In the clinic 










123
Chapter5
In theclinic
OMFS clinics 124
Mandible fractures 126
Orbital oor fractures 128
Zygoma fractures 130
Maxillary fractures 132
Nose, nasoethmoidal, and frontal bone fractures 134
Face and scalp soft tissue injuries 136
Dentoalveolar:assessment for extractions 140
Dentoalveolar:impacted teeth 142
Dentoalveolar:jaw pathologies 144
Temporomandibular joint problems 146
Oral and facial pain 150
Management of oral lesions 152
Management of neck lumps 154
Skin tumours 156
Work- up for major head and neck oncoplastic surgery 160
Reviewing head and neck cancer patients 162
Salivary gland diseases 164
Orthognathic patients 168
Miscellaneous conditions in the clinic 170

124
CHAPTER5 In theclinic
124
OMFS clinics
These include outpatient clinics, pre- admission clinics, and minor surgery/
local anaesthetic clinics. OMFS clinics are often a mixture of all of these, so
you have to be adaptable and so do the nurses. For example, you may be
doing an outpatient clinic and be asked to perform an urgent biopsy of a
suspected cancer or remove an upper wisdom tooth which is traumatizing
the operculum of its counterpart.
Thenurses
Many of the nurses will be dental nurses.
Dental nurses are skilled at assisting you, mixing materials (e.g. for
impressions), and disinfection policies. They are also very good at
calming anxious patients.
They have also probably been there longer than you and will still be
there after you havegone.
However, it will be you in front of the General Medical/ Dental Council,
not them, so don’t do anything you are not happy with and be condent
in what youknow.
You would be unwise to attempt any procedures/ examinations without
having someone else in the room withyou.
Minor surgery
If you think you need help with a procedure talk to a supervisor before
you start. Make the most of having a senior around; it will be invaluable
learning for when you are on call on yourown.
Make sure that you adequately consent the patient. Most hospitals
require written consent even for LA procedures.
Sharps injuries are much too common. Clear away your own sharps;
then everyone knows whose responsibilityitis.
It is good practice to record the batch number and expiry of any local
anaesthetics that you use (it is a CQC requirement in theUK).
See sections on anaesthesia and suturing techniques (see E pp. 220–2
and pp. 228–9).
Equipment
You will often nd that the consulting room has a dentalchair.
You may not have to use it for consultation but you will usually need it
for examination and any clinical procedures. Familiarize yourself with the
controls early as it can be embarrassing otherwise.
Many patients require radiographs. Radiographs may be obtained
by dentists or dental nurses with appropriate training in the clinic (see
E p. 46 regarding legal requirements to take your own radiographs).
Otherwise send radiology requests early to avoid delays in the clinic.
Pre- admission clinics
The general clerking is the same as for any operation and the same
rules apply. Examine the whole patient, ensuring that you have all the
necessary results, and if you request any tests it is your responsibility to
obtain the results prior to the operation.

OMFS CLINICS
125
In maxillofacial surgery, we are sharing the airway with the anaesthetist
so at the pre- assessment clinic you must consider what sort of airway
will be required. Will it be an oral or nasal endotracheal tube? Will a
tracheostomy be required? Will it be done at the start or the end of the
procedure? Will the pathology make the intubation dicult? If you have
any doubts, contact the anaesthetist at this stage. If the intubation is
likely to be dicult, the anaesthetist will usually want to see the patient
themselves well before the operation. They may need endoscopes and
extrahelp.
You should be familiar with a procedure before obtaining consent.
Don’t forget to warn the patient about drains, dressings, and restrictions
such as elastics that they will have to contend with after the operation.
Each unit should have a policy on preoperative bloods. Always check
whether you need to group and save or cross- match blood, and send
o a sickle screen if indicated. Not doing this can delay lists and will not
make you popular.

126
CHAPTER5 In theclinic
126
Mandible fractures
The patients who you see in the clinic will be there either for a postopera-
tive review (e.g. 2 and 6 weeks post- surgery) or for fractures that are being
managed conservatively, who may possibly need surgery.
Plates used for xation are left in situ in adults unless they are causing
symptoms, infection, pain in cold weather, etc. In growing persons, they
should be removed as depositional bone growth causes them to become
deeply buried. In the skull, this can be particularly dangerous.
Postoperativereview
History
What did they have done/ when? Where are the plates? (Conrm with
operation note and pre/ postoperative lms.)
Swelling should be improving by 2 weeks post- surgery.
Diculty in eating— weight loss is not uncommon, check that they are
sticking to a softdiet.
Feeling of malocclusion— is it getting worse or better?
Lip numbness, were they also numb pre- op?
Examination
Remove elastics and assess mouth opening.
Note oral hygiene, and assess occlusion plus wound healing. Is there a
plate exposed?
Any fracture site mobility? 0 Call senior.
Record any numbness diagrammatically.
Painful teeth— teeth may have become non- vital due to trauma and
periapical infection can develop.
Radiographs in addition to the immediate post- op lms are not usually
indicated unless there is a problem.
Problems
Occlusion not correct— always discuss this with a senior. Intermaxillary
xation (IMF) intervention may be possible before resorting to further
surgery (teeth can move!). Options depend on when the surgery was
done and the complexity of the fracture.
Poor oral hygiene— the patient may assume that they shouldn’t brush
their teeth, so reinforce that they should and that mouthwash alone is
not enough. Consider whether IMF can be removed to aid cleansing.
Poor wound healing/ breakdown—chlorhexidine 0.2% mouthwash and
improved oral hygiene. Review.
Loose IMF— tighten/ take o. Patients will come to clinic to have the
arch bars removed. This may be quite uncomfortable as the wires can
become deeply embedded.
Plate removal if pain/ infection/ palpable. This usually needs to be done
in theatre.
Trismus— patients should be encouraged to move the jaw early after
surgery to prevent brous healing. Painless restriction in mouth opening
can be improved by physiotherapy or a device such as a Therabite
®
.
MUA is rarely indicated to break adhesions, but can be required
especially after intracapsular fractures.

MANDIBLE FRACTURES
127
Paraesthesia— must check if this was present preoperatively. It can
improve (can take up to 2years) and they will get used to it. If purely
a postsurgical phenomenon, check screw placement in relation to the
nerve onX- ray
Discharge is at 6 weeks if the fracture is OK and sensation is returning.
Non- union— rare in the facial skeleton. Consider diagnosis of
pathological fracture.
Osteomyelitis— rare but consider.
Children require special attention. Plates are routinely removed after
6 weeks as the bone overgrows. Growth disturbance and ankylosis can
result from trauma, so any sign of asymmetry must be recorded and
followedup.
Conservative management
Patients who have undisplaced/ minimally displaced fractures can be man-
aged conservatively and observed if they are comfortable.
Weekly review is recommended for the rst fewweeks.
Consider surgery if there is pain or increasing malocclusion.
Check that they are being compliant with a soft dietonly.
Radiographs are not routinely indicated unless there is a change in the
clinical picture.
Condylar fractures
These cases deserve a special mention as there is genuine debate about
which patients require ORIF + IMF (i.e. plates on the condyle plus arch
bars) and those that can be managed by IMF alone. It is an important
source of unhappy patients and litigation.
You may be seeing condylar fracture patients because they are being
monitored closely to determine if surgery is indicated, or they are
being managed by IMF (e.g. arch bars and elastics) and require close
monitoring to ensure the IMF is being used eectively. Either way, be
extra vigilant and if they have elastics take them o, sit patient upright,
and allow their occlusion to stabilize before you assess it. If in doubt,
ask for senior help. Achange in occlusion, even subtle, can make the
dierence between an operation or not and failure to make the right
decision can lead to a long- term malocclusion. As a general rule, a
condylar fracture with malocclusion needs either IMF or surgery or
both— don’t ignore or miss this importantpoint.
RemovalofIMF
This is normally done in clinic 6 weeks post xation (see E ‘Bridle wiring
and intermaxillary xation’, p. 233).

128
CHAPTER5 In theclinic
128
Orbital floor fractures
You should make a special point of always looking for an orbital oor frac-
ture in anyone who has had trauma to the face. In particular but not exclu-
sively, those who have had a blow to the orbit and periorbital tissues.
Do not be reassured by thinking the patient has already been seen in the
ED—these are easily missed and sometimes the clinical signs of an orbital
oor fracture will not become apparent until the swelling and bruising has
settled.
The most fragile bone in the facial skeleton is the lamina papyracea (liter-
ally ‘paper layer’), formed of the ethmoid bone in the medial orbital wall
(see E p. 23).
The key to managing these patients well is making sure that you obtain a
proper clinical review of theeye.
Orbit injuries must be seen by an ophthalmic surgeon.
If there is no obvious trauma to the globe but eye signs are present
you need to obtain a full orthoptic assessment.
In the clinic you willsee:
patients in whom there is not a denite diagnosisyet
patients with orbital oor fractures but no decision to operate has
been madeyet
patients with orbital oor fractures who are being managed con-
servatively (but there is always small chance that they might need
surgery)
postoperative patients.
The decision to operate is complicated by trying to predict who will
become symptomatic. Surgery is best performed within 2 weeks, but
post- trauma swelling may initially mask diplopia and enophthalmos.
Diagnosis
Diagnosis (see E pp. 88–90) is often made on CT scan, but in the clinic
always examine for enophthalmos, hypoglobus, and tenderness of the
orbital rim on pressure. See basic knowledge examination of eyes (E p.42).
Discuss treatment planning with a senior. Delayed surgery might require
custom- made implants, which are expensive. Re- dos have a worse progno-
sis, so it is important to get it right rsttime.
Indications for surgery:
Obvious enophthalmos.
Obvious hypoglobus.
Likely to develop enophthalmos (eye sunken in) or hypoglobus (eye
pushed down), i.e. large defect/ hammocking behind the axis of
theorbit.
Relative indications:
Diplopia may be an indication but it could be due to swelling or optic
nerve injury. Afull orthoptic and ophthalmic assessment is needed to
dierentiate between nerve injury and change of orbital volume.
If a decision is made to manage conservatively, the patient may be
discharged on the proviso that they can return to the clinic should
any symptoms develop.

ORBITAL FLOOR FRACTURES
129
Postoperative
Review the wounds (normally 5– 7days postoperatively). You may need
to remove a nylon continuous suture, although various incisions are
possible, some of which are not sutured.
Assess the eye position. Does the patient feel that the eye appears
normal? They are the best judge ofthis.
Check for diplopia and visual elds (NB:swelling will aectthis).
Check your local policy on follow- up and whether or not.
Ophthalmology needs toreview.
Advise patients to perform eye exercises to practise maintaining elds
of vision. Warn them that this might be a little painful atrst.
Children always require follow- up from ophthalmology as they might
need extra- ocular muscle surgery.
Problems
Scars in this region normally heal extremely well and can become invisible in
the creases around the eye. Scar retraction can sometimes cause ectropion
(eyelid is pulled outwards and tissues inside the eyelid may be visible) or
entropion (the eyelid folds in on itself and the eyelashes can be extremely
irritating to theeye).
Ectropion normally settles by itself. The patient should regularly massage
the tissues with a moisturizer or siliconegel.
Entropion needs to be reviewed by a senior as it is more likely to need
treatment (e.g. oculoplastics).
Residual enophthalmos:if the eye position has not been adequately
corrected by surgery, it is usual to wait for a few months for the swelling
to resolve and the eye position to settle. Any further surgery will need
detailed planning but success rates are notgood.
Residual diplopia— patients should be reminded that it is their
responsibility to contact the Driver and Vehicle Licensing Agency
(DVLA) to inform them of changes in their eyesight.

130
CHAPTER5 In theclinic
130
Zygoma fractures
For all zygoma patients, look for the ‘missed’ orbital fracture—it is always
worth an extra minute or two, especially if they haven’t been scanned.
Preoperative
Fractures of the zygomatic complex can be dicult to assess in the imme-
diate post- injury period. If there is no urgent indication for surgery, it is
reasonable to ask these patients back to clinic in 5– 7days for a full assess-
ment. However, some units like to operate early, so check your local policy.
Reassessment
Feel the ZF suture, supra- and infraorbital rims, and zygomatic buttress
(and hence assess mouth opening).
From above and behind the patient check the level of the arches
bilaterally. Is there any attening? Look for enophthalmos by assessing
the position of the globes— retract the upper lids manually and see if
the levels of the pupils are equal. Objective measurement can be made
with a Hertel exophthalmometer.
From the front you may be able to detect attening or hypoglobus and
look for a down- sloping lateral palpebral ssure (lateral canthus).
Record sensation of the rst and second division of the
trigeminalnerve.
Check the occlusion— in young patients the maxilla can be exed, giving
a premature contact on thatside.
Check eye movements and record any diplopia. Measure visual acuity.
Investigations
Plain facial views— these do not need repeating if done inA&E.
CT scan if a complex fracture— ideally with coronal reformatting.
Orthoptic assessment— Hess chart to map any ocular involvement
accurately.
Ophthalmology review— may not be needed if the eye is not involved
(e.g. isolated arch fracture).
Indications forsurgery
Aesthetic (most common)— the timing of surgery is controversial but
most surgeons feel that they are better able to judge the results on the
table if swelling has gone down. Others prefer to operate immediately
when the fracture has not started to repair.
Functional (e.g. restricted mouth opening or inferolateral orbital fractures
which leave the globe vulnerable)— a numb cheek is not an indication
for surgery as it cannot be reliably improved.

ZYGOMA FRACTURES
131
Postoperative
In the rst 24 hours there is a small risk (0.03%) of retrobulbar
haemorrhage (see E pp. 272–4), so eye observations are essential.
You must document the instructions for eye observations clearly in the
patientsnotes.
Patients are normally reviewed at 2 weeks post surgery.
Check the operation notes and post- xation X- rays.
Assess the wounds and see that the bone is still reduced.
Examine for diplopia and numbness. Most numbness will improve over
time, but if there is still residual numbness at 18months it is unlikely to
recover.
If all is satisfactory, the patient can be discharged with a warning to
avoid contact sports for 6 weeks. If they are planning on scuba diving,
they should tell the instructor as it can aect sinuses.
Plates are left unless they are causing problems (e.g. plates at the ZF
suture can be visible if elderly or thin tissues).
Contactsport
As with all fractures we advise against any contact sport for 6 weeks from
the time of xation or injury if there was no ORIF. There have been high-
prole sportsmen wearing face shields and resuming activity within the rec-
ommended healing time— these are not proven to prevent re- injury, nor
available on theNHS.

132
CHAPTER5 In theclinic
132
Maxillary fractures
These injuries are usually the result of signicant trauma and so present in
the hospital rather than the outpatient department (see E Fig. 4.2,p. 85).
Occasionally, the diagnosis may have been missed. Your suspicions should
be aroused when there are bilateral black eyes and a deranged occlusion
without a mandible fracture.
Isolated Le Fort I fractures can be managed conservatively if the seg-
ment is relatively stable (some are incomplete fractures). This is the recom-
mended management in elderly denture wearers. The denture should be
left out for 6 weeks, and a new pair will need to be made once the fracture
has healed.
Postoperative
Normally reviewed weekly or fortnightly (ensure postoperative
radiographs are done unless advised otherwise).
Look at the pattern of injury and assess all aected areas (e.g. condyle
fractures). Check the intra- oral wound and other facial wounds.
The patient will probably have arch bars, which can be very
uncomfortable. See if the wires can be trimmed/ adjusted and advise
orthodontic wax to cover the sharperparts.
Elastic bands may be used to guide the occlusion. Take them o
to assess the bite and then decide with a senior if they need to be
replaced.
Oral hygiene is often bad, so spend some time showing the patient how
best to clean theirteeth.
Ask specically about CSF leak. If this is new or not improving, obtain a
CT scan and discuss with neurology/ ENT.
Midline palatal factures require rigid arch bars to stop the teeth rotating
inwards.
Assess for sensory nerve function.
Removal ofarchbars
These are normally taken o at 4– 6 weeks. A specic appointment will
need to be made as it can take up to 45 minutes.
Local anaesthetic inltration into the buccal sulcus near each of the tying
wires should render the patient comfortable.
Double glove and wear goggles (the patient must also have eye
protection).
Unwind a little of the wire with a heavy clip (anticlockwise) and cut
one side. Pull the clip straight out at 90° to the tooth surface while
supporting the jaw with your non-dominant hand. The wire should pull
through easily.
Wires should be collected in a pot of water (e.g. denture pot) and must
be disposed of safely.

MAXILLARY FRACTURES
133

134
CHAPTER5 In theclinic
134
Nose, nasoethmoidal,
and frontal bone fractures
Nose
Post- injuryreview
These patients are often rst seen in ED and followed up 5– 7days later
(see E p. 92).
If considering MUA you should be able to demonstrate septal/ nasal
bone deviation with cosmetic/ functional component.
Make sure that the injury is not likely to be repeated before xing it (i.e.
retired boxers!).
Postoperative(MUA)
External splints are normally removed at 1 week. You may also need to
remove septal splints (internal) after 724hours.
If the result is unsatisfactory, a denitive rhinoplasty will be necessary (if
the septum is also deviated, it will be a septorhinoplasty). It can take 6–
12months for all the swelling to disappear so review again at 6months
to decide if further surgery is really required.
Nasoethmoidal fractures
Preoperative
Diagnosis— see E p. 92.
Occasionally these can be managed conservatively, but eectively they
are open fractures, even to the cranial contents, and should have close
follow- up.
Indications for surgery include signicant telecanthus, CSF leak, or nasal
deformity. Most surgeons will prescribe antibiotics for CSF leak— test
clear uid with BM sticks (same glucose levels as serum) or send it for
β
2
transferrin if your Trust has themoney and is able to provide this
specic test—many do not!
Early liaison with ophthalmologists is wise because of the risk of damage
to the lacrimal apparatus (look for tearing of the eye— epiphora) and
possible ocular motility problems.
Postoperative
Measure intercanthal distance and assess the form of the nose in prole.
Ask about lacrimal function.
Remove stitches and check the position of plates.
These are dicult fractures to x satisfactorily and the patient may have
to accept a slight change in appearance.

NOSE, NASOETHMOIDAL, AND FRONTAL BONE FRACTURES
135
Frontal fractures
The frontal bone is thick and tough, apart from the area containing the
frontal sinus. The size and shape of the sinus is highly variable.
Signicantly displaced simple frontal bone fractures are rare and indicate
signicant impact. They usually result in massive underlying brain injury.
Fractures involving the frontal sinus are much more common and the
management depends whether the anterior ± posterior walls are
involved.
Isolated anterior wall— these can be managed conservatively if only
minimally displaced. Grossly displaced fractures can give an unsightly
ridge on the forehead, which is an indication for surgery.
Posterior wall— there is now direct communication between the
frontal sinus and the anterior cranial fossa. Surgery is indicated
because the lifetime risk of cerebral abscess and meningitis is of the
order of 60– 70%. The procedure undertaken is cranialization of the
frontal sinus (see E pp. 186–7). Antibiotics are usually prescribed.
Postoperative
If the patient had the bicoronal approach, take out scalp clips at
7– 10days.
Check for CSFleak.
Advise about wound care (e.g. massagescar).
Posterior wall fractures may have a slightly longer follow- up period, but
if surgery has been successful, the patient’s lifetime risk of meningitis will
have been reduced to that of the normal population.

136
CHAPTER5 In theclinic
136
Face and scalp soft tissue injuries
Follow- up is not required for most simple lacerations that are sutured in
theED.
Patients being seen in clinic would generally have complicated
lacerationswhere:
healing is expected to be compromised (e.g. skin loss or
contaminated)
further reconstruction isneeded
scar revision may be required at a laterdate
there are injuries associated with thewound.
Scarring is a normal and essential part of wound healing, even if it has
been sutured. It is important to educate and reassure patients regarding
the normal clinical course of a healing wound so they know what to
expect.
Recently treated lacerations
Assess wound healing.
Look for cellulitis— don’t confuse with normal erythema.
If wound infection or cellulitis is suspected, take a wound swab and
prescribe an empirical antibiotic such as ucloxacillin.
If in doubt, consult microbiology regarding antibiotic choice.
May need surgical debridement.
Generally require cleaning and redressingonly.
Normal clinical course ofascar
1– 2 weeks following injury, the wound appears nicely healed with a thin
redline.
Continues to thicken for 4– 6 weeks as collagen is laiddown.
Can be itchy and tender during this proliferativephase.
Collagen deposition and resorption occurs in equilibrium as the scar
remodels.
The scar gradually softens, becomingpaler.
After 12– 18months, the scar should be pale and asymptomatic.
Removal ofsutures
If the patient is being followed up in clinic, it may be a good opportunity to
remove the sutures to save the patient returning to the dressing clinic or
seeing the GPnurse.
Sutures can be removed as follows:
Eyelid, 3– 4days.
Face, 5– 6days.
Scalp, 7– 10days.
Ears, 10days.
Back/ neck, 10– 14days.
If Dermabond
®
(cyanoacrylate) has been used, ask the patient to apply
white soft paran after 7days and gently massage, which will help the
glue come o. Discourage picking.

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123 Chapter5In theclinicOMFS clinics 124Mandible fractures 126Orbital oor fractures 128Zygoma fractures 130Maxillary fractures 132Nose, nasoethmoidal, and frontal bone fractures 134Face and scalp soft tissue injuries 136Dentoalveolar:assessment for extractions 140Dentoalveolar:impacted teeth 142Dentoalveolar:jaw pathologies 144Temporomandibular joint problems 146Oral and facial pain 150Management of oral lesions 152Management of neck lumps 154Skin tumours 156Work- up for major head and neck oncoplastic surgery 160Reviewing head and neck cancer patients 162Salivary gland diseases 164Orthognathic patients 168Miscellaneous conditions in the clinic 170 124CHAPTER5 In theclinic124OMFS clinicsThese include outpatient clinics, pre- admission clinics, and minor surgery/ local anaesthetic clinics. OMFS clinics are often a mixture of all of these, so you have to be adaptable and so do the nurses. For example, you may be doing an outpatient clinic and be asked to perform an urgent biopsy of a suspected cancer or remove an upper wisdom tooth which is traumatizing the operculum of its counterpart.Thenurses• Many of the nurses will be dental nurses.• Dental nurses are skilled at assisting you, mixing materials (e.g. for impressions), and disinfection policies. They are also very good at calming anxious patients.• They have also probably been there longer than you and will still be there after you havegone.• However, it will be you in front of the General Medical/ Dental Council, not them, so don’t do anything you are not happy with and be condent in what youknow.• You would be unwise to attempt any procedures/ examinations without having someone else in the room withyou.Minor surgery• If you think you need help with a procedure talk to a supervisor before you start. Make the most of having a senior around; it will be invaluable learning for when you are on call on yourown.• Make sure that you adequately consent the patient. Most hospitals require written consent even for LA procedures.• Sharps injuries are much too common. Clear away your own sharps; then everyone knows whose responsibilityitis.• It is good practice to record the batch number and expiry of any local anaesthetics that you use (it is a CQC requirement in theUK).• See sections on anaesthesia and suturing techniques (see E pp. 220–2 and pp. 228–9).Equipment• You will often nd that the consulting room has a dentalchair.• You may not have to use it for consultation but you will usually need it for examination and any clinical procedures. Familiarize yourself with the controls early as it can be embarrassing otherwise.• Many patients require radiographs. Radiographs may be obtained by dentists or dental nurses with appropriate training in the clinic (see E p. 46 regarding legal requirements to take your own radiographs). Otherwise send radiology requests early to avoid delays in the clinic.Pre- admission clinics• The general clerking is the same as for any operation and the same rules apply. Examine the whole patient, ensuring that you have all the necessary results, and if you request any tests it is your responsibility to obtain the results prior to the operation. OMFS CLINICS125 • In maxillofacial surgery, we are sharing the airway with the anaesthetist so at the pre- assessment clinic you must consider what sort of airway will be required. Will it be an oral or nasal endotracheal tube? Will a tracheostomy be required? Will it be done at the start or the end of the procedure? Will the pathology make the intubation dicult? If you have any doubts, contact the anaesthetist at this stage. If the intubation is likely to be dicult, the anaesthetist will usually want to see the patient themselves well before the operation. They may need endoscopes and extrahelp.• You should be familiar with a procedure before obtaining consent. Don’t forget to warn the patient about drains, dressings, and restrictions such as elastics that they will have to contend with after the operation.• Each unit should have a policy on preoperative bloods. Always check whether you need to group and save or cross- match blood, and send o a sickle screen if indicated. Not doing this can delay lists and will not make you popular. 126CHAPTER5 In theclinic126Mandible fracturesThe patients who you see in the clinic will be there either for a postopera-tive review (e.g. 2 and 6 weeks post- surgery) or for fractures that are being managed conservatively, who may possibly need surgery.Plates used for xation are left in situ in adults unless they are causing symptoms, infection, pain in cold weather, etc. In growing persons, they should be removed as depositional bone growth causes them to become deeply buried. In the skull, this can be particularly dangerous.PostoperativereviewHistory• What did they have done/ when? Where are the plates? (Conrm with operation note and pre/ postoperative lms.)• Swelling should be improving by 2 weeks post- surgery.• Diculty in eating— weight loss is not uncommon, check that they are sticking to a softdiet.• Feeling of malocclusion— is it getting worse or better?• Lip numbness, were they also numb pre- op?Examination• Remove elastics and assess mouth opening.• Note oral hygiene, and assess occlusion plus wound healing. Is there a plate exposed?• Any fracture site mobility? 0 Call senior.• Record any numbness diagrammatically.• Painful teeth— teeth may have become non- vital due to trauma and periapical infection can develop.• Radiographs in addition to the immediate post- op lms are not usually indicated unless there is a problem.Problems• Occlusion not correct— always discuss this with a senior. Intermaxillary xation (IMF) intervention may be possible before resorting to further surgery (teeth can move!). Options depend on when the surgery was done and the complexity of the fracture.• Poor oral hygiene— the patient may assume that they shouldn’t brush their teeth, so reinforce that they should and that mouthwash alone is not enough. Consider whether IMF can be removed to aid cleansing.• Poor wound healing/ breakdown—chlorhexidine 0.2% mouthwash and improved oral hygiene. Review.• Loose IMF— tighten/ take o. Patients will come to clinic to have the arch bars removed. This may be quite uncomfortable as the wires can become deeply embedded.• Plate removal if pain/ infection/ palpable. This usually needs to be done in theatre.• Trismus— patients should be encouraged to move the jaw early after surgery to prevent brous healing. Painless restriction in mouth opening can be improved by physiotherapy or a device such as a Therabite®. MUA is rarely indicated to break adhesions, but can be required especially after intracapsular fractures. MANDIBLE FRACTURES127 • Paraesthesia— must check if this was present preoperatively. It can improve (can take up to 2years) and they will get used to it. If purely a postsurgical phenomenon, check screw placement in relation to the nerve onX- ray• Discharge is at 6 weeks if the fracture is OK and sensation is returning.• Non- union— rare in the facial skeleton. Consider diagnosis of pathological fracture.• Osteomyelitis— rare but consider.• Children require special attention. Plates are routinely removed after 6 weeks as the bone overgrows. Growth disturbance and ankylosis can result from trauma, so any sign of asymmetry must be recorded and followedup.Conservative managementPatients who have undisplaced/ minimally displaced fractures can be man-aged conservatively and observed if they are comfortable.• Weekly review is recommended for the rst fewweeks.• Consider surgery if there is pain or increasing malocclusion.• Check that they are being compliant with a soft dietonly.• Radiographs are not routinely indicated unless there is a change in the clinical picture.Condylar fractures• These cases deserve a special mention as there is genuine debate about which patients require ORIF + IMF (i.e. plates on the condyle plus arch bars) and those that can be managed by IMF alone. It is an important source of unhappy patients and litigation.• You may be seeing condylar fracture patients because they are being monitored closely to determine if surgery is indicated, or they are being managed by IMF (e.g. arch bars and elastics) and require close monitoring to ensure the IMF is being used eectively. Either way, be extra vigilant and if they have elastics take them o, sit patient upright, and allow their occlusion to stabilize before you assess it. If in doubt, ask for senior help. Achange in occlusion, even subtle, can make the dierence between an operation or not and failure to make the right decision can lead to a long- term malocclusion. As a general rule, a condylar fracture with malocclusion needs either IMF or surgery or both— don’t ignore or miss this importantpoint.RemovalofIMFThis is normally done in clinic 6 weeks post xation (see E ‘Bridle wiring and intermaxillary xation’, p. 233). 128CHAPTER5 In theclinic128Orbital floor fracturesYou should make a special point of always looking for an orbital oor frac-ture in anyone who has had trauma to the face. In particular but not exclu-sively, those who have had a blow to the orbit and periorbital tissues.Do not be reassured by thinking the patient has already been seen in the ED—these are easily missed and sometimes the clinical signs of an orbital oor fracture will not become apparent until the swelling and bruising has settled.The most fragile bone in the facial skeleton is the lamina papyracea (liter-ally ‘paper layer’), formed of the ethmoid bone in the medial orbital wall (see E p. 23).• The key to managing these patients well is making sure that you obtain a proper clinical review of theeye.• Orbit injuries must be seen by an ophthalmic surgeon.• If there is no obvious trauma to the globe but eye signs are present you need to obtain a full orthoptic assessment.• In the clinic you willsee:• patients in whom there is not a denite diagnosisyet• patients with orbital oor fractures but no decision to operate has been madeyet• patients with orbital oor fractures who are being managed con-servatively (but there is always small chance that they might need surgery)• postoperative patients.• The decision to operate is complicated by trying to predict who will become symptomatic. Surgery is best performed within 2 weeks, but post- trauma swelling may initially mask diplopia and enophthalmos.DiagnosisDiagnosis (see E pp. 88–90) is often made on CT scan, but in the clinic always examine for enophthalmos, hypoglobus, and tenderness of the orbital rim on pressure. See basic knowledge examination of eyes (E p.42). Discuss treatment planning with a senior. Delayed surgery might require custom- made implants, which are expensive. Re- dos have a worse progno-sis, so it is important to get it right rsttime.• Indications for surgery:• Obvious enophthalmos.• Obvious hypoglobus.• Likely to develop enophthalmos (eye sunken in) or hypoglobus (eye pushed down), i.e. large defect/ hammocking behind the axis of theorbit.• Relative indications:• Diplopia may be an indication but it could be due to swelling or optic nerve injury. Afull orthoptic and ophthalmic assessment is needed to dierentiate between nerve injury and change of orbital volume.• If a decision is made to manage conservatively, the patient may be discharged on the proviso that they can return to the clinic should any symptoms develop. ORBITAL FLOOR FRACTURES129 Postoperative• Review the wounds (normally 5– 7days postoperatively). You may need to remove a nylon continuous suture, although various incisions are possible, some of which are not sutured.• Assess the eye position. Does the patient feel that the eye appears normal? They are the best judge ofthis.• Check for diplopia and visual elds (NB:swelling will aectthis).• Check your local policy on follow- up and whether or not. Ophthalmology needs toreview.• Advise patients to perform eye exercises to practise maintaining elds of vision. Warn them that this might be a little painful atrst.• Children always require follow- up from ophthalmology as they might need extra- ocular muscle surgery.ProblemsScars in this region normally heal extremely well and can become invisible in the creases around the eye. Scar retraction can sometimes cause ectropion (eyelid is pulled outwards and tissues inside the eyelid may be visible) or entropion (the eyelid folds in on itself and the eyelashes can be extremely irritating to theeye).• Ectropion normally settles by itself. The patient should regularly massage the tissues with a moisturizer or siliconegel.• Entropion needs to be reviewed by a senior as it is more likely to need treatment (e.g. oculoplastics).• Residual enophthalmos:if the eye position has not been adequately corrected by surgery, it is usual to wait for a few months for the swelling to resolve and the eye position to settle. Any further surgery will need detailed planning but success rates are notgood.• Residual diplopia— patients should be reminded that it is their responsibility to contact the Driver and Vehicle Licensing Agency (DVLA) to inform them of changes in their eyesight. 130CHAPTER5 In theclinic130Zygoma fracturesFor all zygoma patients, look for the ‘missed’ orbital fracture—it is always worth an extra minute or two, especially if they haven’t been scanned.PreoperativeFractures of the zygomatic complex can be dicult to assess in the imme-diate post- injury period. If there is no urgent indication for surgery, it is reasonable to ask these patients back to clinic in 5– 7days for a full assess-ment. However, some units like to operate early, so check your local policy.Reassessment• Feel the ZF suture, supra- and infraorbital rims, and zygomatic buttress (and hence assess mouth opening).• From above and behind the patient check the level of the arches bilaterally. Is there any attening? Look for enophthalmos by assessing the position of the globes— retract the upper lids manually and see if the levels of the pupils are equal. Objective measurement can be made with a Hertel exophthalmometer.• From the front you may be able to detect attening or hypoglobus and look for a down- sloping lateral palpebral ssure (lateral canthus).• Record sensation of the rst and second division of the trigeminalnerve.• Check the occlusion— in young patients the maxilla can be exed, giving a premature contact on thatside.• Check eye movements and record any diplopia. Measure visual acuity.Investigations• Plain facial views— these do not need repeating if done inA&E.• CT scan if a complex fracture— ideally with coronal reformatting.• Orthoptic assessment— Hess chart to map any ocular involvement accurately.• Ophthalmology review— may not be needed if the eye is not involved (e.g. isolated arch fracture).Indications forsurgery• Aesthetic (most common)— the timing of surgery is controversial but most surgeons feel that they are better able to judge the results on the table if swelling has gone down. Others prefer to operate immediately when the fracture has not started to repair.• Functional (e.g. restricted mouth opening or inferolateral orbital fractures which leave the globe vulnerable)— a numb cheek is not an indication for surgery as it cannot be reliably improved. ZYGOMA FRACTURES131 Postoperative• In the rst 24 hours there is a small risk (0.03%) of retrobulbar haemorrhage (see E pp. 272–4), so eye observations are essential.• You must document the instructions for eye observations clearly in the patient’snotes.• Patients are normally reviewed at 2 weeks post surgery.• Check the operation notes and post- xation X- rays.• Assess the wounds and see that the bone is still reduced.• Examine for diplopia and numbness. Most numbness will improve over time, but if there is still residual numbness at 18months it is unlikely to recover.• If all is satisfactory, the patient can be discharged with a warning to avoid contact sports for 6 weeks. If they are planning on scuba diving, they should tell the instructor as it can aect sinuses.• Plates are left unless they are causing problems (e.g. plates at the ZF suture can be visible if elderly or thin tissues).ContactsportAs with all fractures we advise against any contact sport for 6 weeks from the time of xation or injury if there was no ORIF. There have been high- prole sportsmen wearing face shields and resuming activity within the rec-ommended healing time— these are not proven to prevent re- injury, nor available on theNHS. 132CHAPTER5 In theclinic132Maxillary fracturesThese injuries are usually the result of signicant trauma and so present in the hospital rather than the outpatient department (see E Fig. 4.2,p. 85). Occasionally, the diagnosis may have been missed. Your suspicions should be aroused when there are bilateral black eyes and a deranged occlusion without a mandible fracture.Isolated Le Fort I fractures can be managed conservatively if the seg-ment is relatively stable (some are incomplete fractures). This is the recom-mended management in elderly denture wearers. The denture should be left out for 6 weeks, and a new pair will need to be made once the fracture has healed.Postoperative• Normally reviewed weekly or fortnightly (ensure postoperative radiographs are done unless advised otherwise).• Look at the pattern of injury and assess all aected areas (e.g. condyle fractures). Check the intra- oral wound and other facial wounds.• The patient will probably have arch bars, which can be very uncomfortable. See if the wires can be trimmed/ adjusted and advise orthodontic wax to cover the sharperparts.• Elastic bands may be used to guide the occlusion. Take them o to assess the bite and then decide with a senior if they need to be replaced.• Oral hygiene is often bad, so spend some time showing the patient how best to clean theirteeth.• Ask specically about CSF leak. If this is new or not improving, obtain a CT scan and discuss with neurology/ ENT.• Midline palatal factures require rigid arch bars to stop the teeth rotating inwards.• Assess for sensory nerve function.Removal ofarchbarsThese are normally taken o at 4– 6 weeks. A specic appointment will need to be made as it can take up to 45 minutes.• Local anaesthetic inltration into the buccal sulcus near each of the tying wires should render the patient comfortable.• Double glove and wear goggles (the patient must also have eye protection).• Unwind a little of the wire with a heavy clip (anticlockwise) and cut one side. Pull the clip straight out at 90° to the tooth surface while supporting the jaw with your non-dominant hand. The wire should pull through easily.• Wires should be collected in a pot of water (e.g. denture pot) and must be disposed of safely. MAXILLARY FRACTURES133 134CHAPTER5 In theclinic134Nose, nasoethmoidal, and frontal bone fracturesNosePost- injuryreview• These patients are often rst seen in ED and followed up 5– 7days later (see E p. 92).• If considering MUA you should be able to demonstrate septal/ nasal bone deviation with cosmetic/ functional component.• Make sure that the injury is not likely to be repeated before xing it (i.e. retired boxers!).Postoperative(MUA)• External splints are normally removed at 1 week. You may also need to remove septal splints (internal) after 724hours.• If the result is unsatisfactory, a denitive rhinoplasty will be necessary (if the septum is also deviated, it will be a septorhinoplasty). It can take 6– 12months for all the swelling to disappear so review again at 6months to decide if further surgery is really required.Nasoethmoidal fracturesPreoperative• Diagnosis— see E p. 92.• Occasionally these can be managed conservatively, but eectively they are open fractures, even to the cranial contents, and should have close follow- up.• Indications for surgery include signicant telecanthus, CSF leak, or nasal deformity. Most surgeons will prescribe antibiotics for CSF leak— test clear uid with BM sticks (same glucose levels as serum) or send it for β2 transferrin if your Trust has themoney and is able to provide this specic test—many do not!• Early liaison with ophthalmologists is wise because of the risk of damage to the lacrimal apparatus (look for tearing of the eye— epiphora) and possible ocular motility problems.Postoperative• Measure intercanthal distance and assess the form of the nose in prole.• Ask about lacrimal function.• Remove stitches and check the position of plates.• These are dicult fractures to x satisfactorily and the patient may have to accept a slight change in appearance. NOSE, NASOETHMOIDAL, AND FRONTAL BONE FRACTURES 135 Frontal fractures• The frontal bone is thick and tough, apart from the area containing the frontal sinus. The size and shape of the sinus is highly variable.• Signicantly displaced simple frontal bone fractures are rare and indicate signicant impact. They usually result in massive underlying brain injury.• Fractures involving the frontal sinus are much more common and the management depends whether the anterior ± posterior walls are involved.• Isolated anterior wall— these can be managed conservatively if only minimally displaced. Grossly displaced fractures can give an unsightly ridge on the forehead, which is an indication for surgery.• Posterior wall— there is now direct communication between the frontal sinus and the anterior cranial fossa. Surgery is indicated because the lifetime risk of cerebral abscess and meningitis is of the order of 60– 70%. The procedure undertaken is cranialization of the frontal sinus (see E pp. 186–7). Antibiotics are usually prescribed.Postoperative• If the patient had the bicoronal approach, take out scalp clips at 7– 10days.• Check for CSFleak.• Advise about wound care (e.g. massagescar).• Posterior wall fractures may have a slightly longer follow- up period, but if surgery has been successful, the patient’s lifetime risk of meningitis will have been reduced to that of the normal population. 136CHAPTER5 In theclinic136Face and scalp soft tissue injuries• Follow- up is not required for most simple lacerations that are sutured in theED.• Patients being seen in clinic would generally have complicated lacerationswhere:• healing is expected to be compromised (e.g. skin loss or contaminated)• further reconstruction isneeded• scar revision may be required at a laterdate• there are injuries associated with thewound.• Scarring is a normal and essential part of wound healing, even if it has been sutured. It is important to educate and reassure patients regarding the normal clinical course of a healing wound so they know what to expect.Recently treated lacerations• Assess wound healing.• Look for cellulitis— don’t confuse with normal erythema.• If wound infection or cellulitis is suspected, take a wound swab and prescribe an empirical antibiotic such as ucloxacillin.• If in doubt, consult microbiology regarding antibiotic choice.• May need surgical debridement.• Generally require cleaning and redressingonly.Normal clinical course ofascar• 1– 2 weeks following injury, the wound appears nicely healed with a thin redline.• Continues to thicken for 4– 6 weeks as collagen is laiddown.• Can be itchy and tender during this proliferativephase.• Collagen deposition and resorption occurs in equilibrium as the scar remodels.• The scar gradually softens, becomingpaler.• After 12– 18months, the scar should be pale and asymptomatic.Removal ofsuturesIf the patient is being followed up in clinic, it may be a good opportunity to remove the sutures to save the patient returning to the dressing clinic or seeing the GPnurse.• Sutures can be removed as follows:• Eyelid, 3– 4days.• Face, 5– 6days.• Scalp, 7– 10days.• Ears, 10days.• Back/ neck, 10– 14days.• If Dermabond® (cyanoacrylate) has been used, ask the patient to apply white soft paran after 7days and gently massage, which will help the glue come o. Discourage picking. FACE AND SCALP SOFT TISSUE INJURIES137 Assessing thenalresultThe optimal scar is a thin, at, pale line in a relaxed skin tension line, which does not traverse or contract anatomical boundaries or structures.Advise the patient to massage the nal wound with a moisturizer or simple cream to break up the scar tissue and to wear sun protection factor.• For lip lacerations, ensure the vermilion border has been re- aligned.• For wounds around the eyes, check for ectropion (scar tissue pulling the lower lid down and outwards which may cause a watery or redeye).Management ofunsightly, hypertrophic, or keloidscarsHistoryWhy is the scar unsightly? Is it uneven, stretched, sunken, hyperpigmented, hypopigmented, raised, hypertrophic, keloid, or tattooed? Is it inamed and symptomatic? Look at other scars on the body to assess for whether the patient scars poorly.• Hypertrophic scars are thickened and raised, but remain within their original borders. Disordered collagen, high wound turnover, and vascularity. Usually regress spontaneously, and respond to treatment more than keloidscars• Keloid scars are thickened, raised, and extend beyond the boundaries of the original wound. Build- up of collagen, with greater wound turnover and increased vascularity. 5– 15 times more common in black population.MonitorAllow an inamed scar to mature over 1 year. Consider taking clinical photographs.Treatment options• Surgery may simply result in a worse scar, so start with conservative options.• Pressure clips/ facemask:>24mmHg 18– 24 hours/ day for 4– 6months.• Silicone gel:apply for 12– 14 hours/ day for 2– 3months.• Silicone tape/ patches.• Intralesional steroid:triamcinolone 20 mg/ cm scar to a maximum of 120 mg. Course of four injections every 4– 6 weeks. Reduces collagen levels, inammation, pruritus, and tenderness. Side eects include pain on injection, hypopigmentation, crystalline deposits, telangiectasia, and atrophy.• Topical vitamin A(retinoic acid) inhibits broblasts and vitamin E reduces broblast number, 5- uorouracil (5FU) inhibits cell division, penicillamine prevents collagen cross- linking, and colchicine increases collagenase activity.• Laser— can reduce pigmentation and inammation.• Scar excision and re- suture, serial excision, scar re- alignment.• Z- plasty, W- plasty.• Adjunctive therapy, such as radiation, brachytherapy, or steroids, may be used with surgery.• Coleman fat transfer or llers can be used to restore volume. 138CHAPTER5 In theclinic138Other soft tissue problemsHaematoma• May require evacuation to aid healing. Cover with antibiotics.Foreignbodies• Imaging may help to identify. CBCT is the best imaging modality forthis.• May not be necessary to remove (e.g. shotgun injuries).• Low- velocity wounds may be more likely to become infected.• Depends on anatomy.Abrasions• Clean at earlystage.• May require scrubbing under LA/ GA to remove any ingrained dirt or debris and prevent ‘tattooing’.• Dress with appropriate dressing for moist wound. If in doubt, discuss with woundnurse. FACE AND SCALP SOFT TISSUE INJURIES139 140CHAPTER5 In theclinic140Dentoalveolar:assessment forextractionsYou may be asked to review patients for what seem like straightfor-ward extractions, however there are a number of reasons why cer-tain patients are better managed in hospital. For impacted teeth, see E ‘Dentoalveolar:impacted teeth’, pp. 142–3.Indications forhospital- based extractions• Psychological conditions.• Medical co- morbidity.• High risk of complication, e.g.OAC.• Dicult extraction.Psychological complaintsThere are a wide range of psychological conditions including anxiety, dental phobia, and needle phobia which may require specialistinput.• Patients may be signicantly reassured by having their extraction undertaken in a ‘specialist setting’.• Some patients may still require some form of sedation and in a few cases even GA— your department will have a policy regardingthis.• Ashort- acting oral benzodiazepine prior to the procedure is a useful adjunct. GP can prescribe a one- o tablet.Medical co- morbidityCommon problems include:• Patients on anticoagulation— warfarin, aspirin and new anticoagulants such as rivaroxaban can cause signicant bleeding and there is a handy guideline produced by the Scottish Dental Clinical Eectiveness Programme.1• Chronic disease, e.g. signicant cardiovascular or respiratory conditions. These patients do not necessarily need dierent treatment, but they are better managed in a facility where there is rapid access to medical help should it be required.• Patients at risk of medication- related osteonecrosis of the jaws (MRONJ). Although bisphosphonates are the best- known class of drug implicated there are newer classes of antiresorptive and antiangiogenic medications such as denosumab can trigger bone necrosis following extraction. Teeth should be restored rather than extracted if possible. Otherwise careful surgery and close follow- up. Ahelpful summary was produced by the American Association of Oral and Maxillofacial Surgeons.2• Previous jaw irradiation— risk ofORN.• Immune compromise.1 Scottish Dental Clinical Eectiveness Programme. Published Guidance. M http:// www.sdcep.org.uk/ published- guidance/ 2 Ruggiero SL, Dodson TB, Fantasia J, etal. American Association of Oral and Maxillofacial Surgeons position paper on medication- related osteonecrosis of the jaw– 2014 update. J Oral Maxillofac Surg 2014;72:1938– 56. DENTOALVEOLAR:ASSESSMENT FOREXTRACTIONS141 High risk ofcomplicationsAnticipation of diculty, e.g. upper 7s close to sinus, root- lled teeth which are likely to require surgical extraction.The operator in hospital should be able to deal immediately with the complication should it occur, e.g. buccal advancement ap forOAC.Atrophic mandible, particularly <1cm, has higher risk of fracture during extraction.Dicult extractionThese are common problems which will require a planned surgical approach and appropriately trained surgeon:• Ankylosis• Crowded dentition• Retainedroots• Supernumeraryteeth. 142CHAPTER5 In theclinic142Dentoalveolar:impactedteethDenition ofan impactedtooth‘Any tooth that is prevented from reaching its normal position in the mouth by bone, soft tissue or another tooth.’Most commonly impacted teeth are 8s, 3s, 5s, and supernumeraries. These patients will be referred to OMFS by GDPs or orthodontists for assessment in clinic.Impacted thirdmolarsHistoryPain history, number of episodes of pericoronitis, and how severe— whether or not antibiotics required. Exclude other causes such as temporo-mandibular joint dysfunction syndrome (TMJDS). Relevant medical, dental, and social history. Assessment of anxiety.Examination• Extra- oral— facial swelling or asymmetry, lymphadenopathy,TMJ.• Intra- oral— inter- incisal opening, condition of rest of dentition, OH, position of lower third molars, position of upper third molars, position of external oblique ridge, condition of lower second molars, presence of pericoronitis, other features that may be of signicance (removable prostheses, profound gag reex,etc.).Investigation• Assess root morphology, degree of bone impaction, proximity to IDN, and associated disease (e.g. cysts, hypercementosis, TMJ problems).• DPT— position, angulation, root morphology, degree of bone impaction, decay in 7, associated pathology, hypercementosis, proximity to IDN. Look for loss of lines, shadow over apex (juxta- apical radiolucency), and deviation ofcanal.• Radiological features which are thought to raise risk of permanent nerve damage include (not exhaustive):3• deviation of the mandibularcanal• radiolucency across theroots• interruption of the white lines of thecanal• deection of the roots by thecanal• narrowing of theroot.• CBCT— focused 3D imaging of the jaw and a better representation of the relationship of the roots of the third molar to the IDN and can be helpful if there is felt to be signicant risk from theDPT.ManagementMandibular impacted third molars are very common but this surgery should not be undertaken without careful consideration because of the risk of com-plications. In England, for example, there exist NICE guidelines.4 These are, however, rather outdated and many would argue quite inadequate, but include:3 Rood JP, Shebab BA (1990). The radiological prediction of inferior nerve injury during third molar surgery, Br J Oral Maxillofac Surg 28:20– 5.4 National Institute for Health and Care Excellence (NICE) (2000). Guidance on the Extraction of Wisdom Teeth. London:NICE. M https:// www.nice.org.uk/ guidance/ ta1 DENTOALVEOLAR:IMPACTEDTEETH143 • unrestorablecaries• non- treatable pulpal and/ or periapical pathology• cellulitis• abscess• osteomyelitis• internal/ external resorption of tooth or adjacenttooth• fracture oftooth• disease of follicle including cyst/ tumour• tooth/ teeth impeding surgery or reconstructive jaw surgery• within eld of tumour resection• two or more episodes of pericoronitis• one severe episode of pericoronitis.Options• Leave toothalone.• Extracting the opposing (upper) tooth may be enough to prevent further episodes of pericoronitis.• Extract under LA/ LA and IV sedation or GA depending upon tooth, patient factors and local policy.• Coronectomy (removal of just the crown of the tooth) if high risk toIDN.5Potential complications ofsurgerySwelling, bleeding, pain, trismus, nerve damage (lingual nerve or IDN), infection or dry socket, oro- antral communication, damage to other teeth or their restorations (often predictable from OPG), fractured mandible.Impacted caninesHistoryUsually asymptomatic and picked up at routine examination by dentist. May be unerupted.ExaminationLook for retained canines, angulation of lateral incisor. Palpate whether the impacted canines are buccal or palatal.InvestigationsRadiographs, parallax technique (see E p. 52). Cyst, root resorption.ManagementExtraction of deciduous canines (aged 10). Leave canine in situ, surgically remove, expose and bond, transplantation. Be guided by orthodontist.Exposure ofuneruptedteethMain objective is to remove any bone or soft tissue that is preventing erup-tion of the tooth ± bonding of orthodontic appliance to align intoarch.Impacted second premolarsLower 5s usually lingual, upper 5s normally palatal.ManagementLeave, expose, or extract.5 Renton T, Hankins M, Sproat C, etal. (2005). A randomised controlled clinical trial to compare the incidence of injury to the inferior alveolar nerve as a result of coronectomy and removal of mandibular third molars. Br J Oral Maxillofac Surg 43:7– 12. 144CHAPTER5 In theclinic144Dentoalveolar:jaw pathologiesThese patients will normally be referred with pain, swelling, or a radiological abnormality that has been picked up by the dentist.HistorySwollen face, numb lip, pain, trismus, time course of symptoms.ExaminationSwelling, numb lip/ chin (red ag), buccal/ lingual expansion, displaced teeth, lymphadenopathy.Investigations• DPT.• Discuss with senior— CT/ CBCT/ MRI scan, biopsy,etc.• When viewing imaging of any ‘lesion’:• note site, size, shape, outline, radiodensity, eects on surrounding structures, single or multiple lesions• determine whether normal anatomy, artefactual, or pathological.• If pathological, determine whether:• dental abnormality• bone abnormality• superimposed soft tissue calcication or salivary calculi.• foreignbody.Classication• Cysts— odontogenic or non- odontogenic.• Tumours— odontogenic or non- odontogenic, benign or neoplastic.• Bone disorders— non- neoplastic or neoplastic.Ten causes ofmultilocular radiolucency(See Fig.5.1.)• Keratocystic odontogenic tumour (odontogenic keratocyst)• Ameloblastoma• Ameloblastic broma• Odontogenicmyxoma• Calcifying epithelial odontogenic tumour (CEOT) or Pindborgtumour• Central giant celllesion• Brown tumour of hyperparathyroidism• Cherubism• Aneurysmal bonecyst• Central haemangioma.Ten causes ofa variable radiodensitylesion(See Fig.5.2.)• CEOT or Pindborgtumour• Ameloblastic bro- odontoma• Adenomatoid odontogenic tumour(AOT)• Cementoblastoma• Osteoma• Osteogenic sarcoma (often called osteosarcoma) DENTOALVEOLAR:JAW PATHOLOGIES145 • Osseous dysplasia• Familial gigantiform cementoma• Fibrous dysplasia• Ossifying broma.Fig.5.1 Large, well- demarcated multilocular expansile radiolucency, causing root resorption in the left posterior mandible (ameloblastoma). Clinical correlate— no numb lip. Requires biopsy of cyst lining.Fig.5.2 Variable radiodensity lesion, bilateral mandible particularly prominent around roots of the mandibular teeth. This appearance to an experienced dental radiologist is pathognomonic of bro- osseous dysplasia and biopsy is contraindicated due to the risk of introducing infection. 146CHAPTER5 In theclinic146Temporomandibular joint problems• These patients can often be a challenge to diagnose accurately or treat eectively.• The history and examination yields the vast majority of the information leading to accurate diagnosis.• TMJ patients are often chronic pain suerers and may be depressed as a result of that but this is not the same as having pain as a result of depression.TMJ anatomy• The condylar head articulates with the glenoid fossa of the temporalbone.• The TMJ is a synovial joint with a brocartilaginousdisc.• Ligaments include the temporomandibular ligament laterally, and the stylomandibular and sphenomandibular ligaments running medial to thejoint.• For more on the muscles of mastication, see E p. 29 and Table5.1.TMJ conditions• TMJDS.• Facial arthromyalgia or myofascialpain.• Ankylosis.• Trauma— condylar fracture, intracapsular fracture, eusion, dislocation.• Condylar hypo/ hyperplasia.• Arthritides— degenerative or inammatory.• TMJ neoplasia— benign or malignant (metastasis is more likely than primary tumour).HistoryThe features to ask about are pain, clicking, locking, trismus, and history of trauma, including whiplash. Ask about bruxism, jaw clenching, and nail biting or other parafunctional jaw habits. Do they have hypermobility or other joint problems? Do they have headaches and migraines or spine pain? Menorrhagia, IBS, and pelvic pain can also be associated withTMJDS.Record their pain score out of 10 for the aected and unaected sides at rest and in function.Record how much their condition aects their ability to eat normal food and get a concept of how it aects their quality of life(QoL).ExaminationThe features to examine for are joint tenderness or muscle of mastication tenderness, clicking on opening or closing, abnormal path of opening, evi-dence of parafunction (tooth wear), masseteric hypertrophy, bitten nger-nails, and scallopedtongueMeasure opening and lateral excursion open and closed. TEMPOROMANDIBULAR JOINT PROBLEMS147 Investigations• Consider DPT (must include condylar heads)— might reveal asymmetry, osteophytes, attening of condylar head, and reduced joint space. What you are often looking for is something else which may account for the pain, especially wisdomteeth.• MRI scan— this is the Royal College of Radiologists’ recommended imaging modality of choice for the TMJ. It will show the hard and soft tissues of the TMJ in detail, and in particular will show the position and damage to the meniscus at rest and in function. However, it may require special coils and interpretation is highly specialized and may not be available everywhere.• CT scan— this will show the bony anatomy well but not the meniscus. It is required for custom TMJ manufacture (i.e. computer- aided design/ computer- aided manufacturing (CAD/ CAM)).• Study models for monitoring occlusal changes with condylar resorption (e.g. idiopathic condylar resorption post orthognathic surgery).ManagementThis is a dicult area and there is not a great deal of good quality research on the subject.• Apatient with painless click:exclude hypermobility, this can be the rst presentation of this condition. Treatment should start with reassurance and conservative treatment (see following subsection).• Pain without a click (myalgia)— often related to bruxism or clenching. Treat conservatively but may benet from botulinum toxin Ato muscles of mastication.• Pain and locking or prolonged clicking— consider MRI. Irreducible internal derangement on MRI— usually start with adding arthroscopy, lysis, and lavage to the splint and soft diet programme.• Inammatory changes usually treated with addition of corticosteroid and LA mixture to the soft diet splint programme.Conservative measuresFor a summary of conservative measures, see Table5.2.Table5.1 Muscles ofmastication and their movementsElevators Temporalis, masseter, medial pterygoidProtrusion Lateral and medial pterygoidsDepressors (mouth opening) Lateral pterygoid, infra- and suprahyoid musclesLateral excursion Contralateral pterygoids and ipsilateral temporalis 148CHAPTER5 In theclinic148InterventionConsider anaesthetic implications— may require an awake breoptic or elective tracheostomy under LA if profound trismus.Procedures• Arthroscopy.• Arthrocentesis— joint washout often in combination with arthroscopy. Sometimes morphine is also placed in the joint with or without arthroscopy. Alternatively hyaluronic acid may be used if there are extensive adhesions and corticosteroids if there are inammatory changes.• Discectomy/ meniscectomy.• Condylar shave— controversial.• Eminectomy— may be useful in recurrent dislocation.• Joint replacement— reserved for severe symptomatic end- stage joint disease, adult ankylosis, neoplastic processes, or avascular necrosis. Done in specialist centresonly.Table5.2 Conservative measuresReassurance and education Written information is very helpful. Adepartmentally produced leaet is idealStraight- line jaw exercises Written information, or videos available onlineSimple analgesia NSAIDs ideally if tolerated by patientHeat/ cold compress Hot water bottle application alternating with icepack can help with pain and muscle relaxationRest/ soft diet/ relaxation/ modifying lifestyleSloppy diet and especially avoidance of hard food such as apples. Some nd acupuncture and yoga extremely useful. Physiotherapy and osteopathy also have a role. Support jaw when yawningSoft splints/ bite guards/ bite- raising appliances (worn at night)Michigan splint (upper) and Tanner splint (lower) work by opening up the joint space to free the disc, or possible placebo eect. Trial for 3months and if pain returns when the splint is not worn, occlusal reorganization could be considered by restorative dentist TEMPOROMANDIBULAR JOINT PROBLEMS149 150CHAPTER5 In theclinic150Oral and facialpain• Imagine the number of dierent structures in the head and neck region and you will appreciate that there are many possible causes for oral and facialpain.• The key to diagnosis is in the history. In many patients, the examination ndings will not be helpful so listen carefully.Toothache and TMJ disorders are discussed elsewhere in this handbook but what follows is a list of the more common pain conditions and their salient features:Trigeminal neuralgia• ♀>♂; unusual before the age of 50 (suspect another cause).• Intense sharp shooting pain ‘electric shock’ in the distribution of CN V (unilateral and usually the maxillary or mandibular branch).• Pain comes in pulsating spasms of seconds/ minutes and is described as excruciating (severe enough for some patients to resort to suicide).• There may be a specic trigger point which will result in the pain when touched (e.g. the patient avoids shaving a particular patch on cheek).• No sensory or motor impairment, and examination is normal.Causes• Idiopathic.• Diabetes— causes demyelination, check fasting glucose.• Multiple sclerosis— look for other lesions (bladder, optic, etc.) and sensory or motor symptoms.• Intracranial vascular compression of the trigeminal nerve— thought to be responsible for the pulsatile nature of the pain and the basis for treatment by microvascular decompression.• Space- occupying lesion— check for other neurological signs, e.g. loss of corneal reex found in cerebellopontine angle tumours.InvestigationsMRI/ CT may be indicated to exclude a space- occupying lesion in brain, brainstem, or infra- temporal fossa, and is clearly essential if neurosurgical intervention is being considered for vascular decompression.TreatmentLong- lasting LA injection to infraorbital nerve can be diagnostic and a short- term treatment. Carbamazepine is rst- line treatment— dose is titrated to response but the eect can wear o after some years. Pheno/ cryoablation of the nerve can be indicated and microvascular decompression to separate the geniculate ganglion from the intracranial vessels is eective evidence- based treatment (but 0.5% risk of death).Other drugs used include gabapentin, baclofen, and clonazepam.Glossopharyngeal neuralgiaThis is the same problem as trigeminal neuralgia but in a dierent distribu-tion. Pain is in the unilateral base of tongue and can be triggered by swallow-ing, chewing, and coughing. Carbamazepine is eective. ORAL AND FACIALPAIN151 Temporal arteritisTypically >50years of age. Pain in the temporal region and cheek, especially on chewing (masseteric claudication). Prompt treatment with IV steroids is required to prevent ocular sequelae. There may be a tender swollen non- pulsatile supercial temporal artery. Diagnosis is conrmed by biopsy of the artery (at least 2cm should be excised), but treatment may be instituted from examination ndings and high ESR where biopsy cannot be arranged urgently.Cluster headache (SUNCT, periodic migrainous headache)Nine times more common in ♂; age group 30– 50 years. Complain of recurrent headache, which usually occurs at the same time of day and can waken the patient— ‘alarm clock headache’. Usually unilateral and causes intense stabbing pain in distribution of V2 with reddening and tearing of the eye. Alcohol can be a precipitant. Prophylactic ergotamine or intranasal lidocaine can be eective.Atypical facial pain and atypical odontalgiaOften there is a protracted history (many years) with multiple extractions of healthy teeth before this diagnosis is considered. Pain is often described as drawing or gripping and does not relate to normal anatomical bound-aries. Although described as severe, the pain does not wake the patient from sleep or aect their diet. There may also be delusional symptoms such as powder coming out of the gums, or bizarre tastes such as oil or sh. The trick is to recognize this condition before rendering the patient edentulous. Counselling, cognitive behavioural therapy (CBT), and low- dose antide-pressants have all been used as treatment (with varying success). Patients need to be informed that these conditions will not always be curable.Burning mouth syndrome and oral dysaesthesiasMore common in middle- aged females, especially perimenopausal, which has led to suggestion of a hormonal cause. There is a burning sensation in the tongue and sometimes the whole mouth. Taste may be altered and some patients describe a feeling that the cheek mucosa is peeling o and bad breath. Examination is entirely normal. Occasionally a cause can be found such as low iron or vitamin B12 levels (so always take bloods) and gastro- oesophageal reux disease (symptoms worse in the morning and nasendoscopy shows oedematous vocal cords). Often a history of severe stress or depression can be found on probing, although the similarity of symptoms in these patients leads to an interesting discussion of the psycho-logical versus the physical. Treatments such as CBT and nortriptyline have been shown to be eective. Some patients with normal bloods still improve with vitamin B12 supplements. 152CHAPTER5 In theclinic152Management oforal lesions• View the patient as a whole. Oral lesions are often manifestations of systemic disease, and this may be the rst opportunity a clinician has to diagnose that condition.• To biopsy or not to biopsy? Patients can be referred with oral ulcers, white patches, red patches, or mixed patches. Many of these will be benign, but this is impossible to conrm by clinical examination alone. Therefore histopathological diagnosis is required unless there is no doubt as to the benign nature of the lesion.• See E pp. 248–9 for a more detailed description of the various conditions you are likely tosee.History• How long has the lesion been present? Was it initially noticed by the patient or the dentist? Is it symptomatic and are there any other associated problems— otalgia, dysphagia, looseteeth?• Adetailed medical history, drug history, and social and family history are of great relevance. Look for risk factors such as smoking, chewing betel nut, or drinking alcohol.• Do not neglect asking about genitourinary symptoms.• 0 Red ag— non- healing ulcers, pain or nerve involvement a late sign, history of excess alcohol and smoking, paan/ betel nut chewing. But note:you don’t have to use tobacco or alcohol to have mouth cancer and it is rising in incidence in the younger age group so do not rely on risk factors alone to make your decisions.Examination• Examine outside the mouth rst (scalp, face, and neck), particularly for lymphadenopathy.• Intra- orally, examine all soft and hard issues in the mouth after having removed any dentures present (see E pp. 18–22).• Describe the lesion:sessile, pedunculated, reticulate, homogeneous, heterogeneous, erosive, atrophic. Do the lesions wipe o? Note its size, size, shape, and eects on adjacent structures or eects of adjacent structures on it (e.g. trauma from teeth, lichenoid reaction to amalgam lling).• Depending on ndings, a systemic examination may be required (e.g. other sites of lymphadenopathy such as axillae and groin, abdomen for hepatosplenomegaly, breast, etc.). Genitourinary examination may also be also indicated in certain circumstances, though these examinations should be done by a medically qualied practitioner.Investigations• Ulcers:• Biopsy (mandatory if lesion >3 weeks).• Bloods— FBC, vitamin B12, folate, serum ferritin. Consider B vitamins, zinc, and autoantibody immunology and HLA screening.• Swabs.• Vesiculobullous disorders— direct and indirect immunouorescence. MANAGEMENT OFORAL LESIONS153 Conditions ofdenite premalignant potential• Leucoplakia• Erythroplakia• Erythroleucoplakia• Chronic hyperplastic candidiasis.Conditions associated withincreased risk ofmalignant changes• Lichen planus (particularly atrophicform)• Submucous brosis• Syphilitic glossitis• Sideropenic dysphagia.ManagementIn almost all cases biopsy is mandatory.Aphthousulcers• Chlorhexidine mouthwash can decrease length of ulceration.• Oral vitamin B12 in large doses has been shown to be eective even if serum levels of vitamin B12 are within normalrange.• Topical LA (although sensitization can be a problem).• Topical corticosteroids— e.g. betamethasone rinses.• If severe, consider oral prednisolone in a reducing dose (possibly with gastric cover such as omeprazole).• Triamcinolone injections for major aphthae (if biopsy negative for malignancy).White patches• Patient education regarding risk factors, especially stopping smoking.• Photograph.• Monitor in clinic if risk factors, high- risk histological appearance, or high- risk site (oor of mouth, posterior tongue).• Excision/ ablation if biopsy shows dysplasia.Red patches• Excision/ ablationAbout HPV (human papillomavirus)There is increasing publicity about the role of HPV 16 and 18 in oro-pharyngeal squamous cell carcinoma (OSCC). The virus is probably not signicantly implicated in oral SCC but in the oropharynx it seems to have a better prognosis when found in non- smokers. More research is required to determine the exact role of this oncogenic virus in the head and neck. In the UK a vaccination programme has been set up for HPV 16 and 18 to reduce the incidence of cervical cancer— it remains to be seen if this will also aectOSCC. 154CHAPTER5 In theclinic154Management ofnecklumps• New referrals should ideally be seen in a designated neck lump clinic with access to all the diagnostic methods described in this section.• This should not prevent a patient with a neck lump from being seen as soon as possible.• Normal lymph nodes are not normally palpable.• Palpable lymph nodes in young people are usually reactive to infection.• Palpable lymph nodes in elderly people are usually metastatic, e.g. aero- digestive small cell cancer, thyroid, or from below the clavicle (lung, breast, or gastrointestinal (Virchow’s node)).History• When and where rst noticed?• Painful?• Any discomfort on swallowing?• Increasing insize?ExaminationExtra- oral• Site, size, shape, uctuance, compressibility, mobility, xed to related structures, overlying skin, tenderness on palpation, and associated lymphadenopathy.• Any movement with sticking tongue out or swallowing.Intra- oral• Assess the soft tissues, gingivae, and dentition in detail. Soft tissues should include oropharyngeal tissues— base of tongue, tonsillar fossa, anduvula.• Bimanually palpate the submandibular glands.ENT• Preferably, nasoendoscopy should be performed at rst presentation for a neck lump without knowncause.InvestigationsBloodsFBC, ESR, TFT, LDH, ACE, EBV, CMV, HSV, HIV, toxoplasmosis, and bloodlm.FNA cytologyThis should also preferably be performed at rst presentation. Open biopsy is usually contraindicated as it can cause tumour seeding and local spread. FNAC is inconclusive in 30% of cases. ATru- Cut™ biopsy can be consid-ered in this case. This can be taken under US or radiological guidance.UltrasoundUS can determine node architecture, cystic nature, extent, relationship to salivary glands, shape (ovoid more likely to be reactive, rounded suggestive of malignancy), and size. Colour ow Doppler is also useful for assessing whether hilar blood ow is normal or haphazard (seen in malignant nodes). MANAGEMENT OFNECKLUMPS155 CT/ MRIBoth are good at assessing nodal status, although probably not much better than US for lymphadenopathy.Examination underanaesthesia (EUA), panendoscopy, andbiopsyEssential for any suspicious tumour not easily visualized. Blind biopsies are often taken in the unknown primary tumour scenario— tongue base, post- nasal space,etc.Dierential diagnosis ofa necklumpDevelopmental• Branchial cyst— rare, present in childhood or in early adulthood.Infective• Tuberculosis— cervical tuberculous lymphadenitis suggests post- primary or reactivation of previously quiescent infection. May be accompanying pulmonary or evidence of past tuberculosis on chest radiograph.• Cat scratch disease— single markedly enlarged node. Exposure to cats or history of a primary skin infection at the site of a scratch.• Toxoplasmosis— young adults, immunocompromised.• Brucellosis.• Glandular fever— young adults.• HIV infection— causes generalized lymphadenopathy.Inammatory• Sarcoidosis.Neoplastic• Benign:• Salivary gland neoplasm— pleomorphic adenoma, Warthin’s tumour.• Carotid body tumour (paraganglioma)— arises from the carotid body at the carotid bifurcation. Usually found at the anterior border of the sternocleidomastoid. Moves horizontally but not vertically due to attachment to carotid vessel. Pulsation, thrill, or bruit can be palpated or auscultated.• Nerve sheath tumours (e.g. Schwannoma) also occur at this site and may arise from the vagus or other neck nerves.• Soft tissue benign neoplasms.• Malignant:• Metastatic malignancy— cervical lymph node metastasis from a head and neck cancer. Most likely SCC or adenocarcinoma.• Low neck/ supraclavicular fossa metastasis— always think about pathology below the clavicles (although some head and neck cancers can spread directly to the lower neck nodes). 156CHAPTER5 In theclinic156Skin tumours• Some OMFS units specialize in skin tumours.• Check the history for risk factors— sun exposure (sunburn at an early age is important), smoking (SCC of lip), and skin type. Check for industrial exposure (e.g. soldiers in the Far East can receive compensation).• Look for other lesions— examine the parotid and cervical lymphnodes.• As with all malignant tumours, management is decided via MDT. In most cases this will be wide excision and reconstruction, which can often be performed under local anaesthetic.• British Association of Dermatologists (BAD) guidelines are a helpful resource.6Basal cell carcinoma• BCCs are slow growing malignant neoplasms which rarely metastasize but can cause signicant local tissue destruction, ‘rodent ulcer’.• Classical clinical appearance is a raised pearly edge with central ulceration but nodular, cystic, supercial, morphoeic (sclerosing), keratotic, ulcerated and pigmented variants can occur (see Fig.5.3).• Multiple BCCs are found in basal cell nevus (Gorlin) syndrome.• Biopsy is indicated if diagnosis is in doubt (incisional or punch is preferred so margins are relatively undisturbed).Management• Surgical excision— margin determined by histological subtype but as a rule of thumb, 4mm will clear mosttypes.• Moh’s micrographic surgery— performed by surgical dermatologist, accurate resection but time- consuming (can also be used for someSCC).• Follow- up— patients with >1 BCC or risk factors should have surveillance.Cutaneous squamous cell carcinoma• SCC tumours are more aggressive than BCCs, with a shorter history and greater propensity to metastasize.• Typically present as an ulcer with bleeding but may be nodular or keratin horn appearance (see Fig.5.4).Management• Surgical excision— margin depends on high risk or low risk based on size, site, and histologicaltype.• The regional lymph nodes may need to be addressed.• Radiotherapy may have arole.• Follow- up— patients are normally kept under review for 5years.6 British Association of Dermatologists. M http:// www.bad.org.uk SKIN TUMOURS157 Fig.5.3 Nodulocystic BCC. Reproduced from Kerawala C and Newlands C, ‘Oral and Maxillofacial Surgery’ (2014) with permission from Oxford UniversityPress.Fig.5.4 Cutaneous SCC on superior aspect of pinna on background of actinic keratosis. Reproduced from Kerawala C and Newlands C, ‘Oral and Maxillofacial Surgery’ (2014) with permission from Oxford UniversityPress. 158CHAPTER5 In theclinic158Malignant melanoma• MM is the least common type of skin cancer, but the most serious.• Suspicious features— remember ABCDE (asymmetry, irregular border, colour changes, diameter >6mm, elevated prole).• Most common types include supercial spreading (see Fig. 5.5), nodular, and lentigo maligna.Management• Biopsy is required to determine management which is heavily based on histological features (depth of penetration and histological type). Wide excision of the scar may be performedlater.• Lymph nodes are addressed by resection or sentinel node biopsy in all but the earliest tumours.• Systemic treatments (chemotherapy) may also be used adjunctively.• Follow- up— regular review including examination of the lymph nodes is mandatory.Fig.5.5 Supercial spreading melanoma. Reproduced from Kerawala C and Newlands C, ‘Oral and Maxillofacial Surgery’ (2014) with permission from Oxford UniversityPress. SKIN TUMOURS159 160CHAPTER5 In theclinic160Work- up formajor head and neck oncoplastic surgery• Patients suspected of having oral/ oropharyngeal cancer will generally be referred to the OMFS clinic on an accelerated pathway. In the UK, this is within 2weeks.• Anewly referred patient will be seen in clinic by the consultant who will have made a diagnosis based on the history, clinical features, and initial investigations. Further investigations are required to formally stage the tumour and then the patient will be seen at an MDT/ tumour board meeting to decide on the optimum treatmentplan.• Work- up relates to ensuring that all necessary investigation and preparation for surgery has been completed and the results are available.For major head and neck cancer surgery, there are generally two work- up stages:ForMDTYou may be asked to present a patient at the head and neck MDT meeting. Ensure that the following information is available:• Patient’s history and examination; medical, social, dental, and family history.• Include details such as relevant risk factors— smoking, drinking, betel nut use, patient co- morbidity, medications, exercise tolerance, their ASA grade, and anything else that you think may aect which treatment theyhave.• Performance status and co-morbidity scores are recorded by the MDT so it is worthwhile knowing the classications used for these indicators.• Imaging (DPT, CXR, CT scan) of head, neck, thorax, and upper abdomen for staging. Ensure appropriate re- formatting of scans are available, e.g. coronal views of paranasal sinuses.• Have radiological reports (although a head and neck radiologist should be present at the MDT meeting).• Further tests— MRI, CT- PET, US scans ±FNAC.• Biopsy result and histopathological report.• Ensure that it is known whether the patient has been informed of the diagnosisyet.For surgeryHave the ‘For MDT’ documentation ready, plus the following.• Clear treatment plan agreed by MDT, including any adjunctive radio- or chemotherapy.• Further reconstruction- based imaging.• Dental assessment— patients must be dentally t, or have a plan to have any teeth of poor prognosis extracted before treatment, as they may be having radiotherapy and at risk of developing osteoradionecrosis(ORN).• Bloods— have results available, including any requested by the anaesthetist on the morning of surgery. These include preoperative Hb, electrolytes, LFTs, and albumin. WORK-UP FORMAJOR HEAD AND NECK ONCOPLASTIC SURGERY161 • G&S and crossmatch— 4 units for composite aps, 2 units for soft tissue aps and/ or neck dissection (check local transfusion protocols).• Nutrition:• Know what the nutritional plan for the patient is postoperatively.• Enteral feeding— NGT or PEG/ RIG.• Parenteral feeding— rarely required in head and neck cancer patients.• Ensure that dieticians and speech and language therapy (SALT) are aware of the patient.• Book an ITU bed— if this is not done, it can result in the operation being postponed.Specic reconstruction investigationsRadialap• Non- dominant forearm, check no previous surgery or Raynaud’s syndrome, vascular investigations (Allen’s test ± duplex US scan) to ensure patency of radial and ulnar arteries and the palmararch.Fibulaap• Duplex US scan, conventional angiography, MR angiogram or CT angiogram (both are less invasive) to ensure that all three vessels in the leg are patent and healthy.Deep circumex iliac artery (DCIA)ap• Ensure that there is no previous abdominal surgery, check medical/ surgical history, and examine forscars.• Scapular ap— no previous injuries or surgery.Anterolateral thigh (ALT)ap• Hand- held Doppler available for mapping the perforators preoperatively.Neck vessel patency• It is worthwhile doing carotid duplex to assess the patency and ow of the carotid tree particularly in patients who have previously had DXT to the neck (higher risk of atheroma). Previous neck surgery also raises the risk of internal jugular vein thrombosis, so duplex is sometimes useful to assess potential vessels for anastomosis before surgery in these cases! 162CHAPTER5 In theclinic162Reviewing head and neck cancer patients• The postoperative care of a head and neck cancer patient is centred on rehabilitation and early diagnosis of recurrence.• Other benets include early diagnosis of other related conditions; a second primary cancer; ORN (see later in topic); deterioration of comorbidities, chronic obstructive pulmonary disease,etc.• The exact timings of follow- up appointments will vary and you may nd your department has a protocol.• There are specic aspects of rehabilitation to focus on in the clinic to ensure that the clinic visit is worthwhile.• Good documentation of examination ndings and any discussion with the patient or their carer is important.• Make use of specialist nurses and members of theMDT.• Regular assessment is required to ensure that treatment benets are not outweighed by their side eects.Assessing forpostoperative recurrence• Look carefully at the site of tumour, examine the neck bilaterally, check the ap donor site, and examine the PEGsite.• Further investigation for recurrence may include plain lm radiographs, US scan, CT, or CT- PET. Endoscopic examination and biopsy may be required.Assessing postoperative functionAn 11- domain clinical examination was devised in Liverpool to assess the main postoperative functional decits.7 This is a useful examination to per-form postoperatively to assess motor and sensory nerve function and to gauge the success of the reconstruction. The examination assesses:• lip competence• tongue movement• oralmucosa• dentalstate• mouth opening• speech• drooling• diet• appearance• oral sensation• shoulder movement.Assessments of speech and swallowing can be made clinically with the help of SALTs. Special tests such as videouoroscopy and breoptic endoscopic examination may also be required.Assess oral hygiene and dental health, which are particularly at risk if the patient has had radiotherapy or sugar- laden fortied drinks, such as Ensure®. Prosthetic rehabilitation will need to be planned with the help of restorative/ prosthodontic dentists and technicians.7 Rogers SN, Lowe D, Fisher SE, etal. (2002). Health- related quality of life and clinical function after primary surgery for oral cancer. Br J Oral Maxillofac Surg 40:11– 18 REVIEWING HEAD AND NECK CANCER PATIENTS163 Assessing quality oflifeVarious QoL indices are available which can be used to gain an overall understanding of how the patient’s symptoms, function and psychology are aected. These include the University of Washington (UoW) index, the EORTC questionnaire, and the Functional Assessment of Cancer therapy scale. These are all suitable for collecting comparative data on outcome after surgery.There is no ideal questionnaire, and often the best approach is to listen to patients’ direct concerns in the clinic, as they will have prioritized the issues themselves.Note that QoL generally decreases for the rst 3months following major surgery. Postoperative QoL at 1year is more indicative of the long- term outcome.Assessing radiotherapy patients• Short- term problems:mucositis, loss of taste, dry mouth, infection, lymphoedema, bleeding, impaired nutrition and weight loss, sensitive and redskin.• Long- term problems:stula, impaired healing, ORN, impaired swallowing, speech, and taste, xerostomia and radiation caries, loss of hair, radiation- induced tumours, neuropathies, cataracts, hypothyroidism, brosis.Assessing chemotherapy patients• Short- term problems:mucositis, nausea, impaired nutrition, weight loss, diarrhoea, bleeding, hair loss, neurotoxicity, immunosuppression, septicaemia, neutropenia, thrombocytopenia, multi- organ failure.• Long- term problems:nephropathy, cardiomyopathy, pulmonary brosis, ototoxicity, peripheral neuropathy.OsteoradionecrosisOne of the most devastating non- malignant sequelae of treatment of head and neck cancer is severe ORN. It is imperative that any post- radiotherapy patients requiring restorative dental treatment extractions are treated promptly and by experienced clinicians. There is some evidence for pro-phylactic medical treatment but formal randomized controlled trials in this area are required. 164CHAPTER5 In theclinic164Salivary gland diseases• These patients are referred to the OMFS outpatient clinic by primary care doctors or dentists, or present with acute problems to theED.• Salivary gland anatomy— see E pp. 28–32.• Acute salivary presentations— see E pp. 118–19.PreoperativeHistoryIf the patient presents with a lump, ask how long it has been present and whether it is getting larger. Is there pain and swelling at times of salivation (mealtime syndrome due to salivary obstruction)? Is there any facial weak-ness (CN VII involvement)?Examination• Lump/ swelling:size, unilateral or bilateral, diuse or localized, pain, hardness, tethering to deep structure or mobile.• Specically look for whether saliva is expressible from duct, neck nodes, and oropharynx bulge (deep tumour). Test facial nerve function.InvestigationsPlain lm, sialography, US scan, MRI (required to image deep to ramus), FNA (only serves to exclude malignancy; does not give diagnosis except if a cyst). Scintigraphy or sialadenoscopy may be useful.Salivary gland diseases and their managementSalivary gland tumours• The majority are in the parotid gland and are benign.• Pleomorphic salivary adenomas (PSAs) are mainly found in the supercial lobe of the parotid and can be treated by supercial parotidectomy or extracapsular dissection.• Monomorphic adenoma (Warthin’s tumour)— benign, found in elderly.• Lymphangiomas and haemangiomas are the most common salivary tumours found in children.• Mucoepidermoid and acinic cell carcinomas are rare, and can behave aggressively.• Adenolymphoma.• Adenoid cystic carcinoma— more commonly found in the minor salivary glands and can be confused with mucocoeles when found on the upperlip.XerostomiaCauses— radiotherapy, drugs, anxiety, Sjögren syndrome. Remove any causes, investigate for Sjögren syndrome, and then treat symptomatically.Sjögren syndromeAn autoimmune condition causing xerostomia and keratoconjunctivitis sicca. It is sometimes associated with connective tissue disorders such as rheumatoid arthritis. These patients must be monitored for the develop-ment of MALT lymphoma (5%risk). SALIVARY GLAND DISEASES165 Diagnosis ofSjögren syndrome• Ocular symptoms (dry grittyeyes).• Oral symptoms (dry mouth, frequent water intake, sticky tissues).• Positive blood results— ESR, autoantibodies (RhF, SSA/ anti- Ro, SSB/ anti- La).• Decreased salivary ow rate; sialectasis seen on sialography.• Positive labial gland biopsy.• Positive Schirmer test, rose bengalscore.Causes ofdiuse swelling ofsalivaryglands• Viral— mumps, EBV, CMV,HIV.• Bacterial— acute or chronic bacterial sialadenitis.• Sialosis— endocrine abnormalities, nutritional deciency, alcoholism.• Sialithiasis— diagnose with cheek (parotid) or lower 90° occlusal view (submandibular), although only 50% of stones are radio- opaque.• Submandibular stones can be removed by intra- oral open or closed techniques or by removal of the submandibulargland.• Parotid stones are removed by the intra- oral approach or supercial parotidectomy.Mucocoele• Common referrals.• Submucosal cystic swellings caused by damage to the minor salivary gland or itsducts.• Often a history of trauma to region.• The lower lip is a common site— upper lip more likely to be a minor salivary tumour.• Treated by excision of cyst and the associated gland underLA.• Complications include reduced sensation to region as sensory nerve branches can be damaged.Ranula• Aranula is a mucocoele of the sublingual gland and its draining ducts. Aplunging ranula passes through mylohyoid muscle and can appear as a neck swelling.• Excised by an intra- oral and/ or extra- oral approach underGA.PostoperativeComplications ofparotid gland surgery tolook outfor• Paraesthesia of ear lobe due to damage to greater auricularnerve.• Haematoma.• Salivary stula or sialocoele.• Temporal nerve weakness(10%).• Permanent facial nerve weakness(1%).Frey’s syndrome (named after Lucy Frey, Polish neurologist 1852– 1932)— gustatory sweating and redness over the parotid gland when eating. Caused by division of secretomotor bres during surgery and inappropriate rein-nervation of the sweat glands with parasympathetic bres from the auricu-lotemporal nerve. Can be treated with botulinum toxin injections. 166CHAPTER5 In theclinic166Complications ofsubmandibular gland surgery tolook outfor• Submandibularscar.• Haematoma.• Weakness of the marginal mandibular nerve causing immobility and pulling up of angle of the mouth by the unopposed upper lip muscles.• Lingual and hypoglossal nerve damage— rare.• If a stone has been removed, check that the gland is functioning and the duct is patent by milking saliva out of thegland.Follow- up• Any salivary malignancies should be followed up for at least 5years.• Benign disease should be followed up if treated by minimal techniques (e.g. extracapsular dissection forPSAs). SALIVARY GLAND DISEASES167 168CHAPTER5 In theclinic168Orthognathic patients• This is the subspecialty concerned with improving the position of the bones of the cranium and facial skeleton (orthos, straight; gnathos,jaw).• The type of orthognathic cases that you see will depend upon the unit that you work in, but the general situation is that these are complex patients who require months of treatment (orthodontic), assessment (psychological), and detailed technical planning before surgery is undertaken.• The management of these patients is undertaken at consultant level and within the context of an MDT. It is an ideal environment in which to observe the interface of OMFS with other specialties. You may be supernumerary in the clinic, so make the most of this learning opportunity.• Patients will be seen at the joint clinic at various points in their journey:PreoperativeReferral and initial assessment• Identication of the main complaint (e.g. anterior open bite aecting diet). There is a spectrum of normality of the facial skeleton, and it goes without saying that people who fall outside the ideal dimensions do not need corrective surgery unless there is a signicant problem, be it physical or psychological.• Identication of syndromes (e.g. craniosynostoses in children may be part of the Crouzon or Apert syndromes, amongst others).• Identication of patient’s desires and expectations. Many strong features run in families (a famous example is mandibular prognathism in the Spanish royal family— ‘Hapsburg chin’), and it may be important to the patient to retain these characteristics. Their main concern might be having their teeth meet together.AssessmentExamination of the facial proportions (soft tissue, hard tissue, and teeth) is undertaken systematically. The face is examined in the AP and verti-cal dimensions and any asymmetry is noted. Radiographs (lateral cepha-lographs) are essential to categorize the type of abnormalities found by measuring angles between various points on the facial skeleton. Aclassi-cation will be given to both the malocclusion and the skeletal base which will dictate the type and amount of movement needed by orthodontics and surgery. The consent process should start here— patients need to be aware of the risks and benets of surgery before they start a prolonged and expensive course of treatment.Immediately prior tosurgerySurgery is undertaken after the initial phase of orthodontic treatment is nished. Make the following checks:• All the laboratory work (wafers for jaw movements) has been tried on the patient and has been signed o as satisfactory. Some departments no longer use laboratories and model surgery and rely entirely on CT scans and computer modelling with computer generated wafers.• Orthodontics have added hooks to the ortho wires forIMF. ORTHOGNATHIC PATIENTS169 • Preoperative tests are complete (bloods including G&S), and stop aspirin and oral contraceptive pill if possible.• Ensure that any scans are completed and preoperative photographs have beentaken.Postoperative• The orthodontic apparatus is left on for nishing touches after the surgery is complete.• Check the occlusion (with elastics o) and assess the facial proportions (lateral cephalogram/ DPT/ photographs).• Assess sensation— the IDN is vulnerable during mandibular movements.• There is usually some relapse over time, so an over- correction is often made in anticipation ofthis. 170CHAPTER5 In theclinic170Miscellaneous conditions intheclinicSinusitisThis is an important dierential of facial pain. It is often worse on leaning forward (e.g. climbing stairs or wearing high heels). There may be post- nasal drip and purulent discharge from thenose.Imaging is not usually helpful— uid in the sinus and antral polyps are common and do not correlate well with symptoms. Rule out odontogenic and oncological causes; then refer toENT.Epidermoid and pilarcystsThese are very common (old term, sebaceous cyst) and are often found on the face or scalp where they can be multiple. Epidermoid cysts are from a supercial layer of the skin and pilar cysts from the hair follicle, but in practice it is almost impossible to distinguish the two. The lesions are rm, well circumscribed, and tethered to the skin via a punctum (dierential diag-nosis lipoma, neurobroma, turban tumour, etc.). When a cyst is infected it should be treated as an abscess, but formal excision should be arranged after the infection has clearedup.BatearsThe aetiology is a missing crease in the helix that is often hereditary, so be sensitive. Treatment is possible through various approaches but necrosis of the ears has been reported so consider whether it is really necessary. It is usually possible to obtain funding for surgery in children (although in nancially conscious times this may change).Pre- auricularpitThis is a congenital developmental condition. The pit can extend deeply into the parotid. The diagnosis may be made after an abscess in this region. Check the other side and perform MRI. Consider excision.Skin tumours• Some OMFS units specialize in skin tumours.• Check the history for risk factors— sun exposure (sunburn at an early age is important), smoking (SCC of lip), and skin type. Check for industrial exposure (e.g. soldiers in the Far East can receive compensation).• Look for other lesions— examine the parotid and cervical lymphnodes.Thyroid tumours• High on the list of dierential diagnoses of neck lumps.8• Check thyroid function and arrange FNA ± scintigraphy.8 Koch W (ed.) (2009). Early Diagnosis and Treatment of Cancer:Head and Neck Cancer, Chapter12. Philadelphia, PA:WB Saunders.

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