:1355-1362, 1998.
Mokdad AH, Ford ES, Bowman BA, et al: Prevalence of obesity, diabetes
and obesity related health risk factors, JAMA 298:76-79, 2003.

t.me/Dr_Mouayyad_AlbtousH
109
Diabetic Ketoacidosis
M E H R A N M E H R A B I a n d SH A H R O K H C . B AG H ER I

CC pump can result in similar presentation.) She denies the use of

alcohol, tobacco, and recreational drugs.
A 17-year-old female with diabetes presents to the oral and maxil-
lofacial surgery clinic 5 days after extraction of her four third Examination
molars. She complains of “nausea and vomiting.”
General. The patient is an intermittently nonresponsive female
HPI who does not follow commands (altered mental status). She is
breathing without obstruction, but it is deep and slow (Kussmaul
The patient reports a history of poor oral intake and frequent breathing, partial respiratory compensation for metabolic acidosis).
emesis (vomiting) for the past 3 days. She has been feeling pro- Vital signs. Blood pressure is 101/50 mm Hg (hypotension),
gressively more fatigued, with general malaise (secondary to dehy- heart rate is 114 bpm (tachycardia), respirations are 20 per min-
dration). Because she has not been able to eat or drink regularly, ute (hyperventilation illustrates respiratory compensation of met-
she decided to discontinue all her insulin injections. (Lack of in- abolic acidosis), and temperature is 38.8°C (febrile).
sulin is the key cause of diabetic ketoacidosis [DKA].) Orthostatic. When the patient rises from a supine to a standing
She also complains of blurry vision (secondary to volume de- position, the heart rate increases to 140 bpm, and the blood pressure
pletion), vague abdominal pain (metabolic acidosis results in decreases to 80/40 mm Hg. (An increase in heart rate .30 bpm or a
gastric distension and blockage, and b-hydroxybutyrate induces decrease in systolic blood pressure by .20 mg/dL or in diastolic blood
vomiting), cramping in her extremities (secondary to hypokale- pressure by .10 mg/dL is an indication of severe volume depletion.)
mia and dehydration commonly associated with DKA), an ele- Maxillofacial. The patient has significant tenderness (dolor),
vated temperature (secondary to development of infection and edema (tumor), and erythema (rubor) of the left lower face, and
dehydration), and swelling of the left mandible that has progres- her face is warm (calor) to the touch. (These are the cardinal signs
sively exacerbated over the past 48 hours. She reported an increase of inflammation.) Fluctuance is palpated over the angle of the
in the frequency of urination (polyuria) in the first few postop- mandible. She is unable to open her mouth more than 10 mm
erative days but has not voided for the past day (initial osmotic (trismus, suggestive of masticator space infection). The patient is
diuresis causing dehydration). At first, her mother was not con- able to maintain her secretions. (Drooling would be indicative of
cerned about a developing infection because the patient’s breath significant oropharyngeal swelling or dysphagia.)
actually smelled “fruity” (acetone breath odor secondary to ele- Intraoral. Purulence is noted around the extraction socket of
vated plasma ketones). However, she became anxious when her the left mandibular third molar, with surrounding gingival edema
daughter appeared progressively less responsive. (Stupor and coma and erythema. The floor of the mouth is soft and is not raised.
can be caused by rapid increases in blood osmolarity, which cause There is moderate swelling of the left lateral pharyngeal wall, with
water to be drawn out of the central nervous system, resulting in slight deviation of the uvula (indicative of left lateral pharyngeal
cellular dehydration and changes in consciousness.) The on-call spread of infection). Dry mouth (xerostomia) and difficulty swal-
surgeon was contacted the night before and attributed the nausea lowing (dysphagia) can develop secondary to dehydration.
and vomiting to excessive narcotic intake. The swelling was as- Cardiovascular. The patient has sinus tachycardia with inter-
sessed via telephone to appropriately correspond to postsurgical mittent pause, which correlates with premature ventricular con-
edema. The patient was prescribed promethazine and advised to tractions. (Electrolyte abnormalities, such as hyperkalemia, result
see the treating surgeon the next day. (Any suspicion of DKA in abnormal heart rhythms.)
should prompt evaluation in the emergency department as soon Pulmonary. The patient’s chest is bilaterally clear on ausculta-
as possible. Unrecognized DKA can be deleterious.) tion with deep breathing.
Abdominal. Generalized pain on palpation but otherwise
PMHX/PDHX/Medications/Allergies/SH/FH nontender and nondistended.

The patient was diagnosed with diabetes mellitus type 1 at age 14 Imaging
years. She takes regular insulin (short-acting insulin) and NPH
(intermediate-acting insulin) twice a day under the care of an A panoramic radiograph and a computed tomography (CT) scan
endocrinologist. (A clogged tubing in patients on an insulin of the head and neck may be indicated to evaluate the spread of

561
t.me/Dr_Mouayyad_AlbtousH
562 S E C TI O N X Medical Conditions

infection in the parapharyngeal and masticator spaces and for Assessment

evaluation of the airway. In patients with compromised renal
function, as determined by an elevated creatinine level, contrast Diabetic ketoacidosis secondary to parapharyngeal and masticator
CT is contraindicated. Noncontrast CT, although less useful for space infection. (Infection is the leading cause of DKA.)
demonstrating soft tissue spread of infection, can still be of value.
There should be a low threshold for ordering CT or magnetic Treatment
resonance imaging scans to search for brain edema, particularly in
pediatric patients with altered mental status. Treatment begins with assessment of the ABCs—airway, breath-
ing, and circulation. Intravenous (IV) fluid is the first line of
Labs treatment; start with normal saline and subsequently switch to
D10 1/2 normal saline (NS; 10% dextrose in 0.45% normal saline
A full set of laboratory studies (complete blood count, electro- when glucose is ,14 mmol/L) to eliminate ketones. This ad-
lytes, and urinalysis) is essential in the management of DKA. dresses dehydration and decreases the plasma glucose level by di-
DKA patients have a serum ketone concentration greater than lution. Any indication of cardiac instability (peaked T waves,
5 mEq/L. Ketones consist of acetoacetate, b-hydroxybutyrate, wide QRS complexes, and premature ventricular contractions)
and acetone. The following laboratory study results also were ob- caused by hyperkalemia should be treated first with calcium glu-
tained for the current patient: conate. This is followed by an IV insulin drip (0.1 units/kg/hr,
• Hemogram: White blood cell count of 18.2 cells/mL with a also known as a fixed-rate IV insulin infusion) to gradually de-
differential of 70% neutrophils, 20% bands, 8% lymphocytes, crease serum glucose and osmolarity (osmoles of solute per liter of
1% monocytes, and 1% eosinophils (elevated neutrophil solution). The difference between the measured osmolarity and
count is indicative of acute inflammation); hemoglobin and calculated osmolarity (2Na 1 Glucose/18 1 Blood urea nitro-
hematocrit of 15 mg/dL and 45%, respectively (volume deple- gen/2.8 1 Ethanol/4.6) is called the osmolal gap; this would be
tion results in overestimation of the hemoglobin and hemato- elevated because of the high ketones or other anions (which are
crit); and platelet count within normal limits. unmeasured anions and therefore the cause of an anion gap meta-
• Basic metabolic panel: Na1 130 is mEq/dL (hyperglycemia in- bolic acidosis). A rapid reduction in osmolarity results in cerebral
duces an intracellular movement of sodium); K1 is 6.5 mEq/ edema and should be avoided.
dL (elevated secondary to acidosis causing transcellular shift of Diabetic ketoacidosis can result in cerebral edema in small chil-
K1 into the extracellular space in exchange for H1 ions); Cl2 dren and result in pupillary light reflex and death. Glucose is de-
is 95 mEq/dL (normal chloride is consistent with an anion gap creased at about 100 mg/dL/hr. A rapid reduction in glucose
metabolic acidosis [most common causes of anion gap meta- stimulates the counterregulatory hormones and hence ketone
bolic acidosis are ketoacidosis, lactic acidosis, drugs and kidney production. The combination of hydration and insulin decreases
failure), bicarbonate is 10 mEq/dL (a low bicarbonate level is potassium. Urine output is carefully monitored for evaluation of
indicative of metabolic acidosis), blood urea nitrogen is fluid status. With correction of acidosis, the serum potassium may
60 mEq/dL, creatinine is 3 mEq/dL (blood urea nitrogen and precipitously decrease, requiring careful monitoring and supple-
creatinine are both elevated secondary to decreased intravascu- mentation. (Insulin causes transfer of hydrogen ions from the ex-
lar volume [prerenal azotemia]), and glucose is 550 mg/dL tracellular space to the intracellular space.) Other electrolytes to
(primarily secondary to the lack of insulin). consider are magnesium and phosphate; both may need to be re-
• Arterial blood gas (venous blood gas is sufficient) analysis: pH is plenished. Patients commonly have deficiencies of the B-complex
7.1, Pco2 is 25 mm Hg, and PO2 is 90 mm Hg on Fio2 of vitamins (caused by malnutrition), particularly thiamine, which
40%. (A pH of 7.1 is a strong acidemia. These findings, along should be corrected. Bicarbonate is rarely recommended for the
with a low Pco2, are indicative of metabolic acidosis with re- treatment of acidosis (high risk for development of cerebral
spiratory compensation.) edema). It is generally reserved for patients with a pH below 7.0.
• Urine analysis: Positive ketones, 13 glucosuria (the proximal The current patient was admitted to the hospital and started on
convoluted tubules’ ability to reabsorb glucose is maximized at a IV normal saline. Calcium gluconate was administered to main-
blood glucose of 180–200 mg/dL, after which glucose is spilled tain cardiac stability. The patient was started on a regular insulin
into the urine, causing osmotic diuresis); 12 proteinuria. (Glom- drip, with frequent blood glucose checks to adjust the dose. The
eruli damage in diabetic nephropathy results in protein wasting potassium level was evaluated intermittently and supplemented as
and nephrotic syndrome; microproteinuria is indicative of dia- needed. When the blood glucose level dropped below 200 mg/dL,
betic nephropathy and may be avoided or delayed by daily intake dextrose supplementation was used to prevent dangerous hypogly-
of angiotensin-converting enzyme inhibitors.) cemia. The insulin drip was continued until resolution of the
• Urine dipstick test: 14 for nitroprusside (indicative of acetoac- metabolic acidosis. Diagnostically, venous blood gas analysis may
etate and acetone [ketones] in the urine). Rarely, urine ketone be just as valuable as arterial blood gas analysis and may be used to
is negative. Although the predominant ketone in severe DKA reduce arterial complications. The patient was empirically started
is b-hydroxybutyrate, a urine dip stick cannot test for it. As the on ampicillin–sulbactam (combination of b-lactam and b-lacta-
clinical condition improves, the urine dip stick may change mase inhibitor) and was taken to the operating room for surgical
from negative to positive as acetoacetate predominates. drainage of the lesion. The IV fluid was changed to D10 1/2 NS
when the patient was deemed hemodynamically stable and a there
Electrocardiogram was a decrease in serum glucose. Urine output improved, meta-
bolic acidosis and pseudohyperkalemia (elevated plasma potassium
The electrocardiogram shows widened QRS complexes and despite total body depletion secondary to shift of potassium from
peaked T waves (secondary to hyperkalemia) and occasional pre- the intracellular space caused by high H1 concentration) resolved,
mature ventricular contractions. and the patient was transferred to the ward. An American Diabetic

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 CHAPTER 109 Diabetic Ketoacidosis 563

Association 1800-kcal diet was initiated (patient education is criti- include the serum glucose and electrolyte levels; anion gap; blood
cal in preventing reoccurrence). The patient remained afebrile, urea nitrogen; creatinine; urinalysis, including ketones; electro-
with normalization of her white blood cell count, electrolytes, and cardiogram; complete blood count; arterial blood gas analysis;
urinalysis. She was subsequently discharged to home care on a 10- HbA1c levels; and any tests required to determine the underlying
day regimen of amoxicillin with clavulanic acid. DKA resolution cause.
occurs when pH is less than 7.3 units, bicarbonate is above 15 The differential diagnosis of a patient with ketosis also includes
mmol/L, and blood ketone level is less than 0.6 mmol/L. alcoholism and starvation, but only DKA presents with hypergly-
cemia. The excess anions (ketones) in DKA cause an anion gap
Complications metabolic acidosis (gap acidosis) (see Chapter 109). The differen-
tial diagnosis includes methanol toxicity, uremia, DKA, paralde-
Complications of diabetes can be divided into acute and chronic. hyde ingestion, isoniazid toxicity, isopropyl alcohol toxicity, lactic
The acute complications include hypoglycemia (see Chapter 109), acidosis, ethylene glycol toxicity, and salicylate toxicity. However,
DKA, and hyperosmolar hyperglycemic syndrome. Chronic com- only DKA produces hyperglycemia. The symptoms of DKA can
plications include microvascular and macrovascular disease (see arise rapidly (within 24 hours), manifesting as polyuria, polypha-
Chapter 109). Patients with DKA generally present with metabolic gia, polydipsia, weakness, and fatigue in addition to nausea, vom-
acidosis and a blood glucose level below 500 mg/dL, whereas pa- iting, and vague abdominal pain. Mental status may range from
tients with nonketotic hyperglycemia coma present with a blood normal to profound coma. As dehydration becomes pronounced,
glucose level above 1000 mg/dL with no acidosis. The patho- the hypovolemic polyuria is not as prominent.
physiology of both disorders is related to the physiologic response The differential diagnosis for hyperglycemia should include
to stress. Acute insulin deficiency (caused by lack of compliance, dawn and Somogyi phenomena. Dawn phenomenon results from
pump blockage, brittle diabetes), infection (the most common a natural nocturnal increase in counterregulatory hormones (cor-
cause of DKA), trauma, ischemia (cerebrovascular accident, myo- tisol and growth hormone). The Somogyi effect results from an
cardial infarction), or volume depletion can induce signals to in- increase in nocturnal counterregulatory hormones caused by
crease catecholamines, cortisol, growth hormone, and glucagon midsleep hypoglycemia. Therefore, both the dawn and Somogyi
(insulin counterregulatory hormones that increase gluconeogene- phenomena result in hyperglycemia caused by an increase in
sis), resulting in an imbalance of glucose metabolism. These stress counterregulatory hormones. The difference is that the dawn
hormones increase blood glucose and osmolarity while decreasing phenomenon is a natural nocturnal rise in hormones, whereas the
cellular insulin. The lack of insulin results in ketone production by Somogyi effect is caused by a rebound from hypoglycemia.
the liver and the development of an anion gap metabolic acidosis. Acidosis results in a shift of potassium ions from the intracel-
DKA also presents with nausea, vomiting, abdominal pain, poly- lular to the extracellular compartments. This causes elevation of
uria, polydipsia, weight loss, diplopia, delirium, or coma. Objective the plasma potassium concentration. However, with glucose-
laboratory studies reveal a metabolic acidosis, pseudohyperkalemia, driven osmotic diuresis, potassium is excreted by the kidneys,
glucosuria, and both serum and urine b-hydroxybutyrate and ace- causing depletion of total body potassium despite elevated plasma
toacetate (ketones). Because of the rapid onset of acidosis and good levels, hence the term pseudohyperkalemia (seen in more than one-
renal clearance in younger patients with type 1 diabetes, the blood third of patients with DKA). With the correction of acidosis, the
glucose level rarely exceeds 800 mg/dL. extracellular potassium shifts back to the intracellular space, caus-
Diabetic ketoacidosis is the most commonly observed acute ing significant lowering of plasma potassium. The plasma potas-
complication of type 1 diabetes. Patients with type 2 diabetes may sium needs to be replaced as the acidosis is corrected to avoid
also develop DKA, but it is not common. Ketose-prone type 2 life-threatening hypokalemia.
diabetics are more often of Afro-Caribbean or Hispanic descent. The severity of DKA is measured by presence of blood ketone
Patients with type 2 diabetes taking sodium-glucose cotrans- of over 6 mmol/L, bicarbonate level below 5 mmol/L, venous or
porter-2 (SGLT2) inhibitors such as empagliflozin may present arterial pH below 7, hypokalemia on admission, Glasgow Coma
with euglycemia or slightly elevated glucose DKA. Euglycemic Scale score below 12, oxygen saturation below 92%, systolic
ketoacidosis described more recently develop with anionic gap blood pressure below 90 bpm, pulse above 100 or below 60 beats
acidosis, ketonemia, or ketonuria. Patients on ketogenic (low- per minute and anion gap above 16.
carbohydrate diet) should not be placed on SGLT2 inhibitors. Another acute complication of diabetes is hyperosmolar hyper-
The most common cause of DKA is patient noncompliance with glycemic syndrome, which has a less insidious onset than DKA. It
insulin. Other causes are infection, acute vascular event, new di- generally begins with mild hyperglycemia, which is compensated
agnosis of type 1 diabetes, inadequate insulin therapy in the hos- for by glycosuria. As hyperglycemia worsens, osmotic diuresis
pital, and medications such as steroids. wastes more glucose through urine. If the patient maintains ade-
quate hydration, the kidneys continue to excrete the excess glucose.
Discussion As the patient becomes confused or incapacitated, oral hydration
decreases, and the kidneys’ ability to excrete glucose is diminished,
The diagnosis of DKA is based on the history, clinical examination, exacerbating the hyperglycemia and causing mental status changes.
and laboratory findings. This disease arises from a relative or an During treatment, the plasma glucose level should be reduced no
absolute deficiency of insulin and an increase in the counterregula- faster than 75 to 100 mg/dL/hr. A more rapid decline could cause
tory hormones, resulting in gluconeogenesis, glycogenolysis, and brain edema.
lipolysis. It is a triad of ketonemia (3.0 mmol/L or ketonuria
.21), hyperglycemia (11.0 mmol/L) and acidemia (pH ,7.3 or ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
bicarbonate concentration ,15.0 mmol/L). The work-up should complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 563.e1

Bibliography and potassium concentration in critically ill patients? Diabet Med 29(1):
32-35, 2012.
Jerums G, MacIsaac RJ: Treatment of microalbuminuria in patients with
Abramson E, Arky R: Diabetic acidosis with initial hypokalemia, JAMA type 2 diabetes mellitus, Treat Endocrinol 1(3):163-173, 2002.
196(5):401-403, 1966. Joint British Diabetes Societies Inpatient Care Group: The management
Adrogue HJ, Lederer ED, Suski WN, et al: Determinants of plasma po- of diabetic ketoacidosis in adults, March 2010. Available at: http://
tassium levels in diabetic ketoacidosis, Medicine 65:163-172, 1986. www.diabetes.nhs.uk. Accessed October 17, 2012.
Adrogue HJ, Madias NE: Management of life-threatening acid-base dis- Kitabchi AE, Umpierrez GE, Murphy MB, et al: Hyperglycemic crises in
order. First of two parts, N Engl J Med 338(1):26-34, 1998. patients with diabetes mellitus, Diabetes Care 26(Suppl 1):S109-
Arora S, Henderson SO, Long T, et al: Diagnostic accuracy of point-of- S117, 2003.
care testing for diabetic ketoacidosis at emergency-department triage: Kreisberg RA: Diabetic ketoacidosis: new concepts and trends in patho-
b-hydroxybutyrate versus the urine dipstick, Diabetes Care 34(4): genesis and treatment, Ann Intern Med 88(5):681-695, 1978.
852-854, 2011. Matz R: Management of the hyperosmolar hyperglycemic syndrome, Am
Chiasson J, Aris-Jilwan N, Belanger R, et al: Diagnosis and treatment of Fam Physician 60(5):1468-1476, 1999.
diabetic ketoacidosis and hyperglycemic hyperosmolar state, CMAJ Narins RG, Cohen JJ: Bicarbonate therapy for organic acidosis: the case
168(7):859-866, 2003. for its continued use, Ann Intern Med 106(4):615-618, 1987.
Dhatariya KK: The management of diabetic ketoacidosis in adults—an Page MM, Alberti KG, Greenwood R, et al: Treatment of diabetic coma
updated guideline from the Joint British Diabetes Society for Inpa- with continuous low-dose insulin infusion, Br Med J 2(5921):687-
tient Care, Diabet Med 39:e14788, 2022. 690, 1974.
Evans K: Diabetic ketoacidosis, Clin Med 19(5):396-398, 2019. Trachtenbarg DE: Diabetic ketoacidosis, Am Fam Physician 71(9):1705-
Fulop M, Tannenbaum H, Dreyer N: Ketotic hyperosmolar coma, Lan- 1714, 2005.
cet 2(7830):635-639, 1973. Umpierrez G, Freire A: Abdominal pain in patients with hyperglycemic
Herrington WG, Nye HJ, Hammersley MS, et al: Are arterial and venous crisis, J Crit Care 17(1):63-67, 2002.
samples clinically equivalent for the estimation of pH, serum bicarbonate

t.me/Dr_Mouayyad_AlbtousH
110
Acute Myocardial Infarction
N A M H . NG UY E N , J OYC E T. L EE , a n d S H A H R O K H C . B AG H ER I

CC PMHx/PDHx/Medications/Allergies/SH/FH
A 57-year-old male with a history of hypertension, coronary ar- The patient has a history of hypertension, CAD, and hypercho-
tery disease (CAD), and hypercholesterolemia is referred to your lesterolemia, for which he has been taking medications for the
office for evaluation of a biopsy-proved mandibular dentigerous past 15 years. He denies any history of previous myocardial in-
cyst. The perioperative cardiovascular risk assessment includes farction (MI), cerebrovascular accident, or recent hospitalization.
recognition of risk factors such as a history of ischemic heart (With a history of CAD, formal recommendations should be
disease, heart failure, cerebrovascular disease, insulin-dependent sought from the patient’s cardiologist regarding the holding of
diabetes mellitus, or renal insufficiency (preoperative serum cre- any antiplatelet therapy during the perioperative period.) The
atinine $2.0 mg/dL). Risk stratification allows for evaluation of patient’s last physical examination was several months ago, when
the risk of cardiac complication and for optimization before a number of minor adjustments were made to his medications.
surgery. His past surgical history includes an appendectomy and chole-
cystectomy under general anesthesia without any perioperative
HPI complications. (A positive history of adverse events with anesthe-
sia is significant in assessing the future risk of surgery under
The patient is diagnosed with a small dentigerous cyst of the pos- general anesthesia.) His medications include atenolol (a beta-
terior mandible. blocker), lisinopril (an angiotensin-converting enzyme [ACE]
The preoperative assessment includes inquiry into the pa- inhibitor), atorvastatin (an HMG-CoA reductase inhibitor, a
tient’s cardiovascular system review. This includes any symptoms cholesterol-lowering medication), and aspirin. He has smoked
such as angina (the two major types of angina are stable angina, one pack of cigarettes per day for the past 20 years and admits to
which occurs with exertion, and unstable angina, which occurs at a sedentary lifestyle. He has no symptoms of depression. (Depres-
rest), dyspnea, syncope, and palpitations; history of heart disease, sion is a common comorbid condition in patients with CAD and
including ischemic, valvular, or cardiomyopathic disease; and a a well-documented risk factor for recurrent cardiac events and
history of hypertension, diabetes, chronic kidney disease, and death.) His family history is significant for the death of his father
cerebrovascular or peripheral artery disease. Positive symptoms or at age 50 years from a massive acute myocardial infarction (AMI).
recent significant health events are indicators for additional pre-
operative questioning and testing. In addition, the patient’s Examination
metabolic equivalent of task levels (METs) in performing daily
activities is necessary to ascertain functional status or capacity. General. The patient is a moderately obese male in no distress.
One MET is defined as 3.5 mL of O2 uptake/kg per minutes, Vital signs. Normal except for a baseline blood pressure of
which is the resting oxygen uptake in a sitting position. Typically, 155/88 mm Hg (stage 1 hypertension).
METs of 4 or higher (climbing a flight of stairs or walking up a Maxillofacial: Minimal expansion of the buccal cortex of the
hill), in the absence of cardiac complaints, preclude the need for left posterior mandible is noted.
further cardiac testing (gold standard is the cardiac stress test) for Cardiovascular. The cardiovascular examination shows the
non–high-risk surgeries. following:
Risk assessment is not exclusively for patients with known • Inspection: The chest wall appears normal. The point of maxi-
cardiac disease because a significant number of patients have un- mum impulse is located at the normal position along the
diagnosed heart disease. The guidelines published by the Ameri- midclavicular line at the fifth intercostal space.
can College of Cardiology (ACC)/American Heart Association • Auscultation: No audible bruits are heard using the bell of the
(AHA) outline the algorithm for cardiovascular risk assessment in stethoscope. This portion of the examination includes ausculta-
individuals undergoing noncardiac surgery. tion for bruits at the neck (carotid), midabdomen (aorta), and
The current patient denies any cardiovascular complaints, in- lateral flanks (renal). (Audible bruits would be indicative of
cluding chest pain, shortness of breath, and dyspnea on exertion. significant atherosclerotic plaques, suggestive of systemic ath-
He reports that he is able to climb a flight of stairs without diffi- erosclerosis.) Auscultation of the heart reveals a regular rate and
culty (MET . 4). rhythm, no murmurs, normal S1 and S2 with no S3 (usually

564
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 CHAPTER 110 Acute Myocardial Infarction 565

abnormal in patients .40 years old; common early finding of volume that is expelled from the left ventricle with systole; the
heart failure caused by left ventricular volume overloading or normal range is 55% to 70%. Left ventricular systolic dysfunction
dilation) or S4 noted (caused by poor compliance and stiffness is defined by an ejection fraction of 40% or less. An echocardio-
of the left ventricles). gram is not routinely ordered unless the patient is having active or
• Jugular venous pressure: Within normal limits at 3 cm above the new cardiac complaints.
sternal angle. (Jugular venous distension is a sign of venous Cardiac catheterization is the gold standard for evaluating the
hypertension, most commonly secondary to right-sided heart coronary anatomy and assessing for the presence of significant
failure.) atherosclerosis. However, it is not routinely recommended for
• Peripheral pulses and extremities: No edema of the extremities preoperative assessment, given the invasive nature of the proce-
(a sign of heart failure) or clubbing of the nail beds (seen with dure, unless the patient has a significant abnormality on cardiac
chronic pulmonary disease). (The peripheral pulses are in- stress testing and it is recommended by the consulting cardiologist.
spected for symmetry and strength. [Pulsus alternans denotes Evaluation of blood cholesterol levels is also important for as-
an alternating strong and weak pulse and may signify left sessment of future risks of cardiovascular events. The ACC recom-
ventricular heart failure.].) mends targeting the low-density lipoprotein (LDL) level at below
• Fundoscopic examination: Bilateral retinal plaques (secondary to 100 mg/dL in individuals with CAD or diabetes mellitus. How-
atherosclerosis) and arteriovenous nicking (secondary to hyper- ever, the target LDL level may be below 70 mg/dL, depending on
tension). (Examination of the retinas is an important part of a the patient’s comorbidities. The target high-density lipoprotein
complete cardiovascular examination because it allows direct (HDL) levels are above 40 mg/dL for males and above 50 mg/dL
visualization of the microvasculature. Cotton-wool spots or dot for females.
or blot retinal hemorrhages are signs of diabetic retinopathy.) The current patient’s most recent testing was done at his last
Pulmonary. The chest is bilaterally clear on auscultation. physical examination several months ago. His total cholesterol was
(With left-sided heart failure, blood backs up into the pulmonary 190 mg/dL, LDL was 125 mg/dL, and HDL was 37 mg/dL. The
circulation, causing “congestion” and the leakage of fluid from the basic metabolic profile was within normal limits. (Levels of potas-
pulmonary capillaries into the interstitium; this leads to pulmo- sium must be monitored in the patients with hypertension who are
nary edema [“wet lung”], which is detected as rales or crackles on taking diuretics.) A treadmill cardiac stress test done within the
auscultation of the lungs.) past year did not reveal any signs of myocardial ischemia.
A 12-lead ECG revealed no abnormalities. (ECG is an invaluable
Imaging tool for obtaining information on cardiac conduction, chamber
enlargement, electrolyte disturbances, drug toxicities, myocardial
Other than a panoramic radiograph, no other routine radio- ischemia, and infarction. Elevation of the ST segment is strongly
graphic imaging studies are indicated for excision of a cyst under suspicious of myocardial injury, whereas ST depression is suggestive
intravenous (IV) sedation. A preoperative chest radiograph may of myocardial ischemia.)
be obtained in select patients based on the history and physical
examination findings. Routine preoperative chest radiographs in Assessment
asymptomatic, healthy adults is not indicated.
In the current patient, the panoramic radiograph demon- A 57-year-old male with a history of CAD, hypertension, and hyper-
strated a 2-cm 3 2-cm unilocular radiolucency of the posterior cholesterolemia, requiring outpatient removal of a dentigerous cyst
mandible, consistent with a dentigerous cyst. under IV sedation anesthesia.
The treating cardiologist was contacted for perioperative risk
Labs and Other Tests assessment for an elective low-risk surgery. (Procedures of the head
and neck are classified as being either low or intermediate risk.) He
The preoperative laboratory tests for the evaluation of a patient with stratified the patient as intermediate risk for surgery with a recom-
significant cardiovascular disease (CVD) should be done in conjunc- mendation to continue the existing atenolol regimen without in-
tion with the treating primary care doctor, cardiologist, or both. terruption. He noted that the aspirin could be held preoperatively,
A variety of stress tests, in conjunction with electrocardio- if necessary, to minimize potential bleeding complications and
graphic (ECG) monitoring, may be performed to further risk then resumed after surgery. (A preoperative medical evaluation
stratify higher risk patients undergoing intermediate- to high-risk serves to assess the patient’s risk of morbidity and mortality in the
surgery. The cardiovascular system is tested, or “stressed,” either perioperative period. There is insufficient evidence to support the
with physical activity (walking on a treadmill) or pharmacologi- use of beta-blockers in patients undergoing low-risk procedures;
cally using vasodilators (e.g., adenosine or dipyridamole) or inotro- however, they are continued during the perioperative period in
pes or chronotropes (e.g., dobutamine), to test for any significant patients already on a beta-blocker regimen.)
myocardial ischemia. Determination of cardiac function and risk
stratification are based on the duration of exercise, any symptoms Treatment
that develop, and the presence of ECG findings such as flipped T
waves or ST-segment depression or elevation. In addition to the After discussion of the risks, benefits, and alternatives, the patient
ECG portion, stress testing may include imaging with echocar- elected to proceed with the procedure. He was instructed to with-
diography or myocardial perfusion with labeled radioisotopes. hold all his morning medications with the exception of his blood
Echocardiography is a diagnostic test performed to assess car- pressure pills, which were to be taken with a small sip of water.
diac structure and function. Several parameters can be estimated The patient was also counseled on the benefits of tobacco cessa-
from echocardiography, such as the degree of valvular insuffi- tion and improved dietary and exercise habits.
ciency or stenosis, wall motion abnormalities, and the ejection Surgery was carried out with the patient monitored using the
fraction. The ejection fraction is the percentage of the stroke American Society of Anesthesiologists (ASA) I standards for outpatient

t.me/Dr_Mouayyad_AlbtousH
566 S E C TI O N X Medical Conditions

procedures. (ASA I monitoring includes ECG, blood pressure, heart The immediate- and long-term sequelae of an AMI are related to the
rate, and pulse oximeter monitoring.) IV anesthesia was planned using extent and location of the necrotic myocardial tissue. Subsequent
a combination of midazolam (Versed) and fentanyl. Five minutes into inflammatory and electrical conduction abnormalities that lead to
the procedure, the ECG showed multiple unifocal premature ven- mechanical dysfunction of the heart can be variable in both chronol-
tricular contractions (the most frequent mechanism is localized reen- ogy and severity.
try) at the rate of about 10 per minute. The patient’s oxygen saturation Cardiac arrhythmias are commonly seen during an AMI. In-
declined from 98% on room air to 92% with 4 L/min oxygen flow farction of specialized myocardial tissue, such as the sinoatrial
via a nasal cannula. His oxygen flow was increased to 8 L/min, result- node, atrioventricular node, or bundle branches, can lead to a
ing in improvement of the oxygen saturation to 97%. The patient variety of arrhythmias and conduction blocks. Ventricular fibrilla-
then suddenly became noticeably agitated, tachypneic with shallow tion is a nonperfusing rhythm that needs to be rapidly identified
breaths, and tachycardic, with a heart rate of 135 bpm. (Agitation can and treated via the ACLS protocol.
be a sign of hypoxia.) The procedure was aborted, and all IV anesthet- Impaired myocardial function can cause failure of the heart to
ics were halted. His blood pressure now measured 90/45 mm Hg adequately pump blood into the systemic circulation, with subse-
(hypotensive). His condition continued to deteriorate, with ST-seg- quent congestion of blood into the pulmonary circulation, result-
ment elevation and multifocal premature ventricular contractions ing in congestive heart failure. AMI may also lead to cardiogenic
showing on the ECG. He remained tachycardic with persistent hypo- shock, which is defined as tissue hypoperfusion secondary to heart
tension. The patient emerged from anesthesia and complained of chest failure, resulting in decreased cardiac output and hypotension.
tightness while putting his fist over his chest (a positive Levine sign; Ischemia or necrosis of specific anatomic locations may result
the patient places their hand over the sternal region because of the dull, in mechanical dysfunctions such as rupture of the papillary mus-
aching, squeezing discomfort of ischemic chest pain). A diagnosis of cles, ventricular septal perforation, or rupture of the ventricular
AMI was suspected, and emergency medical services (EMS) was im- free wall and subsequent cardiac tamponade (usually resulting in
mediately activated. EMS personnel arrived within minutes and death). Other long-term complications include pericarditis (in-
transported the patient to a local hospital. flammation of the pericardium) and thromboembolic events
A suspected AMI should be managed with use of the AHA’s originating within the cardiac chamber secondary to endothelial
adult Advanced Cardiac Life Support (ACLS) algorithm for isch- injury, stasis of blood, and turbulent flow.
emic chest pain. The primary goal is to reduce the risk of death and
the extent of permanent cardiac injury associated with AMI. Im- Discussion
mediate treatment should include administration of supplemental
oxygen to an oxygen saturation greater than 90% (to increase oxy- The prevalence of CVD in the United States was updated in 2019
gen delivery), along with 325 mg (NN) of chewable aspirin or as- by the AHA reporting that 48% of people 20 years of age or older
pirin per rectum (to inhibit platelet function and clot propagation). have CVD, which includes coronary heart disease, heart failure,
Sublingual nitroglycerin (vasodilator) is administered to increase stroke, and hypertension. It is estimated that cardiac deaths and
coronary blood flow, which reduces cardiac ischemia and therefore MI occur in 0.2% (50,000 deaths) of all cases of surgery under
pain. If there are no signs or risks of heart failure, 25 mg (NN) of general anesthesia annually. As the baby boomer population ages
metoprolol tartrate has been shown to have beneficial effects. A and the number of patients undergoing elective surgery increases,
clopidogrel loading dose of 300 mg (NN) if the patient is age perioperative cardiovascular evaluation should be performed me-
75 years or younger (if older than 75 years of age, give a loading ticulously in patients at risk.
dose of 75 mg (NN)), in addition to aspirin, aids in reperfusion. If The causes of MI span a broad range of pathologic processes,
chest pain is not resolved after giving nitrates and other medical including atherosclerosis with thromboembolic events, vascular
therapy, morphine should be administered intravenously. The rou- syndromes, coronary aneurysms, primary and drug-induced coro-
tine administration of morphine to all patients with ST-segment nary spasms (cocaine), severe conditions of oxygen demand with
elevation myocardial infarction (STEMI) has been shown to have hypotension (aortic stenosis, sepsis), and hyperviscosity states
no clear clinical benefit and may cause harm. The mnemonic (polycythemia vera). Signs and symptoms of AMI are not always
MONA (morphine, oxygen, nitroglycerin, and aspirin) outlines evident. Approximately 20% of patients who sustain an AMI are
this treatment. Vital signs and oxygen saturation should be moni- asymptomatic and have retrospective positive ECG findings. This
tored during these interventions. IV access should be initiated is particularly significant in patients with diabetes, who may not
immediately for drug delivery. A 12-lead ECG, serum cardiac experience painful symptoms because of underlying peripheral
markers, serum electrolytes and coagulation studies, and a portable neuropathy.
chest radiograph should be obtained as soon as possible. The deci- Studies have provided evidence that the use of beta-blockers
sion whether to treat the patient with pharmacologic agents, in- reduces morbidity and mortality in patients with AMI and those
cluding IV heparin, glycoprotein IIb/IIIa receptor inhibitors, direct in heart failure caused by left ventricular systolic dysfunction. By
thrombin inhibitors, and nitroglycerin, is based on the ECG find- reducing the sympathetic drive to the myocardium (and hence
ings and continuous clinical assessment. In the setting of STEMI, workload), beta-blockers have been shown to reduce the rate of
rapid assessment and transport to a cardiac catheterization labora- reinfarction and recurrent ischemia. In addition, ACE inhibitors,
tory are essential; the goal is a door-to-balloon time under 90 min- sodium-glucose cotransporter-2 inhibitors, hydralazine plus ni-
utes for revascularization of the affected vessel or vessels. Therapy trate, and mineralocorticoid receptor antagonists have been
becomes less effective with each minute its delivery is delayed. proven to increase survival rates in patients with AMI.
With progressive ischemia and subsequent MI, the ECG findings
Complications include T-wave inversions (ischemia), ST-segment elevation (sugges-
tive of acute myocardial infarct), ST-segment depression (nontrans-
The most feared complication of an AMI is sudden death (most mural infarct or ischemia), and the development of Q waves
commonly caused by ventricular fibrillation or myocardial rupture). (indicative of MI). The leads in which an ST-segment elevation

t.me/Dr_Mouayyad_AlbtousH
 CHAPTER 110 Acute Myocardial Infarction 567

occur correspond to the area of cardiac injury. On a 12-lead ECG, leads Sweating
V1 through V6 are designated as the precordial chest leads, and leads I, Anxious, nausea,
II, III, aVL, aVR, and aVF are the limb leads. Whereas an inferior in- vomiting
farct commonly presents with abnormalities in leads II, II, and aVF,
findings on leads V1 through V6 represent injury to the anterior wall. Chest and arm pain
and shortness
Cardiac enzymes are plasma diagnostic markers released during of breath
myocardial necrosis. Based on the onset of injury, concentration,
and metabolic half-life of the enzymes released, myocardial cell
necrosis can be confirmed. In addition, the approximate time of Epigastric pain
infarction can be predicted. Several enzymes are used, including
creatine kinase, creatine kinase–myocardial band (CK-MB), and
troponin I or T. Creatine kinase and myoglobin are not specific to
myocardial tissue and can be elevated from other causes. The Sitting
CK-MB enzymes can also be found in skeletal muscles and are not
as cardiac specific for myocardial tissue. Troponins T and I are cur-
rently the markers of choice for determining acute cardiac injury
because they have higher cardiac specificity and are much more Classic findings and symptoms include:
sensitive than the CK-MB enzyme. Troponin levels can be - Male or female (M > F)
detected as soon as 4 to 8 hours after injury and may remain elevated - Older > younger
until 5 to 9 days later. Myocardial muscle creatinine kinase isoen- - Patients are typically sitting down
zymes are helpful in detecting reinfarction as levels typically peak at - Holding chest with left hand (chest pain seen in 80%)
24 hours, with a return to the normal range in 48 to 72 hours.
- Shortness of breath (72%)
In summary, a thorough patient history and physical examina-
- Nausea or vomiting (60%)
tion are essential in determining the general health and preopera-
tive risk of the patient. This should be done in cooperation with - Appearing anxious (30%)
the patient’s primary care physician and cardiologist when indi- - Arm or radiating pain (15%)
cated. In the event of an AMI in the office setting, early detection - Epigastric pain (10%)
of symptoms is critical (Fig. 110.1). Management should follow • Fig. 110.1 Common symptoms of acute myocardial infarction.
ACLS guidelines, including defibrillation for indicated arrhyth-
mias; early initiation of the appropriate pharmacologic agents;
and timely transfer to the hospital setting, where continued
medical therapy and cardiac catheterization can significantly in-
crease the likelihood of patient survival.

,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for

complete set of bibliography.

t.me/Dr_Mouayyad_AlbtousH
 567.e1

Bibliography Lee TH, Marcantonio ER, Mangione CM, et al: Derivation and prospective
validation of a simple index for prediction of cardiac risk of major non-
cardiac surgery, Circulation 100(10):1043-1049, 1999. doi:10.1161/01.
Benjamin EJ, Muntner P, Alonso A, et al: Heart disease and stroke statis- cir.100.10.1043.
tics—2019 update: a report from the American Heart Association [pub- Lurati Buse GAL, Puelacher C, Gualandro DM, et al: Association be-
lished correction appears in Circulation. 2020 Jan 14;141(2):e33], Circu- tween self-reported functional capacity and major adverse cardiac
lation 139(10):e56-e528, 2019. doi:10.1161/CIR.0000000000000659. events in patients at elevated risk undergoing noncardiac surgery: a
Bhatt DL, Lopes RD, Harrington RA: Diagnosis and treatment of acute prospective diagnostic cohort study, Br J Anaesth 126(1):102-110,
coronary syndromes: a review [published correction appears in JAMA. 2021. doi:10.1016/j.bja.2020.08.041.
2022 May 3;327(17):1710]. JAMA. 2022;327(7):662-675. doi:10. Panchal AR, Bartos JA, Cabañas JG, et al: Part 3: Adult Basic and Ad-
1001/jama.2022.0358 vanced Life Support: 2020 American Heart Association Guidelines
Committee on Standards and Practice Parameters, Apfelbaum JL, Connis for Cardiopulmonary Resuscitation and Emergency Cardiovascular
RT, et al: Practice advisory for preanesthesia evaluation: an updated Care, Circulation 142(16_Suppl_2):S366-S468, 2020. doi:10.1161/
report by the American Society of Anesthesiologists Task Force on CIR.0000000000000916.
Preanesthesia Evaluation, Anesthesiology 116(3):522-538, 2012. Rosengren A, Hawken S, Ounpuu S, et al: Association of psychosocial
doi:10.1097/ALN.0b013e31823c1067. risk factors with risk of acute myocardial infarction in 11119 cases
Fleisher LA, Fleischmann KE, Auerbach AD, et al: 2014 ACC/AHA and 13648 controls from 52 countries (the INTERHEART study):
guideline on perioperative cardiovascular evaluation and management case-control study, Lancet 364(9438):953-962, 2004. doi:10.1016/
of patients undergoing noncardiac surgery: a report of the American S0140-6736(04)17019-0.
College of Cardiology/American Heart Association Task Force on Stone NJ, Robinson JG, Lichtenstein AH, et al: 2013 ACC/AHA guide-
Practice Guidelines, Circulation 130(24):e278-e333, 2014. doi:10. line on the treatment of blood cholesterol to reduce atherosclerotic
1161/CIR.0000000000000106. cardiovascular risk in adults: a report of the American College of
Heidenreich PA, Bozkurt B, Aguilar D, et al: 2022 AHA/ACC/HFSA Cardiology/American Heart Association Task Force on Practice
Guideline for the management of heart failure: a report of the Amer- Guidelines [published correction appears in Circulation. 2014 Jun
ican College of Cardiology/American Heart Association Joint Com- 24;129(25 Suppl 2):S46-8] [published correction appears in Circula-
mittee on Clinical Practice Guidelines [published correction appears tion. 2015 Dec 22;132(25):e396], Circulation 129(25 Suppl 2):
in Circulation. 2022 May 3;145(18):e1033] [published correction S1-S45, 2014. doi:10.1161/01.cir.0000437738.63853.7a.
appears in Circulation. 2022 Sep 27;146(13):e185], Circulation
145(18):e895-e1032, 2022. doi:10.1161/CIR.0000000000001063.
Jampol LM, Glassman AR, Sun J: Evaluation and care of patients with
diabetic retinopathy, N Engl J Med 382(17):1629-1637, 2020.
doi:10.1056/NEJMra1909637.

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111
Hypertension
P O OYA N S A D R - ES H K E VA R I a n d M E H R A N M E H R A B I

CC Vital signs. His sitting blood pressure is 185/104 mm Hg in

the right arm and 181/101 mm Hg in the left arm (although an
A 40-year-old African American male presents to the office with a inter-arm blood pressure difference of about 10 mm Hg may be
referral for extraction of third molars because of periodontal dis- normal, a greater difference may be consistent with aortic dissec-
ease. (Essential hypertension is most commonly diagnosed during tion or subclavian stenosis). His other vitals consist of a heart rate
the third to fifth decades of life, has a higher prevalence in African of 80 bpm, a respiratory rate of 16 breaths per minute, a tempera-
American males, and is more resistant to therapy in African ture of 37.4°C measured on the forehead, and a visual analog scale
Americans.) score for pain of 0 out of 10 (In 1995, Dr. James Campbell urged
the American Pain Society to treat pain as the “fifth vital sign”
HPI (P5VS)—pain may cause an acute increase in blood pressure.)
Maxillofacial. No facial edema, erythema, or induration is
The patient complains of a 2-week history of bilateral mandibular found. Neck examination is benign, with no evidence of masses or
third molar looseness. Triage of the patient reveals that his blood lymphadenopathy. The jugular venous distension is undetectable.
pressure is elevated, which he attributes to anxiety. (Emerging (A jugular venous pressure .3 cm or a measured central venous
evidence indicates that anxiety may be an independent risk factor pressure .8 is consistent with right ventricular failure. The most
for incident hypertension.) He states that he has never seen a common cause of right ventricular failure is left ventricular failure.)
primary care physician and denies any history of hypertension. Intraoral. Examination is consistent with mobile lower third
He denies headache, dizziness, blurred vision, chest pain, lower molars with an 8-mm periodontal probing depth.
extremity edema, and shortness of breath (signs of potential end- Cardiovascular. No carotid, femoral, or renal bruits are
organ damage commonly seen inhypertensive emergency). present (these are indicative of peripheral vascular disease). The
apical impulse is palpated at the fifth intercostal space and the
PMHX/PDHX/Medications/Allergies/SH/FH midclavicular line (normal position). It is enlarged at 4 cm (nor-
mal is 2–3 cm), sustained, and strong in intensity (indicative of
The patient describes himself as “healthy as a horse” (hypertension ventricular hypertrophy). On auscultation, in addition to S1 (first
is an asymptomatic disease) but physically out of shape because of heart sound) and S2 (second heart sound), there is a S4 gallop (a
a lack of exercise. He does not take any medications currently. He pathologic heart sound during the late diastolic period produced
smokes one pack of cigarettes daily and has consumed four alco- by the atrium pushing on an inelastic myocardium) just before
holic beverages daily for the past 10 years. (Smoking, consumption S1. (In comparison, an S3 sound may be auscultated in patients
of alcohol, and a sedentary lifestyle increase the risk of hypertension with congestive heart failure [CHF], secondary to uncontrolled
and coronary artery disease [CAD].) He is single, and his typical hypertension. An S3 is heard shortly after an S2). The rhythm is
diet consists of fast foods (a diet high in sodium, saturated fat, and regular (irregularly irregular rhythm can be due to atrial fibrilla-
simple sugars). His family history is significant for the sudden death tion caused by hypertension). There is no murmur or rub on
of his father at age 44 years from a heart attack. (A family history auscultation. Peripheral pulses are bounding, with rapid upstroke
of myocardial infarction [MI] is significant when the paternal age is and 21 intensity, and synchronous with appropriate amplitude.
less than 45 years and the maternal age is less than 55 years.) His (A delayed femoral pulse, compared with the radial pulse, is con-
father also was known to had diabetes for the last 6 years. (Family sistent with coarctation, a congenital cause of hypertension.)
history of diabetes and CAD are nonpreventable risk factors; but Pulmonary. The chest is clear on auscultation bilaterally.
obesity, smoking, and excessive alcohol consumption are prevent- There are no crackles or wheezing. (Cardiogenic wheeze is pro-
able risk factors for cardiovascular disease.) duced by pulmonary edema in acute CHF.)
Abdomen. The patient is obese and has no evidence of surgical
Examination scars or striae (present in hypercortisolism secondary to adrenal
tumor, pituitary tumor, or paraneoplastic syndromes). Bowel
General. The patient is awake, alert, and oriented; calm and co- sounds are present on auscultation. The abdomen is soft and non-
operative; and follows commands well. He appears to be in no tender to palpation. The kidneys are nonpalpable. (Individuals
apparent distress. He weighs 240 lb and is 5 feet, 7 inches tall (a with enlarged kidneys, as seen in polycystic kidney disease, may
body mass index of 37.6 kg/m2, consistent with class II obesity). present with hypertension.) The liver is 10 cm at the midclavicular

568
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 CHAPTER 111 Hypertension 569

line (normal, 10–12 cm). The aorta is not palpable and is not en- TABLE The Most Recent Classification and Overall
larged. (If it were enlarged, this would be suggestive of an acute 111.1 Management of Hypertension According to the
abdominal aneurysm.) No abdominal bruit was auscultated. (An
Most Recent Guidelines from the Joint National
upper abdominal bruit with a diastolic component that lateralizes
to either side should raise suspicion for renal artery stenosis.) Commission (JNC-8)
Blood Systolic Diastolic
Imaging Pressure (mm Hg) (mm Hg) Management
Normal ,120 ,80 LSM, follow-up every year
The panoramic radiograph is the study of choice when evaluating
third molars. In the current patient, there is evidence of bone loss Elevated ,140 ,90 LSM, follow-up every 6 months
surrounding the roots of mandibular third molars. In the setting Stage I ,160 ,100 LSM, medications, follow-up
of controlled hypertension, no additional radiographs are re- every month until titrated
quired for minor surgical procedures. On evaluation of hyperten-
sive urgency or emergency in the emergency department (ED), Stage II $160 $100 LSM, two medications, follow-
up every month until titrated
additional studies are required and may include a chest radio-
graph (to evaluate for cardiogenic pulmonary edema and cardio- Urgency $180 $110 IV medications, refer to ED
megaly), electrocardiogram (ECG) (to rule out acute MI), and
Emergency $180 1 $110 1 Gtt medications, ICU
head computed tomography (to rule out intracerebral hemor- EOD EOD
rhage). Depending on the clinical history and findings, a preop-
erative ECG may be warranted for patients undergoing general ED, Emergency department; EOD, end-organ damage; Gtt, drip; LSM, lifestyle modification.
anesthesia who have risk factors for cardiovascular disease (hyper-
tension, diabetes, smoking, hypercholesterolemia, and age older
than 45 years in males and older than 55 years in females). blood pressure of the patient, and they should be instructed to
avoid these before their measurements. A dental visit is often the
Labs first time a suspicion of hypertension is raised.5511
According to the eighth report of the Joint National Committee
Laboratory studies are obtained based on the patient’s medical his- on Prevention, Detection, Evaluation, and Treatment of High
tory. For a patient with essential hypertension who presents for Blood Pressure (JNC-8), a normal systolic blood pressure is below
minor surgical procedures, no laboratory studies are indicated. 120 mm Hg, and a normal diastolic blood pressure is below
Several laboratory parameters may be measured by the primary 80 mm Hg. A patient with normal blood pressure meets both these
care physician or measured preoperatively to detect secondary criteria. The blood pressure may be considered normal, elevated,
causes of hypertension. A basic metabolic panel is obtained to as- stage I, or stage II. Beyond stage II hypertension, the patient may
sess plasma sodium (rennin-producing tumors, renal disease), po- experience hypertensive urgency or emergency. JNC 8 bundles hy-
tassium (renal or adrenal disease), and creatinine (renal disease). pertensive urgency and emergency under the term crisis, with end-
Thyroid-stimulating hormone is often ordered to rule out hyper- organ damage being the differentiating factor (Table 111.1). The
tension secondary to hyperthyroidism or other thyroid disorders. effects on the end organs, such as the heart, brain, kidney, and eyes,
Routine workup of the newly diagnosed hypertension also are in a linear relationship.
includes an estimated glomerular filtration rate, a lipid panel, uri-
nalysis (including urine albumin–to–creatinine ratio), and an Treatment
ECG. Other tests to consider are urine vanillylmandelic acid
(pheochromocytoma) and serum cortisol, which may find the Management of a patient with hypertension begins with an accu-
potential causes of secondary hypertension. An astute clinician rate diagnosis. Blood pressure is determined by cardiac output
uses the patient’s history and physical examination to develop a (stroke volume 3 heart rate) and total peripheral resistance. It is
differential diagnosis. Radiographic, laboratory, and other tests are measured with the patient in a sitting position with the arm at the
used to assess the validity of specific diagnoses. level of the heart. Patients should avoid smoking and caffeine 30
minutes and 1 hour, respectively, before a blood pressure reading is
Assessment taken. Note that a large cuff produces an erroneously low reading,
and a small cuff produces an erroneously high reading. The blood
Chronic severe localized periodontitis complicated by elevated blood pressure can be measured in both arms. A difference greater than
pressure. 10 mm Hg may be suggestive of aortic dissection. The most com-
The diagnosis of hypertension requires additional blood pres- mon site for measurement of blood pressure is the brachial artery.
sure readings. If these readings are confirmed in subsequent evalu- The cuff is applied to the arm. It is tightened as the radial pulse is
ations, the patient is classified as having stage II hypertension. The palpated, and the pressure is raised until it is 30 mm Hg above
correct diagnosis of blood pressure includes having two elevated where the radial pulse disappears. This technique ensures that an
reads in two visits 2 weeks apart. However, based on the 2021 auscultatory gap (a period of silence as the blood pressure cuff pres-
Updated Evidence Report and Systematic Review for the US sure decreases) does not result in an erroneously low reading. As
Preventive Services Task Force on Screening for Hypertension in discussed earlier, measurements are repeated two or three times in
Adults, the office-based blood pressure screening has major accu- different settings before the diagnosis of hypertension is made.
racy limitations, including misdiagnosis. Alternatively, patients The confirmation of diagnosis should be followed by further
use home blood pressure monitoring devices, which relies on their evaluation to determine the duration of hypertension, the presence
correct use of the device. Exercise, alcohol, caffeine, amphet- and extent of target-organ damage through physical and laboratory
amines, and other similar chemicals distort the true baseline workup, and the 10-year atherosclerotic cardiovascular disease risk.

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570 S E C TI O N X Medical Conditions

Treatment options are recommended based on the stage of hyper- ARBs in lowering odds of all-cause death except for the kidney
tension. In general, however, all the management strategies include events and the cardiovascular events in the subgroup of patients
lifestyle modification. Decreasing salt intake, Dietary Approaches with advanced CKD. This is still a subject of controversy. The key
to Stop Hypertension (DASH), increased intake of citrus fruits, points of JNC-8 guidelines are summarized in Table 111.3.
decreasing alcohol intake to one standard drink per day for females Consultation with the primary care physician is valuable when
and two for males, a minimum of 30 minutes of exercise per day, and possible but may not always be feasible. This should not cause
weight loss to a target body mass index below 25 are the most impor- a significant delay in patient care, especially if the deferring the
tant items in lifestyle modification. Several medications are available elective procedure may potentially cause a bigger problem soon.
for the management of hypertension (Table 111.2). Examples are active dentoalveolar infections, significant pain, or a
Often the selection of the optimal medication depends on suspicious mass in need of biopsy. If there is no surgical emer-
race, comorbidities, and other factors. Although in patients with gency, temporary analgesia may be achieved with a long-acting
cardiac comorbidities, beta-blockers and angiotensin-converting local anesthetic and analgesic medications. When treating an ur-
enzyme (ACE) inhibitors are preferred, the medications of choice gent surgical problem in a patient with hypertension, the clinician
of are ACE inhibitors and hydrochlorothiazide in patients with may choose local anesthesia, office sedation, or hospital-based
cerebrovascular disease. ACE inhibitors have cardioprotective and general anesthesia, depending on the clinician’s training and com-
renoprotective effects, hence their use in patients with diabetes fort, location of practice, and the facility’s monitoring capability.
and CHF. Despite the popular belief that the use of ACE inhibi- When patients with a history of hypertension present for office
tors in patients with stage IV kidney disease should be avoided intravenous (IV) sedation, they should continue their daily anti-
because of concern for decreasing the prerenal volume and exac- hypertensive medications. Abrupt withdrawal of certain antihy-
erbation of kidney failure, a recent network meta-analysis has pertensive medications, such as clonidine or beta-blockers, may
demonstrated that ACE inhibitors are superior to angiotensin result in hypertensive urgencies (rebound hypertension). General
receptor blockers and other antihypertensive agents in reducing anesthetic medications that may result in hypertension, such as
adverse cardiovascular and renal events and all-cause mortality in ketamine (sympathomimetic effects), should be avoided or used
patients with nondialysis chronic kidney disease (CKD) stage 3 to cautiously. Local anesthetics with vasoconstrictors should be used
5. This study also indicates that ACE inhibitors are superior to cautiously and sparingly. Most dental literature recommends

TABLE
111.2 The Most Common Antihypertensive Medications

Classes Examples Mechanism of Action Indications Contraindications Side Effects

ACE inhibitors Lisinopril Convert angiotensin I to angiotensin II in the CHF Pregnancy Dry cough
Enalapril lungs Type I diabetes Hyperkalemia Worsening renal
Captopril Nondiabetic Bilateral RAS dysfunction
nephropathy Angioedema
ARBs Losartan Block the angiotensin II receptors in the heart, Type II diabetes Pregnancy Transaminitis
Valsartan blood vessels, kidney, adrenal cortex, lungs, Proteinuria Hyperkalemia Worsening renal
Eprosartan and brain LVH Bilateral RAS dysfunction
Hyperkalemia
Alpha-block- Doxazosin Selectively block a1 receptors BPH Orthostatic hypotension Orthostatic hypotension
ers Terazosin Hyperlipidemia Pregnancy Drowsiness
Prazosin Pheochromocytoma Urinary incontinence Syncope
Beta-blockers Propranolol Either nonselective or selective; whereas non- Angina Asthma Arrythmias
Metoprolol selective beta-blockers display both b1 and Post-MI COPD Nightmares
Labetalol b2 antagonism, most of the other commonly Pregnancy PVD Impotence
used beta-blockers are b1-selective, also
known as cardioselective
CCBs Amlodipine The main class of CCB used for the treatment of ISH CHF Headache
Nifedipine hypertension is the dihydropyridines, which Older adults Heart block Palpitation
Verapamil are used to reduce systemic vascular Pregnancy Edema
resistance and arterial pressure; nondihy-
dropyridines are selective to the myocar-
dium to varying degrees and may be used in
the treatment of patients with angina
Diuretics Furosemide Help reduce fluid buildup in the body CHF Gout (HCTZ) Dry mouth
Amiloride ESRD (loop diuretic) Renal failure (SPL) Abdominal pain
Hydrochloro- African Americans Hyperkalemia (SPL) Lower extremity
thiazide (HCTZ) pain

ACE, Angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BPH, benign prostatic hypertrophy; CCB, calcium channel blocker; CHF, congestive heart failure; COPD, chronic obstructive
pulmonary disease; ESRD, end-stage renal disease; HCTZ, hydrochlorothiazide; ISH, isolated systolic hypertension; LVH, left ventricular hypertrophy; MI, myocardial infarction; PVD, peripheral vascular
disease; RAS, renal artery stenosis; SPL, spironolactone.

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 CHAPTER 111 Hypertension 571

TABLE The Key Points from the Most Recent (2014) Joint National Committee on Prevention, Detection, Evaluation,
111.3 and Treatment of Hight Blood Pressure (JNC-8) Guidelines as Summarized by Dr. Carrie Armstrong, the
Senior Editor of the journal of American Family Physician
In the general population, pharmacologic treatment should be initiated when blood pressure is 150/90 mm Hg or higher in adults 60 years and older, or
140/90 mm Hg or higher in adults younger than 60 years.
In patients with hypertension and diabetes, pharmacologic treatment should be initiated when blood pressure is 140/90 mm Hg or higher, regardless of age.
Initial antihypertensive treatment should include a thiazide diuretic, calcium channel blocker, ACE inhibitor, or ARB in the general nonblack population or a
thiazide diuretic or calcium channel blocker in the general black population.
If the target blood pressure is not reached within one month after initiating therapy, the dosage of the initial medication should be increased, or a second
medication should be added.

From Armstrong, Carrie. “JNC8 guidelines for the management of hypertension in adults.” American family physician 90.7 (2014): 503-504.

limiting epinephrine to 0.04 mg in patients with cardiovascular ARBs are more prone to hypotension during general anesthesia.
disease; however, this is a subject of controversy. A recent report Propofol administered as a bolus can lower the systolic blood
published by the Agency for Healthcare Research and Quality pressure up to 30 mm Hg, which can be exaggerated in patients
evaluated the use of local anesthesia for dental extractions with with hypertension. Inhalation general anesthetics may also precipi-
and without epinephrine in hypertensive and normotensive indi- tously lower mean arterial pressures (caused by vasodilation). IV
viduals. The difference in systolic blood pressure and heart rate for fluid bolus should be the first-line treatment (250 mL or 10 mL/kg
epinephrine versus no epinephrine was 4 mm Hg and 6 bpm, of lactated Ringer’s or normal saline solution). Hypotension most
respectively, in patients with hypertension when up to two car- commonly responds well to volume or preload correction. If the
pules (1.8 mL each) of anesthetic agents were used. patient is not responsive to conservative fluid treatment, a vasopres-
The cause of intraoperative hypertensive episodes needs to be sor agent may be required. The choice of vasopressor agent depends
rapidly assessed and appropriately managed. Hypertension may be on both the blood pressure and heart rate. In a patient with hypo-
caused by hypoxia, hypercarbia, anxiety, pain, full bladder, or prior tension and bradycardia, vasogenic stimulators that cause a reflex
medications, or it may be idiopathic (primary hypertension). Dur- bradycardia should be avoided (phenylephrine). The standard treat-
ing IV office sedation, drug errors should also be ruled out. Stop- ment for hypotension with bradycardia is atropine 0.5 mg every 3
ping the painful stimuli, deepening the sedation, or administering to 5 minutes up to a maximum dose of 3.0 mg. Alternatively,
more local anesthesia may resolve the hypertension. Common IV ephedrine (an alpha and beta agonist) may be used for the hypoten-
antihypertensives used in ambulatory surgery are beta-blockers, sive patient unresponsive to IV fluid bolus and a decreased level of
calcium channel blockers, and hydralazine. Beta-blockers, such as anesthesia who presents with either bradycardia or normal heart
esmolol (short acting) and labetalol (longer acting), reduce the rate (5 mg every 5–10 minutes). For hypotension with tachycardia,
blood pressure and heart rate; hydralazine reduces blood pressure 100 mg of phenylephrine 1% (an alpha agonist with reflex brady-
with concurrent reflex tachycardia. It is extremely important not to cardia effect) every 5 minutes is used. In hypotension as a manifes-
treat numbers but rather to evaluate the patient as a whole. Factors tation of anaphylaxis, epinephrine should be used intramuscularly
that must be considered include the patient’s age, past medical his- (0.3 mg of 1:1,000 in mild cases; in severe cases, 10 to 20 mg of
tory, family history (age, race, family history of hypertension), and 1:10,000 epinephrine is administered intravenously).
social history (cocaine, methamphetamine, methoxymethyl meth- Patients (particularly older adults) admitted to hospitals are at
amphetamine abuse); initial blood pressure (baseline); type of greater risk of hypotension than hypertension. This may be due to
procedure; medications used (ketamine); respiratory rate (pain); a low-sodium diet, concurrent medications, narcotic use, or lack of
heart rate; and temperature (malignant hyperthermia). If hyper- physical activity. Therefore, hypertensive medications, such as di-
tension presents with bradycardia, hydralazine (2.5–5.0 mg IV uretics, ACE inhibitors, ARBs, alpha-blockers, or calcium channel
every 10 minutes up to a maximum dose of 25 mg). Hypertension blockers, should be prescribed when the blood pressure is elevated.
presenting with acute coronary syndrome or acute pulmonary Beta-blockers should be continued not only for their cardioprotec-
edema may be treated with nitroglycerin sublingual tablets (0.4 mg tive effect but also for possible rebound tachycardia. (Perioperative
every 5 minutes). Hypertension with tachycardia is best managed administration of beta-blockers has been shown to decrease anes-
by esmolol (5–10 mg every 3 minutes up to a maximum dose of thetic complications.) Rebound hypertension also is common with
100–300 mg) or labetalol (20 mg by slow IV injection over a the use of clonidine, but this medication is now rarely used. When
2-minute period; additional injections of 40 to 80 mg can be given patients are discharged from the hospital or office, they should
at 10-minute intervals until a desired supine blood pressure is continue their prior antihypertensive medication regimen.
achieved or a total of 300 mg has been used). The current patient was referred to his primary care physician
The discussion of blood pressure management would not be for evaluation and management of his blood pressure. Three sub-
complete without the mention of hypotension. It can result from sequent blood pressure readings in the physician’s office, in addi-
hypovolemia (lack of fluid intake due to pain or nothing-by-mouth tion to those from an automatic blood pressure monitor at the
status), general anesthetics, cardiac (dysrhythmia, MI), or pulmo- local pharmacy, reflected a systolic blood pressure of 175 to
nary (pulmonary embolism, pneumothorax) events. Hypotension, 185 mm Hg and a diastolic blood pressure of 95 to 105 mm Hg.
especially in combination with tachycardia, may be a sign of ana- The patient was instructed to restrict sodium and alcohol intake,
phylaxis. The patient’s allergies and medications administered to quit smoking, and to start aerobic exercise. However, the patient
should be reviewed. Patients taking diuretics or ACE inhibitors or remained hypertensive at 150/90 mm Hg. He was subsequently

t.me/Dr_Mouayyad_AlbtousH
572 S E C TI O N X Medical Conditions

prescribed hydrochlorothiazide. (Diuretics are considered first-line SIGNS, SYMPTOMS & EFFECTS OF HYPERTENSION
therapy.) At follow-up, his blood pressure was 130/82 mm Hg. Dizziness, headaches
After his blood pressure had stabilized, the patient was scheduled
for surgical extraction of the lower third molars using IV sedation. Weakness or syncope
He was instructed to continue the hydrochlorothiazide. (Antihyper-
tensive medications should be continued in the perioperative pe- Cardiac symptoms
riod.) His blood pressure remained stable throughout the procedure. (irregular, AMI)
Nausea and
vomiting
Complications
In the dental office, the main concerns with a critically elevated
blood pressure are the possibility of a hemorrhagic stroke, arryth-
mias, MI, or end-organ damage. White coat syndrome, epineph-
rine, pressure from the procedure, and pain can further elevate the
blood pressure and tip the patient to hypertensive urgency or
Fatigue
emergency. Hypertensive urgency is hypertension with a blood
pressure above 180/120 mm Hg in an asymptomatic patient. Pa-
tients are admitted to the ED, and the blood pressure is gradually
lowered with oral medications. The blood pressure should not be
abruptly reduced to less than 160/110 mm Hg because of the risk
of cerebral and myocardial hypoperfusion. Hypertensive emergency
is hypertension with evidence of end-organ damage (brain, heart, Long-term effects
kidneys, eyes), such as retinal hemorrhages and exudates, papill- 1. Altered or blurred vision
edema, renal failure (malignant nephrosclerosis), neurologic symp- 2. Cardiac disease
toms (headache, weakness, or neurosensory deficit), and cardiac 3. Kidney disease
symptoms (e.g., chest pain). Arteriovenous nicking and an arterio- 4. Stroke
lar light reflex (“copper wiring”) with no evidence of retinal necrosis
5. Vascular disease
or disc edema is seen in fundoscopic examination. The pathophysi-
ology of the retinal vessels is like that of the cerebral and coronary • Fig. 111.1 The classic signs, symptoms, and effects of hypertension.
blood vessels. The initial changes seen with hypertension include AMI, Acute myocardial infarction.
vasoconstriction followed by hyaline degeneration. As blood pres-
sure increases, arterial narrowing (arteriovenous nicking) and arte-
riolar light reflex (copper wiring) may be seen. In uncontrolled blood pressure of unknown etiology, elective procedures should
hypertension, there is a breakdown of the blood–retina barrier and best be deferred and the patient instructed to make an appoint-
presentation of hemorrhage and areas of infarction (cotton-wool ment with their primary care physician for further workup. If a
spots). The same mechanism of injury may involve the brain, kid- patient presents with symptoms of hypertensive emergency (dip-
neys, and heart. Fig. 111.1 is a diagrammatic representation of lopia, dizziness, headaches, shortness of breath, sudden leg swell-
classic signs, symptoms, and effects of hypertension. ing, chest pain), the patient is referred to the ED for further
As discussed, IV medications, such as nitroprusside (0.25– workup and management.
0.5 mg/kg/min, up to 8 to 10 mg/kg/min), nicardipine (5–15 mg/ Many patients are understandably anxious when presenting to
hr), or labetalol (0.5–2 mg/min), may be used to control blood an oral surgeon or to a dentist in general. Often after measuring
pressure. Note that nitroprusside may result in cyanide toxicity, their blood pressure, they rightfully attribute it to their anxiety. This
which can be treated with sodium thiosulfate. Non-IV routes statement should not be taken lightly, because a delay in proper care
(e.g., oral, nasal, or transcutaneous route) can be used, but they may exacerbate both dental and general health of the patient. In the
are not as titratable. A rapid decline in blood pressure can be as absence of large-scale randomized clinical trials, a recent meta-
harmful as a rapid increase. Close monitoring of vital signs is analysis suggested that anxiety and hypertension are significantly
more important than the route of administration. correlated in cross-sectional studies, and a direct association was
Chronic complications of hypertension include CAD, CHF, also observed in prospective studies. Consistently, two other meta-
cerebrovascular accident, renal disease, ophthalmologic disease, analyses have shown a reciprocal association between anxiety and
and others. Treatment of hypertension significantly reduces the heart rate variability. Anxiety increases sympathetic tone, activating
risk of CAD, MI, heart failure, and cerebrovascular accidents. the renin–angiotensin system, and elevates the blood pressure by
Antihypertensive medications can cause various side effects or elevating plasma levels of angiotensin II and increasing systemic
complications, including orthostatic hypotension (especially in vascular resistance. Chronic anxiety may have a more lasting effect
older adults), resulting in syncope and ground-level falls. on the vasculature and the hormonal homeostasis.
Many patients experience improvement of their blood pressure
Discussion after they receive nitrous oxide for a couple of minutes. In general,
often the risks of having a vascular accident should be weighed
A blood pressure reading should be obtained before all surgical against the benefit of performing a procedure in a patient with
procedures even in the absence of symptoms or a positive medical hypertension. Always remember that a patient who presents with
history. Contraindications to surgery in a patient with hyperten- high blood pressure may become even more hypertensive on in-
sion are not based on the actual blood pressure but rather on jection of the local anesthetic, in response to epinephrine, or in
clinical judgment in assessing the risks and benefits of surgical or response to painful stimuli or pressure during the procedure.
nonsurgical interventions. In the event of a sudden increase in Therefore, it may be premature to assume that the patient is high

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 CHAPTER 111 Hypertension 573

risk for IV sedation. Sedation, as the name implies, alleviates Intervention for Endpoint Reduction (LIFE), and Australian
anxiety and hence is likely to decrease blood pressure. General National Blood Pressure (ANBP) studies.
anesthetics, such as propofol, are likely to cause vasodilation and The JNC-8 recommendations are based on the Antihypertensive
to decrease blood pressure, often at the expense of reflex tachycar- and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALL-
dia. Medications such as ketamine, on the other hand, may best HAT). This study was a randomized examination of 45,000 patients
be avoided because they cause an increase in blood pressure. Of with hypertension and one other risk factor (e.g., left ventricular
paramount importance, oral surgeons should exert caution in the hypertrophy, diabetes, cerebrovascular accident). The current recom-
administration of fluids to avoid exacerbating the hemodynamics mendation is initiation of a low-dose hydrochlorothiazide (a sodium
by increasing the intravascular volume. potassium channel blocker at the distal tubule of kidneys) as first-
Hypertension is frequently referred to as a “silent killer” and is line antihypertensive therapy (higher doses may produce hypokale-
a common disorder. In the United States, it is most prevalent mia, hypertriglyceridemia, hyperglycemia, and gout).
among African Americans, followed by Hispanics and Whites. The A beta-blocker may be a better choice in patients with CAD
incidence of hypertension increases with age and excess body because of its post-MI cardioprotective effect. Also, it may be the
weight. Other risk factors include genetics (hypertension is twice as drug of choice in patients with migraine-type headaches, glaucoma,
common when one or both parents have hypertension), alcohol angina pectoris, essential tremor, and resting tachycardia. Sudden
consumption, tobacco use, and male gender. A low-salt diet de- cessation of this medication can produce a withdrawal reaction and
creases blood pressure in patients with hypertension, whereas a should be avoided. ACE inhibitors prevent the formation of angio-
high-salt diet makes hypertension more resistant to therapy. Other tensin II and aldosterone. They are commonly considered the initial
factors, such as salt intake and type A personality, have not been therapy in patients with diabetes and microproteinuria, and they
shown to be risk factors for the development of hypertension. may be beneficial for post-MI cardioprotection, comparable to that
Hypertension may be divided into primary, or essential (95%), of beta-blockers. ACE inhibitors are contraindicated in patients
and secondary (5%) categories. Although secondary hypertension who develop angioneurotic edema or hyperkalemia, and in rare
is less common, diagnosis is important because frequently a cure cases, they can cause neutropenia. A dry cough is a side effect of
rather than treatment is possible. Essential (idiopathic) hyperten- ACE inhibitors, most likely caused by the buildup of bradykinins;
sion is generally diagnosed between the ages of 30 and 50 years, this is best treated by changing to another class of medication.
whereas secondary hypertension is most commonly identified ARBs are an alternative to ACE inhibitors in certain patients.
prior to age 30 years or after age 50 years. Secondary hypertension Calcium channel blockers are potent vasodilators; in general,
tends to be more severe and less susceptible to the routine treat- they are not recommended for initial therapy. Their use in pa-
ment used for essential hypertension. tients with CHF increases mortality rates. They also exacerbate
Secondary hypertension includes a variety of hormonal or struc- reflux in patients known to have gastroesophageal reflux disorder
tural defects. Elevation of steroid levels (primary adrenal tumor, (GERD). However, they are beneficial in patients with peripheral
secondary pituitary tumor, or tertiary paraneoplastic syndrome), vascular disease or vasospasm, such as in Raynaud’s disease. The
calcium (hyperparathyroidism), and hypothyroidism (and hyper- alpha-blockers (e.g., prazosin, doxazosin, and terazosin) are not
thyroid crisis) are common hormonal causes. A structural defect, first-line medications. They produce syncope, headache, and
such as coarctation of the aorta or renal artery stenosis and intracra- weakness. They may be indicated in patients with benign prostatic
nial hypertension, may also cause systemic hypertension. hypertrophy. Antihypertensive medications considered safe dur-
Treatment should be considered when two or three consecu- ing pregnancy include methyldopa and hydralazine, which gener-
tive blood pressure readings are found to be above 140/80 mm Hg. ally are not considered in nonpregnant patients.
Conservative treatment, such as weight reduction, a low-salt (so- Other antihypertensive medications, such as clonidine (a central
dium) diet, aerobic exercise, and cessation of alcohol and tobacco a2-agonist), trimethaphan (a ganglionic blocker), and phentolamine
products, can be beneficial in preventing medical therapy. and phenoxybenzamine (competitive and noncompetitive a1- and
Two landmark studies evaluated the effect of diet on hyperten- a2-blockers, respectively) are rarely used except for specific indications.
sion. In the Treatment of Mild Hypertension Study (TOMHS), 902 Hypertension is a common, asymptomatic disease; if left
patients with a diastolic blood pressure of 90 to 100 mm Hg partici- treated, it may result in various end-organ injuries. CAD, CHF,
pated in a regimen of sodium and alcohol restriction, weight reduc- cerebrovascular accidents, end-stage renal disease, retinal disease,
tion, and increased physical activity; they showed an improvement in and peripheral vascular disease are examples of complications. A
the systolic and diastolic blood pressures of 8.6 mm Hg compared dental office is more frequently visited than a primary care physi-
with the placebo group. The DASH study consisted of 459 patients cian’s office for “otherwise healthy” individuals and may be the first
with hypertension with blood pressures less than 160/90 mg Hg who place a patient’s blood pressure is evaluated. Nonpharmacologic
were placed on a diet consisting of fruits and vegetables that was low therapy, such as weight reduction, diet modification, exercise, and
in saturated fats. Blood pressure was reduced by 5.5/3 mm Hg in alcohol and tobacco cessation, is an inexpensive and effective
normotensive patients and by 11.4/5.5 mm Hg in patients with hy- means of reducing blood pressure with few side effects. When
pertension. This was followed by the DASH/low-sodium trial, which pharmacologic therapy is indicated, a compromise should be
showed an additive effect. Blood pressure reduction with a low-so- made, focusing on the drug with the least problematic side effects
dium diet works independently of a healthy diet low in saturated fats that can prevent complications and achieve patient compliance.
and high in fruits and vegetables.
A variety of studies have examined various initial therapies for Acknowledgment
hypertension; these include the Medical Research Council (MRC)
trial (showing the cardioprotective effect of beta-blockers over The authors and publisher acknowledge Dr. Chris Jo for his con-
thiazide diuretics in patients with CAD), Captopril Prevention tribution on this topic to the previous edition.
Project (CAPPP study, showing the benefits of ACE inhibitors in
diabetics), UK Prospective Diabetes Study, STOP Hypertension ,Visit Elsevier eBooks1 (eBooks.Health.Elsevier.com) for
Trial, Heart Outcomes Prevention Evaluation (HOPE), Losartan complete set of bibliography.

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 573.e1

Bibliography Neaton JD, Grimm RH Jr, Prineas RJ, et al: Treatment of mild hyperten-
sion study: final results. Treatment of Mild Hypertension Study Re-
search Group, JAMA 270:713-724, 1993.
Dahlof B, Devereux RB, Kjeldsen SE, et al: Cardiovascular morbidity Neutel JM, Smith DH, Wallin D, et al: A comparison of intravenous
and mortality in the Losartan Intervention for Endpoint Reduction in nicardipine and sodium nitroprusside in the immediate treatment of
Hypertension study (LIFE): a randomized trial against atenolol, Lan- severe hypertension, Am J Hypertens 7:623, 1994.
cet 359:995-1003, 2002. Outcomes Heart Prevention Evaluation Study Investigators: Effects of
Guirguis-Blake JM, Evans CV, Webber EM, et al: Screening for hyper- ramipril on cardiovascular and microvascular outcomes in people with
tension in adults: updated evidence report and systematic review for diabetes mellitus: results of the HOPE study and MICRO-HOPE
the US Preventive Services Task Force, JAMA 325(16):1657-1669, substudy, Lancet 355:253-259, 2000.
2021. Sacks FM, Svetkey LP, Vollmer WM, et al: Effects on blood pressure of
Hansson L, Lindholm LH, Niskanen L, et al: Effect of angiotensin-converting- reduced dietary sodium and the Dietary Approaches to Stop Hyper-
enzyme inhibition compared with conventional therapy on cardiovascular tension (DASH) diet. DASH–Sodium Collaborative Research Group,
morbidity and mortality in hypertension: the Captopril Prevention N Engl J Med 344:3-10, 2001.
Project (CAPPP) randomized trial, Lancet 353:611-616, 1999. Schulz V: Clinical pharmacokinetics of nitroprusside, cyanide, thiosul-
James PA, Oparil S, Carter BL, et al: 2014 evidence-based guideline for phate and thiocyanate, Clin Pharmacokinet 9:239, 1984.
the management of high blood pressure in adults: report from the Vaughan CJ, Delanty N: Hypertensive emergencies, Lancet 356:411, 2000.
panel members appointed to the Eighth Joint National Committee Zhang Y, He D, Zhang W, et al: ACE inhibitor benefit to kidney and
(JNC 8), JAMA 311(5):507-520, 2014. cardiovascular outcomes for patients with non-dialysis chronic kidney
Miall WE: Beta-blockers vs thiazides in the treatment of hypertension: a disease stages 3–5: a network meta-analysis of randomised clinical
review of the experience of the large national trials, J Cardiovasc Phar- trials, Drugs 80(8):797-811, 2020. doi:10.1007/s40265-020-01290-3.
macol 16(Suppl 5):S58-S63, 1990.

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t.me/Dr_Mouayyad_AlbtousH
Appendix 1
Abbreviations
AAOMS American Association of Oral and Maxillofacial Surgeons CNS central nervous system
ABC airway-breathing-circulation Co condylion
AC activated charcoal COPD chronic obstructive pulmonary disease
ACC acinic cell carcinoma CP cleft palate
ACE angiotensin-converting enzyme CRI chronic renal insufficiency
ACLS advanced cardiac life support CRP chronic recurrent parotitis
AdCC adenoid cystic carcinoma CSF cerebrospinal fluid
ADR adverse drug reaction CT computed tomography
AHA American Heart Association CTX c-telopeptide
AHG acute herpetic gingivostomatitis CVA cerebrovascular accident
AHI apnea-hypopnea index CVS cardiovascular system
AIDS acquired immunodeficiency syndrome CXR chest x-ray
ALT alanine aminotransferase 5% dextrose in half normal saline
AMI acute myocardial infarction DC dentigerous cyst
AMPLE allergies–medications–past medical history/pregnancy– DDAVP 1-desamino-8-d-arginine vasopressin
last meal–environment/events surrounding trauma DKA diabetic ketoacidosis
ANB A point–nasion–B point (angle) DT delerium tremens
ANS anterior nasal spine DVT deep venous thrombosis
ANUP acute necrotizing ulcerative periodontitis EBV Epstein-Barr virus
ARB angiotensin receptor blocker ECG, EKG electrocardiogram
ARF acute renal failure ED emergency department
AS Apert syndrome EEG electroencephalogram
ASA American Society of Anesthesiology EF ejection fraction
ASP acute suppurative parotitis ELISA enzyme-linked immunosorbent assay
AST aspartate aminotransferase EMG electromyogram
ATLS advanced trauma life support EMS emergency medical services
ATN acute tubular necrosis EOG electro-oculogram
AVPU awake–responds to voice–responds to pain–unresponsive ESRD end-stage renal disease
AWS alcohol withdrawal syndrome FDG fluorodeoxyglucose
BAL blood alcohol level FENa fractional excretion of sodium
BMI body mass index FEV1 forced expiratory volume in 1 second
BMP basic metabolic panel FH family history
BP blood pressure FH Frankfurt horizontal
bpm beats per minute Fio2 fraction of inspired percent oxygen concentration
BRONJ bisphosphonate-related osteonecrosis of the jaws FISS Facial Injury Severity Scale
BUN blood urea nitrogen FNA fine needle aspiration
C centigrade GCS Glasgow Coma Scale
CAD coronary artery disease GFR glomerular filtration rate
CAD-CAM computer-assisted design/computer-assisted GGT g-glutamyl transpeptidase
manufacturing GI gastrointestinal
CBC complete blood count HAART highly active antiretroviral therapy
CC chief complaint HDL high-density lipoprotein
CPP cerebral perfusion pressure HF heart failure
CHF congestive heart failure HFM hemifacial microsomia
CHI closed head injury HIV human immunodeficiency virus
CL cleft lip HPI history of present illness
CLP cleft lip and palate HR heart rate
CMP complete metabolic panel hr hours
CMV cytomegalovirus HRT hormone replacement therapy
CN cranial nerve HSV herpes simplex virus

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e2 Abbreviations

HUS hemolytic uremic syndrome PERRLA pupils are equal, round, and reactive to light and
I&D incision and drainage accommodation
IAN inferior alveolar nerve PET positron emission tomography
ICD intercanthal distance Pg pogonion
ICP intracranial pressure PMHx past medical history
ICU intensive care unit PND paroxysmal nocturnal dyspnea
IM intramuscular PNI perineural invasion
IMF intermaxillary fixation PO by mouth (Latin)
INR international normalized ratio POBHx past obstetric history
ITP idiopathic thrombocytopenic purpura PRN as needed (Latin)
IV intravenous PRP platelet-rich plasma
JVD jugular venous distention PSG polysomnograph
KOH potassium hydroxide PT prothrombin time
KS Kaposi’s sarcoma PTT partial thromboplastin time
LAD lymphadenopathy PVC premature ventricular contraction
LDH lactate dehydrogenase PVL proliferative verrucous leukoplakia
LDL low-density lipoprotein q8 h every 8 hours
LFM lowering the floor of the mouth RDI respiratory distress index
LN lingual nerve RFFF radial forearm free flap
LOC loss of consciousness RR respirations
MAP mean arterial pressure RRR regular rate and rhythm
Me menton SAH subarachnoid hemorrhage
MECa mucoepidermoid carcinoma Sao2 oxygen saturation
mEq/L milliequivalents per liter SCCa squamous cell carcinoma
mg milligram SH social history
MI myocardial infarction SMAS superficial musculoaponeurotic system
MIO maximal interincisal opening SMV submentovertex
MMA maxillomandibular advancement SNA sella–nasion–A point (angle)
MP mandibular plane SNB sella–nasion–B point (angle)
MRI magnetic resonance imaging STAT immediately (Latin)
MRSA methicillin-resistant Staphylococcus aureus STSG split-thickness skin graft
MVA motor vehicle accident T temperature
MVC motor vehicle collision TMD temporomandibular dysfunction
NAC N-acetylcysteine TMJ temporomandibular joint
NAD no apparent distress TTP thrombotic thrombocytopenic purpura
NG nasogastric UA urinalysis
NOE naso-orbito-ethmoid UDS urine drug screen
NPO nothing by mouth (Latin) UPP uvulopalatoplasty
NSAID nonsteroidal antiinflammatory drug UPPP uvulopalatopharyngoplasty
NSC nonsyndromic craniosynostosis V1 first division of the trigeminal nerve
NSP nonsuppurative parotitis V2 second division of the trigeminal nerve
NT/ND nontender nondistended V3 third division of the trigeminal nerve
OD right eye (oculus dexter) VA visual acuity
OG orogastric VAS visual analog scale
OKC odontogenic keratocyst VC verrucous carcinoma
OMFS oral and maxillofacial surgery VPI velopharyngeal incompetence
ONJ osteonecrosis of the jaws VSS AF vital signs stable and afebrile
OR operating room vWF von Willebrand factor
ORIF open reduction with internal fixation WBC white blood cell
ORN osteoradionecrosis WD/WN well-developed and well-nourished
OS left eye (oculus sinister) WNL within normal limits
OSA obstructive sleep apnea ZF zygomaticofrontal
OSAS obstructive sleep apnea syndrome ZM zygomaticomaxillary
PAS posterior airway space ZMC zygomaticomaxillary complex
PCP primary care physician ZS zygomaticosphenoid
PDHx past dental history ZT zygomaticotemporal

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Appendix 2
Normal Laboratory Test
References for Adults
Test Result (Normal)
Blood
acid phosphatase 0.11-0.60 U/L
AIDS serology No evidence of HIV antigen or antibodies
AIDS T-lymphocyte marker (CD4 count) Total CD4 count . 1,000 cells/mm3
alanine aminotransferase (ALT) 8-20 U/L (elderly and infants higher than adults)
alkaline phosphatase (ALP) 42-128 U/L
ammonia level 15-110 µg/dl
aspartate aminotransferase (AST) 8-20 U/L (females slightly lower than males)
bilirubin, total 0.1-1.0 mg/dl
bilirubin, indirect 0.2-0.8 mg/dl
bilirubin, direct 0.1-1.3 mg/dl
bleeding time (BT) 1-9 min (Ivy method) (critical value .12 min)
blood culture and sensitivity Negative
blood gases
pH 7.35-7.45
Pco2 35-45 mm Hg
HCO3 2 21-28 mEq/L
Po2 80-100 mm Hg
O2 saturation 95%-100%
calcium 9.0-10.5 mg/dl
chloride 90-110 mEq/L
cholesterol , 200 mg/dl
complete blood count See individual components (white blood cells, hemoglobin, hematocrit, platelets)
C-reactive protein , 0.8 mg/dl
creatine phosphokinase (CPK) Male: 12-50 U/ml
Female: 10-55 U/ml
creatinine Male: 0.6-1.2 mg/dl
Female: 0.5-1.1 mg/dl
D-dimer test Negative (no D-dimer fragments)
erythrocyte sedimentation rate (ESR) Male: #15 mm/hr
Female: #20 mm/hr
ethanol (blood alcohol level) None
ferritin Male: 12-300 ng/dl
Female: 10-50 ng/dl
g-glutamyl transpeptidase (GGT) 8-38 U/L
glucose 70-105 mg/dl (also depends on fasting status)
glycosylated hemoglobin (HbA1c) 4%-8%
hematocrit Male: 42%-52%
Female: 37%-47%
hemoglobin Male: 14-18 g/dl
Female: 12-16 g/dl
human chorionic gonadotropin (pregnancy test) Negative, unless pregnancy or pathology
lactate dehydrogenase 45-90 U/L
magnesium 1.2-2.0 mEq/L
myoglobin 0.85 ng/ml
osmolality 285-295 mOsm/kg

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e4 Normal Laboratory Test References for Adults

Test Result (Normal)

oximetry (pulse oximetry) .95%
partial thromboplastin time (PTT) 30-40 seconds
phosphorus 3.0-4.5 mg/dl
platelet count 150,000-400,000/mm3
potassium 3.5-5.0 mEq/L
prealbumin 15-36 mg/dl
protein 6.4-8.3 g/dl
albumin 3.5-5.0 g/dl
prothrombin time (PT) 11.0-12.5 seconds
red blood cell (RBC) count Male: 4.7-6.1 million/mm3
Female: 4.2-5.4 million/mm3
reticulocyte count 0.5%-2%
sodium 136-145 mEq/L
thyroid-stimulating hormone 2-10 µU/ml
blood urea nitrogen (BUN) 10-20 mg/dl
uric acid Male: 2.1-8.5 mg/dl
Female: 2.0-6.6 mg/dl
white blood cell (WBC) count and differential count
white blood cells 5,000-10,000/mm3
neutrophils 55%-70%
lymphocytes 20%-40%
monocytes 2%-8%
eosinophils 1%-4%
basophils 0.5%-1.0%
Urine
bilirubin No bilirubin in urine
calcium, urine (24 hr) Varies with diet; normal diet, 100-300 mg/day
chloride, urine (24 hr) 110-250 mEq/day
osmolality 12- to 14-hour fluid restriction: . 850 mOsm/kg H2O
potassium (24 hr) 25-120 mEq/L/day
sodium (24 hr) 40-220 mEq/L/day (varies greatly with dietary intake)
urinalysis (UA)
appearance Clear
color Amber yellow
odor Aromatic
pH 4.6-8.0 (average, 6.0)
protein None or # 8 mg/dl
specific gravity 1.005-1.030
leukocyte esterase Negative
nitrites Negative
ketones Negative
crystals Negative
casts None present
glucose Negative (, 0.5 g/day)
white blood cells 0-4 cells/low-power field
white blood cell casts Negative
ed rblood cells # 2/low-power field
ed rblood cell casts None
vanillylmandelic acid 2-7 mg/24 hr

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